Content Analysis of Health Concerns among Housing First Residents with a History of Alcohol Use Disorder

Abstract

Previous research has utilized survey and administrative data to document health problems among Housing First (HF) residents; however, little is known about residents’ personal perspectives on their health. The purpose of this study was to utilize conventional content analysis to analyze health-related concerns among HF residents with histories of alcohol use disorder. Between June and December 2013, we interviewed 44 adults who had histories of chronic homelessness and alcohol use disorder and were residing in single-site HF in Seattle, Washington. Responses centered on five primary topics: alcohol-related harm, perceived health vulnerability, concern for fellow residents’ health, end of life, and health and safety promotion. HF residents experience complex alcohol-exacerbated health difficulties and existing health services may not meet the needs of those whose health is particularly compromised. Considering that HF facilitates aging in place, end-of-life care and grief counseling should be integrated into HF services.

Homelessness is associated with adverse health outcomes, including elevated rates of intentional and unintentional injury (e.g., traumatic brain injury),¹ communicable disease (e.g., human immunodeficiency virus),² metabolic disorders (e.g., diabetes),² and substance-use disorders.³ In particular, alcohol use disorders are 10 times more prevalent among homeless adults than the general population.³ Consequently, homeless adults experience a higher prevalence of chronic, alcohol-related morbidity and mortality.⁴ Among adults who utilized Boston Health Care for the Homeless services (2003–2008), the standardized mortality rate was quadruple that of the general population; average age of death was 51 years.⁵

More than 565,000 people are homeless in the US on any given night; one in four are chronically homeless (excluding families with children).⁶ Of the approximately 20,000 people who were homeless in Washington State on a single night in 2019, half were in the Seattle area and 20% were chronically homeless.⁷ Chronic homelessness is defined by the Homeless Emergency Assistance and Rapid Transition to Housing Act as continuous homelessness for one year or longer or four or more episodes of homelessness in a 3-year period.⁸ Health inequities emerge at the intersection of social (e.g., racism, socioeconomic marginalization) and structural factors (e.g., resource distribution, physical and social environments), and lack of housing is an important determinant of health.⁹

Housing First (HF) entails provision of immediate, permanent, low-barrier, nonabstinence-based housing and is an evidence-based means of addressing some of these inequities.¹⁰ HF is prefaced on harm reduction, wherein practical strategies to reduce adverse effects of substance use are supported, and abstinence from substances and attendance at abstinence-based treatment is not required.^11,12 HF is delivered in a single- or scattered-site format. In single-site HF, residents are offered private/semiprivate living quarters within a single building; on-site case management and other services may be available.¹³ Conversely, in scattered-site HF, individuals are offered affordable units dispersed throughout the community and access to assertive case management.¹² Both models are associated with positive physical and mental health outcomes, including fewer alcohol-related problems,^14,15 reduced psychological distress and improved quality of life,¹⁶ and decreased utilization of publicly funded services (e.g., ambulance use, emergency department/hospital admissions, jail bookings).^17–21 Some studies have suggested better outcomes in some domains in single-site settings (e.g., sense of community, recovery²²); however, limited privacy and interpersonal violence, particularly in shared spaces, are disadvantages of the single-site model.²³ Scattered-site HF has been suggested to be advantageous for certain groups, such as families, as it may enable greater integration in the broader community.²⁴

Despite substantial research on HF, few studies have given voice to the lived experiences of residents, particularly those with alcohol use disorder. Qualitative studies conducted with HF residents with histories of chronic homelessness and alcohol use disorder have identified chronic health conditions as residents’ third most commonly expressed concern (surpassed only by acute physical effects of alcohol and alcohol dependence)²⁵ and have documented suggestions for improving HF programming, including access to meaningful activities and alternative pathways to recovery.²⁶ Similarly, a recent study found that health was a frequently mentioned life priority among older adults with histories of co-occurring substance abuse who were residing permanent supportive housing.²⁷ Collectively, those studies added to the literature by identifying health as a priority for people with histories of homelessness and substance use disorder. Quantitative studies have also underscored the importance of health in this population, in which the co-occurrence of alcohol use disorder, in particular, is associated with 6 to 10 times greater risk of mortality.^28,29 However, no studies to date have analyzed—from their own perspectives—the specific health-related concerns of HF residents with histories of alcohol use disorder.

To address this gap in the literature, we aimed to provide a conceptual, thematic description of health-related concerns among HF residents with alcohol use disorder using conventional content analysis. We then used those findings to inform the development of ideas for providers of housing, clinical, and social services to enhance health service delivery for this subgroup of HF residents.

Method

Participants and setting.

Participants were 44 adults who resided in a single-site HF program in Seattle, Washington. Given the high service needs of this population, residents are assigned a housing case manager upon move-in, following a housing-based intensive case management model of care. Engagement with case managers is optional and varies by resident, depending on resident preferences and needs. Caseloads vary but are typically 1:15–20. This support is in addition to other on-site support staff, resident counselors, and a variety of other services commonly found in permanent supportive housing programs (e.g., medication monitoring, nurse-led primary care; see Malone, Collins, and Clifasefi¹³ for more details about this HF program). Prior research has indicated that residents lived in this particular housing program for a median of 675 days (range 19–730) over a 2-year period.³⁰ To be considered for a unit in this building at the time, residents had to meet federal criteria for chronic homelessness, which entails having experienced homelessness for at least 1 continuous year or at least 4 times in the past 3 years.⁸ Participants were taking part in a broader qualitative study that explored their experiences of chronic homelessness and HF and sought recommendations for program enhancement. All residents had a history of chronic homelessness and an alcohol use disorder and were eligible to participate in this study.

Instrumentation.

A set of questions assessed participants’ age, gender, race, and ethnicity. These were followed by open-ended interview prompts that explored their day-to-day experiences in HF, including alcohol use and recommendations for program enhancement, housing, and supportive services (e.g., “What are some of the challenges of/things you like about living here?”); see Box 1 for a complete list of interview prompts.

BOX 1. SUMMARY OF INTERVIEW PROMPTS.

Interview Prompts
• Can you tell me about your first alcohol experience? How old were you? What do you remember about it?
• Thinking about your current drinking, how would you describe the role that alcohol plays in your life?
• What are some of the good things/things you like about your drinking? What are some of the not-so-good things/things you don’t like as much about your drinking?
• A lot of treatment programs ask people to stop drinking. Have you been to such a program? If yes, what was that like for you?
• Would you be interested in programs to help reduce the side effects of your drinking? What would an ideal program look like for you?
• What would you think of a treatment program where abstinence is not required and you could pick your own goals?
• What is it like living at [HF program]?
• What was it like when you moved in here at [HF program]? Specific probes: What was it like to go from where you were living before to here? What kind of paperwork did you fill out? Did you meet with a counselor? What happened? What was that like?
• What do you like about [HF program]?
• What would you like to change about [HF program]?
• What are some services that you would like to see offered here at [HF program] (i.e., ones that you feel would make your experience here better)?
• What do you think of the activities (e.g., bingo, movie nights, outings) here? What other activities would you like to see happen?
• How would you describe your relationship with other residents?
• How would you describe your relationship with staff ?
• What do you think about the drinking policy at [HF program]? Specific probes: How is this different from your experiences at other places you have stayed? How did this influence your choice to live at [HF program] over other options? How is [HF program] different from other places that you have lived?)
• Have you heard about the voluntary Managed Alcohol Program (MAP) here at [HF program]? Explain the service if they haven’t heard about it. Have you ever participated in the MAP? If yes, what has that been like for you? If no, what is your understanding of the MAP? What has made you interested [or, depending on prior responses, not interested] in participating?
• Is there anything else you feel like we should know?

Note:

HF = Housing First, MAP = Managed Alcohol Program

Research staff allotted approximately 5 to 10 minutes for each question and were encouraged to use probes, such as “tell me more,” “what else,” “how so,” and “anything else?” to elicit greater detail from respondents.

Procedures.

HF residents were approached by research team members and invited to participate; no residents who were approached declined. Residents were informed of study purposes, procedures, and their rights/role as participants. After written, informed consent was obtained, participants were interviewed between June and December 2013 by one of two psychologists (SLC and SEC) and compensated $20 USD. Each 45- to 60-minute interview occurred on-site at the HF program and was audio recorded, transcribed, and stripped of identifying information prior to analyses. Study procedures were approved by the institutional review board of the University of Washington.

Data analysis.

Our research team (i.e., two psychologists, two postdoctoral fellows, one doctoral trainee) conducted conventional content analysis, a systematic process wherein codes are derived from the data, rather than preconceived categories.³¹ Atlas.ti version 7 (2012) was used for data management.

A constant comparative approach was utilized.³² First, we conducted line-by-line coding to narrate individual actions that occurred in the interviews. During consensus meetings, we consolidated codes, collapsing or removing those that were redundant or idiosyncratic, and created a codebook. Due to the emergent observation that aspects of health were frequently mentioned by participants, the current study was then conceptualized to more specifically analyze all mentions of health-related concerns, experiences, and needs. Next, we employed a double-coding process, during which two team members independently coded 10% of interview transcripts until adequate intercoder consistency was reached (target: 80%, actual: 81.3%).³³ After intercoder consistency was achieved, remaining transcripts were coded independently and individually. Member checking occurred after initial coding and memo summarization, and prior to drafting this manuscript. Research team leaders (SLC and SEC) met with a community advisory board representing study participants to communicate themes that emerged through our initial coding process and to elicit feedback concerning the resonance, credibility, and usefulness of interpretations. Minor edits were made and additional quotes added to clarify constructs, as necessary. Interpretations were largely viewed as accurate and appropriate.

Results

Participants averaged 53.2 years of age (SD=7.8), and most identified as male (81.8%; n=36). Twenty-three percent self-identified as American Indian/Alaska Native/First Nations, 11% as Black/African American, 21% as Multiracial (all of whom identified as American Indian/Alaska Native/First Nations plus another race), 2% as “Other”, and 43% as White/European American. 9% identified as Hispanic/Latinx.

We distilled five primary topics: alcohol-related harm, perceived health vulnerability, concern for fellow residents, end of life, and health and safety promotion (Table 1). All participants mentioned health-related concerns consistent with one or more primary topics.

Table 1.

HEALTH-RELATED TOPICS AND PERCENTAGE OF PARTICIPANTS WHO MENTIONED EACH CATEGORY (N = 44)

Topics/Categories	Examples	Participants Mentioning Each Category N (%)
Alcohol-related harm
Link between alcohol and health problems	“Alcoholism leads to death. It leads to pancreatitis.” (PT39) “You can look in my eyes and tell the liver’s gone.” (PT36) “I’m killing myself every day by drinking. I see that.” (PT09) “God’s gonna take me soon if I keep it up [drinking] … I’m making my fucking self worse and worse and worse to where I’m gonna kill myself.” (PT20)	21 (47.7)
In-utero alcohol exposure	“… my mom was dead drunk all the time she carried me.” (PT20) “I was born an alcohol syndrome baby.” (PT33)	4 (9.1)
Perceived health vulnerability
Illness and aging	“I can’t even jog half a block without basically running out of breath.” (PT23) “My arthritis is so bad I can’t even put my socks on inside my shoes.” (PT10)	30 (68.2)
Intentional and unintentional injury	“I had another seizure. I cracked my head.” (PT21) “Fell off a barstool at the [Name of bar]. Nice place. Broke my pelvis.” (PT25) “Beat me up bloody, lump on the back of my head. They could’ve killed me.” (PT12)	18 (40.9)
Cognitive impairment	“I don’t keep track of time very well.” (PT09) “I don’t remember what I did yesterday … I’m just worried about losing my mind.” (PT10)	16 (36.4)
Concern for fellow residents
	“There are people in here that are disabled.” (PT42) “They [fellow residents] fall and literally bust their head.” (PT30)	24 (54.5)
End of life
	“They just came in here to die. That’s all there is to it.” (PT42) “I think they know in the back of their mind they’re going to die here.” (PT05) “Every month there would be a new person that died.” (PT27) “A friend of mine died about two weeks ago.” (PT42)	15 (34.1)
Health and safety promotion
	“I did the liver treatment for Hepatitis C and I did that successfully [in Housing First].” (PT27) “I didn’t seem to have to go to the hospital aft er I moved in here.” (PT12) “I can lock the door. Nobody can come in and hurt me, and I can even lock the window.” (PT24)	27 (61.4)

Alcohol-related harm.

Link between alcohol and health problems.

Insight that alcohol was linked to health problems (e.g., illness, memory problems) was woven throughout 48% (n=21) of narratives. One participant reflected:

I shouldn’t even be drinking. My Hep C alone is killing my liver. Even though it rejuvenates itself, it can’t rejuvenate itself when I’m kicking Hep C and alcohol both at the same time … might as well take a gun and blow my head off, you know what I’m saying? (PT20)

Likewise, a 51-year-old participant stated:

Another frustrating thing is that my feet and my legs have really been bothering me lately as far as standing and walking … that’s another thing that they said probably had to do with all the heavy drinking I was doing. (PT03)

Although many participants described the connection between alcohol and health problems, more than half did not mention alcohol as a factor that was exacerbating—if not causing—their health problems. One participant asserted that high-quality alcohol would not have adverse effects; another negated the role of alcohol in injury, suggesting balance problems were attributable solely to medication side effects. Others were uncertain about the effect of alcohol on health:

I was bleeding, internally bleeding. I don’t know if it was due to drinking or what. (PT12)

In-utero alcohol exposure.

Four participants (9.1%) indicated being exposed to alcohol in-utero and remarked about lasting teratogenic effects. One participant shared:

I did six months of my life in an incubator because my mom was dead drunk all the time she carried me” (PT20)

Another recounted a similar story:

I was born with a birth defect, fetal alcohol effect. My brother’s got fetal alcohol syndrome. The fetal alcohol syndrome occurs with the facial features. Fetal alcohol effect occurs neurologically in the brain. And [mother] drank the whole nine months when she had me. (PT06)

A purported consequence of being an “alcohol baby” was an inevitable trajectory toward alcoholism (i.e., “predestination”). One participant stated that in-utero alcohol exposure meant “you’re born with [alcoholism]” (PT06).

Perceived health vulnerability.

Illness and aging.

Statements about poor or declining health were common, even among younger participants (68.2%; n=30). A 44-year-old shared:

Sometimes I just be like feeling so crappy, man. It’s like—nah—I can barely move out of bed … my health has started going, deteriorating, like, you know, astronomically. (PT13)

In addition to severe alcohol use disorder, the majority of participants mentioned at least one health complaint or chronic illness (e.g., arthritis, hypertension) affecting their functioning. Symptoms of illness and deleterious effects of aging were barriers to completing activities of daily living. A participant who uses a combination of a walker and wheelchair explained:

I’m getting older, and my arms just don’t want to propel me, and I have foot problems on both, both feet. (PT38)

Participants mentioned grappling with pain (20.5%; n=9), sleep difficulties (15.9%; n=7), and dental issues. Eleven percent (n=5) disclosed that poor dental health was a source of physical pain and shame:

I walked around with no upper teeth for almost two years and my bottom teeth just like four or five. I really felt … you know, I felt terrible because your smile is so—people don’t realize how important your teeth are until you miss, you lose them. (PT24)

Concerns about health problems featured commonly in participants’ interviews, but obtaining support to manage those difficulties, such as through seeking healthcare or assistance from professional caregivers in HF, was sometimes experienced as dismissive or lacking in care. Several participants attributed this to stigma against people with alcohol use disorder.

[Healthcare providers] say, “Oh, yeah, you’re just a drunk. You can wait your turn.” You know, they don’t think I gotta problem. They just think I’m a big drunk. (PT34)

The caregivers don’t care. Why? Because we’re drunks. That’s how we see it. Nobody cares about us. (PT25)

Intentional and unintentional injury.

Injuries were spontaneously mentioned by 18 participants in the sample (40.9%) and were especially salient among women, all but one of whom (7 of 8 women) discussed being injured. Injuries occurred in various contexts and spanned the spectrum of severity from minor (e.g., bruises) to severe (e.g., broken bones, gunshot wounds). In some cases, alcohol was cited as a contributing factor:

That’s how I keep bonking myself when I’m drinking every day. I go on a binge. But, uh, yeah, usually when I drink hard liquor, I fall down. That’s how I broke my hip. (PT12)

Violence that preceded moving into HF (e.g., family violence, assault while homeless) was described:

Some guys come up and hit me in the back of the head with a stick, cut my arm down there. (PT12)

Assault was particularly common among women; half reported surviving physical and/or sexual assault-related injuries before moving into HF, compared with 1 in 20 men. One female participant recalled:

Before I got here, I got my jaw broken in two places, and I’ve had my tooth knocked out. A guy pushed me off by the freeway, and I fell 30 feet…it took me a year and a half to rehabilitate. (PT24)

Cognitive impairment.

Thirty-six percent (n=16) described memory problems as a source of distress or frustration. Inconsistent and/or imprecise reporting observed in several interviews (e.g., uncertainty regarding number of years lived in HF program) corroborated self-reported cognitive complaints. Although ascertaining details about cognitive complaints was beyond the scope of this study (e.g., review of medical records), participant narratives suggested that traumatic brain injury and alcohol-related dementias may have been contributory. For example, one participant reported:

I’ve got a really bad memory because I’ve been beat up so viciously. My head really pounded on the fucking concrete … more than once. (PT20)

For some, perceived cognitive impairment appeared to trigger deprecating self-talk, which was suggestive of internalized stigmatization about people with alcohol use problems:

Most of us are idiots. If we weren’t idiots then we wouldn’t need the assistance, and we could do it on our own, you know. I recognize the fact that, yeah, that 90% of the people in this building, myself included, are a little weak in mental functions. (PT43)

Use of stigmatizing language extended to descriptions of fellow residents’ apparent cognitive difficulties. Speculating that other residents’ cognitive difficulties may be linked with alcohol use evoked fear for one participant that they, too, might decline cognitively:

[I see] guys who have drank to where they are incognizant birdbrains. And I think that could be me. I’m not far from that. That could be me. (PT25)

Difficulties with and/or changes in cognitive functioning made sustaining employment challenging for some participants and may have contributed to the chronicity of their homelessness. With regard to tasks required in his prior profession, a participant in his early fifties stated:

Things that I’d done for years—and they’re so damn easy. I mean, I just didn’t even have to think about it. It started getting really difficult … I kept getting confused and mixed up. (PT03)

Cognitive difficulties also affected some participants’ daily living tasks:

To even take a bath is hard for me. I can’t think straight … I start a lot of things and I get all confused. (PT20)

Concern for fellow residents.

Fifty-five percent (n=24) indicated awareness that fellow residents experience health-related difficulties. Some were surprised to learn upon moving into HF that residents had complex and, in some cases, debilitating health problems:

When I first moved in here, I walked through that door and I thought I was going to move into a nursing home. That’s what it looked like. Seeing all these people like, [resident name] in a wheelchair and people pushing walkers and people walking with canes. (PT44)

One participant disclosed that residents “have a lot of accidents”:

They’re falling left and right. I’ve seen people bust their head time and time again, over and over and over. (PT30)

Participants suggested that “some [residents] are capable of taking care of themselves and some just need a little bit more help” (PT13). Others worried the HF program was not equipped to meet the needs of particularly vulnerable residents and proposed transitioning them to a different facility:

It’s not a nursing home … it’s as though they’re in the wrong building. They’re in the wrong facility. They need to be somewhere where people can care for them, and care for them even better. (PT30)

Participants presented ideas for structural and programmatic modifications to increase safety. Installation of additional grab bars, wheelchair-friendly kitchen spaces, and chairs and railings in outdoor spaces were proposed to improve accessibility for residents with ambulatory difficulties (e.g., cane- and wheelchair-users). Modifying meal options for residents with compromised dental health was recommended:

A lot of people don’t have teeth … there needs to be like more food that would be soft for them. (PT28)

Having caregivers assist certain residents with activities of daily living (e.g., bathing, laundry) was also suggested. The need for consistent, high-quality care was emphasized.

Many residents were empathic toward those with compromised health and expressed a desire to assist others. One participant expressed encouragement:

This is not an easy ride, but [residents] need to just grab onto that horse tight and just don’t let go. (PT13)

Awareness of fellow residents’ vulnerability motivated some participants to provide support to their neighbors by volunteering to attend medical appointments with them or to assist with daily activities (e.g., cooking). One participant stated:

I’m not a medic but I was keeping tabs on [another resident’s] foot and I kept telling him, “You need to go to [hospital]. I would go with you” (PT28)

Another described himself as the “caretaker … in a way” (PT38) of a resident who had been injured.

End of life.

One-third (n=15) remarked about ways in which their HF tenure had involved exposure to death and loss. Participants noted that the health of individuals to whom HF was offered was, in some cases, so compromised they could not be “saved” by housing:

For some of these people here, this is their last stop, you know? I’ve seen three or four people die here … because they were so sick when they came in here that they were beyond help. And what they did is they just came in here to die. (PT42)

Participants formed meaningful relationships with fellow residents and were deeply affected when those individuals died (e.g., “My neighbor passed away. You know, I couldn’t deal with it” [PT33]). Exposure to death was seen by some as an inevitable aspect of living in HF:

There’s a couple of people now I know that I have had to work really hard on a relationship with, and they’re on their way to death, but the thing is—in one sense—if this is where people want to come to die, so be it. (PT24)

Some participants expressed fears about issues they may face at the end of their lives (e.g., “I don’t want to die alone, you know” [PT38]), whereas others approached perceived impending mortality with acceptance (e.g., “I don’t expect to be alive very much longer but that’s okay” [PT23]) or even indifference (e.g., “He’d just sit there and brag about death like it didn’t mean anything … ‘Drink up, I’ll be dead before the year is over with’” [PT36]).

Perceived societal rejection was juxtaposed with inner community-building and intertwined with death. One participant remarked:

They [domiciled community] consider us castoffs … it’s like a house of death. (PT22)

Another explained that residents honored those who died, such as by creating photo and candle memorials, which interviewers (SLC and SEC) regularly observed and attended in common spaces.

Health and safety promotion.

Although HF was seen as a place where people go to die, stable housing also appeared to motivate and/or enable health-promoting behavior (e.g., reduced drinking, treatment for illness) and engender a sense of safety. One participant stated:

My liver was all screwed up, and [HF] made it possible for me to sober up … I was finally [able to] take care of a couple of huge [health] problems. (PT27)

Although participants valued on-site healthcare services, particularly nursing, they felt additional services would be useful, and the importance of consistent providers was stressed. For example, having a provider “who knows whether or not you know your body and if you need help understanding your body [would be a] major improvement” (PT13).

Despite personal health problems and concerns about morbidity and mortality among fellow residents, HF as safe or even lifesaving was reiterated. These sentiments were exemplified in statements, such as:

I can lock my door. I can let in who I want, right. That’s safe. (PT32)

Ain’t anybody going to beat me up [in HF]. (PT23)

I really wanted to have a roof over my head, because I know I would have died out there. (PT44)

Several participants indicated that HF staff were cognizant of residents whose health was particularly compromised, which provided an additional safety net:

If I don’t call up or go downstairs, whatever, the front staff, if they don’t see me, they’ll call me up. If I don’t answer, they will come right then. They’ll come bang on my door and check on me. (PT23)

Since moving into HF, some participants experienced a renewed desire to make meaningful, life-extending choices, such as modifying drinking patterns (e.g., harm-reduction strategies) or getting involved in new activities. Likewise, witnessing deteriorating health of fellow residents catalyzed some toward behavioral change:

I didn’t want to end up like that, spending my life here and dying. So I guess seeing it all the time just kept reinforcing how much time I was wasting, and it kind of woke me up. (PT05)

Another avowed:

You know, ‘I’m not dying here.’ I told that in my head … No, I’m not. I’m not. I didn’t come here to die. (PT22)

Discussion

The purposes of this study were to describe—in their own words—health-related concerns and experiences of HF residents with a history of chronic homelessness and alcohol use disorder and to present ideas for health service delivery for this subgroup of HF residents (see Box 2). Five primary topics were identified: alcohol-related harm, perceived health vulnerability, concern for fellow residents, end of life, and health and safety promotion.

Box 2. RECOMMENDATIONS FOR HEALTH SERVICE DELIVERY IN SINGLE-SITE HOUSING FIRST.

Domain	Recommendations
Alcohol-related harm	• Provide staff training on harm reduction, social determinants of health, and trauma-informed care principles. • Use individual- and community-level harm-reduction approaches to address residents’ alcohol-related harm. • Ensure approaches to addressing alcohol-related harm are environmentally and culturally appropriate for residents in the particular HF community.
Perceived health vulnerability	• Provide training to staff and other providers who work in close proximity to the HF community on medical and psychological sequelae common among people with co-occurring alcohol use disorder and homelessness (e.g., traumatic brain injury, cognitive deficits due to heavy alcohol use, earlier onset of geriatric conditions, posttraumatic stress disorder). • Orient residents upon move-in to the available health services and steps to access them. • Deliver women’s groups to offer a safe space for women to obtain support. • Ensure adequate accommodations are made for residents with disabilities, both in terms of the built environment and in the health services provided.
Concern for fellow residents	• Upon move-in, prepare HF residents for the scope of health difficulties among fellow residents and its potential impact. • Schedule community meetings and invite residents to share with staff and one another what they need to ensure the community is effectively supported. • Support residents’ in establishing their own support groups, depending on the unique needs of the HF community.
End of life	• Provide support for staff on palliative approaches to service delivery. • Ensure external healthcare providers who deliver onsite end-of-life care are educated on issues unique to dying among individuals with a history of homelessness. • Ascertain and document resident preferences for end-of-life care. • Employ a harm reduction approach to substance use in end-of-life care. • Enable dying in place, if preferred by resident, when possible. • Respect cultural beliefs and end-of-life practices. • Support housewide memorials and services for residents who have died. • Integrate grief counselling services into HF, ideally with individual and group milieu options; make services available to both residents and staff.
Health and safety promotion	• Co-locate physical and mental health services on-site. • Establish links with external services to manage complex conditions and provide specialized (e.g., dental care) or intensive (e.g., skilled nursing facility) care. • Strive for care continuity across healthcare providers and auxiliary supports (e.g., carers). • Conduct resident wellness checks. • Design private and communal spaces that are safe and accessible (e.g., install grab bars, design wheelchair-friendly kitchen and bathroom spaces). • Remind staff and residents about safety measures (e.g. post fl yers). • Conduct further research into the lived experiences of residents in single-site and scattered-site HF to establish best practices approaches to healthcare provision, including end-of-life care, across diff erent HF models.

Note:

HF = Housing First

These recommendations were based on responses from residents in single-site HF and may or may not be relevant for other HF configurations (i.e., scattered-site). For information to guide policy development related to end-of-life planning for people experiencing homelessness more generally, visit the National Health Care for the Homeless Council website: https://nhchc.org/clinical-practice/diseases-and-conditions/end-of-life-care/

Alcohol-related harm.

Alcohol as a source of harm was not only distinguished as a primary topic, but was integrated throughout the other themes as well. This finding is unsurprising given the prevalence of substance use among chronically homeless people,^19,34 and the well-established link between heavy alcohol use and illness (e.g., cardiovascular disease, cirrhosis) and injury (e.g., violence, falls). Likewise, American Indian/Alaska Native/First Nations people, who comprised a large proportion of the sample, are disproportionately affected by alcohol use disorder, which has been associated with the ongoing effects of historical trauma (e.g., colonization, forced relocation, boarding schools, assimilation policies).³⁵ Residents’ narratives revealed that many are concerned about how drinking is diminishing their health.

Whether people with active substance use disorders are suitable for HF programs has been questioned.^36,37 However, a growing body of research demonstrates that individuals with substance use disorders are able to sustain HF tenancy^30,38 and, in some instances, reduce alcohol use.^15,17 Research must now focus on what supports may be helpful in aiding residents to achieve their goals. Given that traditional substance use interventions (e.g., abstinence-only programs) are not particularly effective for, nor preferred by, this population,^34,39 alternative pathways to recovery that reduce harm and align with personal goals are being explored.⁴⁰ Early studies show promising effects of individual^41,42 and community-level interventions^43,44 in reducing alcohol use and alcohol-related harm. Providing low-barrier, resident-led pathways to healing within HF is recommended

Perceived health vulnerability.

Although illness and injury were not queried specifically, a preponderance of participants mentioned the topic, which underscores the salience of health—particularly health problems—in HF residents’ lives. Women mentioned injury more often than men, which may be reflective of gender differences in symptom reporting,⁴⁵ differences in exposure to types of violence (e.g., sexual assault) compared with men,⁴⁶ or homeless women being more likely than men to describe health-improvement goals.⁴⁷

The constellation of serious health conditions (e.g., cognitive impairment, arthritis, cancer) reported by participants who were chronologically quite young (M=53.2 years) supports previous reports that homelessness is associated with accelerated aging⁴⁸ and earlier onset of geriatric conditions relative to the general population.⁴⁹ Age 50 has been proposed as the inception of older adulthood among homeless people.⁵⁰

Although discerning the etiology of self-reported conditions was beyond the scope of this study, possibilities were cited by participants, including substance use and traumatic brain injury. Health effects of heavy alcohol use among persons experiencing homelessness have been well-documented,² but traumatic brain injury has received attention only in recent years.^1,51,52 Problem drinking after traumatic brain injury has been linked to poorer outcomes, including reinjury, in both homeless and domiciled populations.^53,54 In this study, HF staff often had bachelor’s degrees but not necessarily in the health or caring professions, and staff were not specifically trained to work with individuals who may be living with the sequelae of traumatic brain injury and comorbid substance use disorder. Providing such training for staff is an important consideration for housing agencies.

The desire for consistent providers and to be treated with dignity in healthcare settings has been described previously⁵⁵ and was reiterated by participants in this study. Prior research investigated transitions into housing and long-term case management upon discharge from hospital with positive results (e.g., fewer hospitalizations and emergency department visits⁵⁶), suggesting continuity may yield better outcomes. Given the confluence of heath, mental health, and psychosocial difficulties faced by HF residents, however, some healthcare providers may be unprepared to address the social determinants of health that confront these patients⁵⁷ and may contribute to self-stigmatization among these individuals.⁵⁸ Training on these topics, including provision of trauma-informed care, is necessary to ensure providers who care for HF residents deliver effective, holistic services. Moreover, co-location of physical and mental health services is recommended.

Concern for fellow residents.

In addition to worries about their own health, participants were concerned about the well-being of fellow residents. Pragmatic improvements to promote health and safety in HF were suggested, including ensuring programs are designed to accommodate people with physical disabilities, both in terms of the built environment (e.g., accessible spaces) and services provided. Although the HF program provided some support services, some participants had stepped into caregiving roles for one another by assisting with day-to-day tasks (e.g., cooking meals, accompanying to appointments), and it was unclear whether this was driven by a desire to help fellow community members and/or in response to a perceived dearth of resources (e.g., lack of access to professional caregivers). Golembiewski and colleagues⁵⁹ suggested that although single-site HF may prune social networks, residents describe higher-quality connections one year after moving in. The establishment of such relationships may lead to informal caregiving networks within single-site HF. Whether such relationships benefit health merits further study.

On-site access to healthcare services, particularly nursing services, was viewed favorably by residents in this HF program. However, the diversity of health problems, both in type and severity, highlighted the importance of establishing links with external clinics to manage complex conditions and made clear that specialized (e.g., dental care) or intensive (e.g., skilled nursing facility) care may be needed. Thus, although HF facilitates aging in place and is conducive to improving health, housing in and of itself is not sufficient to meet all residents’ needs. Studies have begun to investigate whether service utilization and health outcomes differ between HF configurations (i.e., single-site vs. scattered-site).¹⁶ Research on the lived experience of residents in each type is warranted, including investigation into how healthcare services might be most effectively delivered in, or coordinated for, each type.

End of life.

Participants recounted their own and other residents’ brushes with death and shared fears that health problems, particularly those associated with alcohol use, put them at risk for premature mortality. Consistent with this, Henwood and colleagues⁶⁰ documented high rates of mortality among HF residents in Philadelphia, wherein tenants had an average age of death 20 years younger than the general population.

End-of-life care systems generally assume that dying patients have stable housing, loved ones to assist with care, and the ability to pay for supplemental services. HF may not be conducive to provision of traditional end-of-life care; however, for residents who have tenuous health and modest social supports, the question of where they would go is practically and economically complex. Moreover, substance use difficulties may preclude eligibility for hospice or hospital-based end-of-life care.⁶¹ Thus, for residents with a history of alcohol use disorder, HF may become a de facto site of end-of-life care, regardless of whether it was intended to be. Similar to domiciled populations, terminally ill people with a history of homelessness prefer to die in familiar places (e.g., shelters, permanent supportive housing).⁶² A preference for dying in place may be cemented by adverse healthcare experiences (e.g., discrimination) and public stigma, which may be internalized among people with substance use problems.⁶³ Such experiences may be particularly common among members of minority groups (e.g., American Indian/Alaska Native/First Nations peoples),⁶⁴ which constituted the majority of our sample. Studies have described ways HF might be tailored to better meet the needs of minority groups.⁶⁵ Such tailoring should extend to palliative care, as honoring cultural beliefs and practices at the end of life is important to people with a history of homelessness.^55,65

A patient-centered approach is fundamental to effective end-of-life care, but HF providers may not feel comfortable addressing end-of-life issues.⁶⁶ Likewise, palliative care providers may lack knowledge about issues unique to dying patients who have a history of homelessness.⁶⁷ Provision of end-of-life care for these individuals has received attention in recent years,⁶⁸ but further investigation and staff training is needed. Developing innovative ways to provide dignified end-of-life care in HF, potentially informed by economical programs implemented in shelters,⁶⁹ is necessary. Inclusion of grief counseling in HF should also be considered and may be particularly important in single-site settings, where residents live in close proximity and share communal spaces. Close bonds may form and resident deaths may deeply affect individuals and the HF community more broadly.

Health and safety promotion.

Participants conceptualized HF as a health- and safety-promoting intervention, and the notion of housing as healthcare was woven throughout the data. According to Wenzel and colleagues,⁷⁰ health-improvement goals become increasingly salient among people in permanent supportive housing over time. Moreover, research has identified social and psychological benefits of HF (e.g., sustained tenancy, improved quality of life, better community functioning).⁷¹ Stable housing may enable individuals to rebuild familial and cultural connections and to change substance-use patterns,⁷² which may have lasting effects on health and healthcare costs. Indeed, HF reduces public costs, particularly for high service utilizers.⁷³ Future research is necessary to assess the health needs of HF residents in greater depth and to identify cost-effective models of service provision that align with residents’ needs and preferences.

Limitations.

This study was conducted in a single-site HF program in a large US Pacific Northwest city, and all participants had histories of chronic homelessness and alcohol use disorder. These findings may not generalize to other housing programs (e.g., scattered-site HF, continuum-of-care housing) or populations (e.g., unsheltered homeless population, HF residents without histories of alcohol use disorder). Health was frequently mentioned by participants in this study and warranted in-depth analysis; however, interview prompts did not query health specifically. Thus, the breadth of health concerns reported herein is almost certainly incomplete. Future studies should explore the spectrum of illness and injury among HF residents to comprehensively assess needs and include residents in program planning.

Conclusion

This content analysis describes complex health difficulties experienced by HF residents with histories of chronic homelessness and alcohol use disorder. Although this study featured a sample with a mean age in the early 50s, participants described health problems of an older population (e.g., mobility and memory problems). This finding likely reflects the physical toll of chronic homelessness and alcohol use. Although HF appeared to promote health and safety, and on-site services were valued, existing services were considered insufficient to meet the needs of residents with particularly compromised health. To optimize the utility of HF, research clarifying the range of health needs and service preferences of residents is warranted, including exploring opportunities to provide grief counseling and to incorporate end-of-life care that is tailored to residents’ needs.