What constitutes effective problematic substance use treatment from the perspective of people who are homeless? A systematic review and meta-ethnography

Abstract

Background: People experiencing homelessness have higher rates of problematic substance use but difficulty engaging with treatment services. There is limited evidence regarding how problematic substance use treatment should be delivered for these individuals. Previous qualitative research has explored perceptions of effective treatment by people who are homeless, but these individual studies need to be synthesised to generate further practice-relevant insights from the perspective of this group. Methods: Meta-ethnography was conducted to synthesise research reporting views on substance use treatment by people experiencing homelessness. Studies were identified through systematic searching of electronic databases (CINAHL; Criminal Justice Abstracts; Health Source; MEDLINE; PsycINFO; SocINDEX; Scopus; and Web of Science) and websites and were quality appraised. Original participant quotes and author interpretations were extracted and coded thematically. Concepts identified were compared to determine similarities and differences between studies. Findings were translated (reciprocally and refutationally) across studies, enabling development of an original overarching line-of-argument and conceptual model. Results: Twenty-three papers published since 2002 in three countries, involving 462 participants, were synthesised. Findings broadly related, through personal descriptions of, and views on, the particular intervention components considered effective to people experiencing homelessness. Participants of all types of interventions had a preference for harm reduction-oriented services. Participants considered treatment effective when it provided a facilitative service environment; compassionate and non-judgemental support; time; choices; and opportunities to (re)learn how to live. Interventions that were of longer duration and offered stability to service users were valued, especially by women. From the line-of-argument synthesis, a new model was developed highlighting critical components of effective substance use treatment from the service user's perspective, including a service context of good relationships, with person-centred care and an understanding of the complexity of people's lives.

‘They already operated like it was a crisis, because it always has been a crisis’: a qualitative exploration of the response of one homeless service in Scotland to the COVID-19 pandemic

“…These are some of the well-documented emotional and psychological difficulties of working with people with complex lives, including homelessness [ 58 ]. Those providing support to such individuals are placed in chaotic and challenging situations on a daily basis, with high rates of burnout and high staff turnover [ 59 ], which also impacts on the service able to be provided and client experiences of support [ 60 ]. Reflective practice, supervision, staff meetings, and effective training, can have positive effects on staff wellbeing [ 58 ], and are also critical within a PIEs-informed approach [ 45 ].…”

“…Such service provision should continue because of the effectiveness of these interventions in reducing harms such as BBVs, and drug overdose, in this population [ 62 ]. More attention needs to be focused on alcohol harm reduction which continues to be neglected [ 60 ]. Removing policy barriers, for example to naloxone provision to people at risk of overdose, is essential post-COVID-19.…”

Investigating the need for alcohol harm reduction and managed alcohol programs for people experiencing homelessness and alcohol use disorders in Scotland

“…Access to mental and physical health‐care services can be challenging for this group of people [10]. For many people who experience homelessness and AUD, treatment options are limited, abstinence‐based programs can be hard to comply with because of unrealistic or undesirable goals [11], and many express a preference for harm reduction options [12] such as safer drinking approaches and alcohol friendly accommodation [13]. Many struggle to access appropriate treatment services [14] and, when they do, they often have no choice of approach to managing their alcohol use, resulting in repeated experiences of detoxification [6].…”

Contexts and mechanisms that promote access to healthcare for populations experiencing homelessness: a realist review

“…(10) In addition to lacking stable housing, populations experiencing homelessness often face a host of health problems and addiction behaviours associated with complex life circumstances and events including early childhood trauma, having been in care, relationship breakdowns, poverty, lack of employment and more. (2,11) While these are common experiences, it is important to stress that they happen to varying degrees and sometimes not at all. (11) The majority of research exploring access to healthcare for homeless populations has focused on individual level factors and particularly on why, whether and how individuals experiencing homelessness do or do not access healthcare (3,(12)(13)(14)(15)(16)(17)(18)(19)(20).…”

“…(2,11) While these are common experiences, it is important to stress that they happen to varying degrees and sometimes not at all. (11) The majority of research exploring access to healthcare for homeless populations has focused on individual level factors and particularly on why, whether and how individuals experiencing homelessness do or do not access healthcare (3,(12)(13)(14)(15)(16)(17)(18)(19)(20). A focus on individual level factors is illuminating but without understanding and balancing this with health system factors there is a risk that responsibility for accessing services is inappropriately placed with the individual (21,22).…”