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标题：Substance-Use Disorders and Poverty as Prospective Predictors of First-Time Homelessness in the United States
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作者：Ronald G. Thompson Jr ; Melanie M. Wall ; Eliana Greenstein 等
期刊名称：American journal of public health
印刷版ISSN：0090-0036
出版年度：2013
卷号：103
期号：Suppl 2
页码：S282-S288
DOI：10.2105/AJPH.2013.301302
语种：English
出版社：American Public Health Association
摘要：Objectives. We examined whether substance-use disorders and poverty predicted first-time homelessness over 3 years. Methods. We analyzed longitudinal data from waves 1 (2001–2002) and 2 (2004–2005) of the National Epidemiologic Survey on Alcohol and Related Conditions to determine the main and interactive effects of wave 1 substance use disorders and poverty on first-time homelessness by wave 2, among those who were never homeless at wave 1 (n = 30 558). First-time homelessness was defined as having no regular place to live or having to live with others for 1 month or more as a result of having no place of one’s own since wave 1. Results. Alcohol-use disorders (adjusted odds ratio [AOR] = 1.34), drug-use disorders (AOR = 2.51), and poverty (AOR = 1.34) independently increased prospective risk for first-time homelessness, after adjustment for ecological variables. Substance-use disorders and poverty interacted to differentially influence risk for first-time homelessness ( P < .05), before, but not after, adjustment for controls. Conclusions. This study reinforces the importance of both substance-use disorders and poverty in the risk for first-time homelessness, and can serve as a benchmark for future studies. Substance abuse treatment should address financial status and risk of future homelessness. Approximately 3.5 million Americans experience an episode of homelessness in a given year, with about 75 000 experiencing homelessness on any given night. 1,2 In addition to intense distress, homelessness is associated with increased risk for morbidity and mortality. 3–5 Thus, homelessness is a significant public health concern, as is understanding its risk factors in the general population. In the United States, homelessness is associated with poverty. 6–10 In cross-sectional studies, alcohol and drug problems are also associated with homelessness, 6–8,11 although the strength of association varies widely across studies. Several issues limit our understanding of the relationships between substance-use disorders and poverty to homelessness in the general population. Most research has focused on recipients of services in homeless shelters, psychiatric facilities, substance abuse treatment, emergency rooms, and other settings, 10,12 potentially overrepresenting long-term and recurrent homeless individuals and underrepresenting those who are homeless for short periods of time and those who are homeless for the first time. Geographic and measurement differences across studies may explain the wide variation in the estimates of substance-use disorders among homeless individuals. 13,14 Also, most associations between substance-use disorders and homelessness have been identified in cross-sectional studies. This limits the ability to draw causal inferences about the effects of substance-use disorders on homelessness because of the possibility of reverse causation. The few longitudinal studies of adults used narrow subsamples of homeless individuals. 8–11 Homelessness does not occur in a vacuum, solely the result of individual traits and behaviors, but rather in a broader social and economic context. Homelessness has been conceptualized from the ecological perspective 15–17 as the product of the dynamic interplay between individuals and their environments. The model emphasizes the context in which homeless people live and the complex interactions between personal, social, and economic systems, positing that personal vulnerability is exacerbated by the loss of social and financial support systems and lack of effective social policies required for individuals to survive in a complex society. Thus, in an ecological perspective, substance-use disorders and poverty are each conditions likely to increase the risk for first-time homelessness. Although the role of limited financial resources among those in poverty in becoming homeless seems obvious, not all individuals in poverty in the United States are homeless. Substance-use disorders in the general population are associated with considerable impairment in psychosocial functioning. 4,5 The impaired functioning associated with substance-use disorders may limit the ability of those in poverty to manage psychosocial and limited financial resources to retain housing. Thus, a better understanding of the relationships among substance-use disorders, poverty, and the subsequent occurrence of first-time adult homelessness is needed. However, no studies have prospectively examined the independent and combined effects of substance-use disorders and poverty on the risk for first-time homelessness, including whether poverty moderates the relationship between substance-use disorders and subsequent first-time homelessness. Prospective, conceptually based, general population studies using standardized diagnostic measures that can control for relevant covariates are necessary to establish temporality between substance-use disorders, poverty, and first-time homelessness. Such studies are needed to inform public health policy and clinical interventions to reduce poverty and homelessness, as well as efforts to address substance-use disorders among homeless individuals. Therefore, we used data from a large, longitudinal, nationally representative survey of adults that employed standardized diagnostic measures to determine the main and interactive effects of substance-use disorders and poverty at a baseline interview on first-time homelessness by 3-year follow-up. Guided by the ecological perspective of homelessness, we analyzed baseline and follow-up data from individuals who initially were never homeless to test the following hypotheses, controlling for relevant personal, social, and economic covariates: (1) baseline poverty would increase the likelihood of first-time homelessness at any point during the 3-year follow-up, (2) current (past year) substance-use disorders at baseline would increase the likelihood of first-time homelessness at any point over the 3-year follow-up, and (3) baseline poverty and substance-use disorders would interact to differentially increase risk for first-time homelessness during the 3-year follow-up.