Stress, Trauma, and Illness for Women Experiencing Homelessness: The need for integrated trauma-informed care

Authors

  • Chelsea Bullard Oklahoma State University Center for Health Sciences College of Osteopathic Medicine (OSU-COM)
  • Kelley Sittner Oklahoma State University

Keywords:

stress-process model, trauma-informed care, homeless women, victimization, chronic conditions, child abuse

Abstract

Stressful and traumatic events predispose women to homelessness, but being homeless also places women at risk for experiencing traumatic events. This vicious cycle is further worsened by physical ailments. We apply the stress-process model to examine the relationship between stressful life events, victimization, and chronic physical conditions with a sample of 150 women experiencing homelessness in three U.S. cities. Correlation results indicate significant associations between the prevalence of childhood abuse, stressful life events, victimization while homeless, and the number of chronic health conditions. Regression models show significant relationships between child abuse, stressful life events and the number of chronic conditions experienced by homeless women. As stress process model research hypothesizes, primary or early traumas can reduce coping resources and make individuals more susceptible to later secondary traumas and re-victimization experiences due to inability to handle stress. By acknowledging these women as victims of traumatic and stressful lives before and during episodes of homelessness and by utilizing a trauma-informed care model during treatment, we may be able to better address their currently unmet health needs.

References

Henry M, Watt R, Rosenthal L, Shivji A. Part 1 Point-in-time estimates of homelessness: The 2017 annual homeless assessment report (AHAR) to Congress. Washington, DC: US Department of Housing and Urban Development. Retrieved …; 2017.

Pearlin LI, Menaghan EG, Lieberman MA, Mullan JT. The stress process. Journal of Health and Social behavior. 1981:337-356.

Pearlin LI. The sociological study of stress. Journal of health and social behavior. 1989:241-256.

Wheaton B, Young M, Montazer S, Stuart-Lahman K. Social stress in the twenty-first century. Handbook of the sociology of mental health: Springer; 2013:299-323.

Turner RJ, Avison WR. Status variations in stress exposure: Implications for the interpretation of research on race, socioeconomic status, and gender. Journal of Health and Social Behavior. 2003;44(4):488.

Thoits PA. Self, identity, stress, and mental health. Handbook of the sociology of mental health: Springer; 2013:357-377.

Turner RJ, Lloyd DA. The stress process and the social distribution of depression. Journal of Health and Social Behavior. 1999:374-404.

Aneshensel CS. Social stress: Theory and research. Annual review of sociology. 1992;18(1):15-38.

Pearlin LI. The life course and the stress process: Some conceptual comparisons. Journals of Gerontology Series B: Psychological Sciences and Social Sciences. 2009;65(2):207-215.

Mays VM, Cochran SD. Mental health correlates of perceived discrimination among lesbian, gay, and bisexual adults in the United States. American journal of public health. 2001;91(11):1869-1876.

Lazarus RS, Folkman S. Stress, appraisal, and coping. Springer publishing company; 1984.

Pearlin LI, Schooler C. The structure of coping. Journal of health and social behavior. 1978:2-21.

Ross CE, Mirowsky J. Explaining the social patterns of depression: Control and problem solving--or support and talking? Journal of health and social behavior. 1989:206-219.

Turner RJ, Roszell P. Psychosocial resources and the stress process. Stress and mental health: Springer; 1994:179-210.

Adler N, Marmot M, McEwen B, Stewart J. Socio-economic status and health in industrialised nations: Social, psychological and biological pathways. Annals of the New York Academy of Sciences. 2001;896.

Aviv A. Telomeres and human somatic fitness. The Journals of Gerontology Series A: Biological Sciences and Medical Sciences. 2006;61(8):871-873.

Avison WR, Ali J, Walters D. Family structure, stress, and psychological distress: A demonstration of the impact of differential exposure. Journal of Health and Social Behavior. 2007;48(3):301-317.

Lloyd DA, Turner RJ. Cumulative lifetime adversities and alcohol dependence in adolescence and young adulthood. Drug and alcohol dependence. 2008;93(3):217-226.

Turner RJ. Understanding health disparities: The promise of the stress process model. Advances in the conceptualization of the stress process: Springer; 2009:3-21.

K Hopper E, L Bassuk E, Olivet J. Shelter from the storm: Trauma-informed care in homelessness services settings. The Open Health Services and Policy Journal. 2010;3(1).

Goodman LA, Saxe L, Harvey M. Homelessness as psychological trauma: Broadening perspectives. American psychologist. 1991;46(11):1219.

Sandanger I, Nygård JF, Sørensen T, Moum T. Is women’s mental health more susceptible than men’s to the influence of surrounding stress? Social psychiatry and psychiatric epidemiology. 2004;39(3):177-184.

Stein JA, Andersen R, Gelberg L. Applying the Gelberg-Andersen behavioral model for vulnerable populations to health services utilization in homeless women. Journal of health psychology. 2007;12(5):791-804.

Browne A, Bassuk SS. Intimate violence in the lives of homeless and poor housed women: Prevalence and patterns in an ethnically diverse sample. American journal of orthopsychiatry. 1997;67(2):261-278.

Goodman LA, Smyth KF, Borges AM, Singer R. When crises collide: How intimate partner violence and poverty intersect to shape women’s mental health and coping? Trauma, Violence, & Abuse. 2009;10(4):306-329.

Hamilton AB, Poza I, Washington DL. “Homelessness and trauma go hand-in-handâ€: Pathways to homelessness among women veterans. Women's Health Issues. 2011;21(4):S203-S209.

Sundin EC, Baguley T. Prevalence of childhood abuse among people who are homeless in Western

countries: a systematic review and meta-analysis. Social psychiatry and psychiatric epidemiology. 2015;50(2):183-194.

Tolman RM, Rosen D. Domestic violence in the lives of women receiving welfare: Mental health, substance dependence, and economic well-being. Violence against women. 2001;7(2):141-158.

Kessler RC, McLeod JD. Sex differences in vulnerability to undesirable life events. American sociological review. 1984:620-631.

Abouserie R. Sources and levels of stress in relation to locus of control and self esteem in university students. Educational psychology. 1994;14(3):323-330.

O'Toole TP, Gibbon JL, Hanusa BH, Fine MJ. Utilization of health care services among subgroups of urban homeless and housed poor. Journal of Health Politics, Policy and Law. 1999;24(1):91-114.

Hwang SW. Homelessness and health. Cmaj. 2001;164(2):229-233.

Kushel MB, Vittinghoff E, Haas JS. Factors associated with the health care utilization of homeless persons. Jama. 2001;285(2):200-206.

Salomon A, Bassuk SS, Brooks MG. Patterns of welfare use among poor and homeless women.

American Journal of Orthopsychiatry. 1996;66(4):510-525.

Wright JD. The health of homeless people: evidence from the National Health Care for the Homeless Program. Under the Safety Net: The Health and Social Welfare of the Homeless in the United States New York, NY: Norton. 1990:15-31.

Davis LR, Holleman WL, Weller NF, Jadhav M. Dietary intake of homeless women residing at a transitional living center. Journal of Health Care for the Poor and Underserved. 2008;19(3):952-962.

Drake MA. The nutritional status and dietary adequacy of single homeless women and their children in shelters. Public Health Reports. 1992;107(3):312.

McMurray-Avila M. Organizing health services for homeless people: A practical guide. National Health Care for the Homeless Council; 2001.

Silver G, Panares R. The health of homeless women: information for state maternal and child health programs. Johns Hopkins University, School of Public Health, Women's and Children's …; 2000.

Lim YW, Andersen R, Leake B, Cunningham W, Gelberg L. How accessible is medical care for homeless women? Medical care. 2002;40(6):510-520.

Burt MR. Homelessness: Programs and the people they serve. Vol 1: Diane Publishing; 1999.

Kushel MB, Perry S, Bangsberg D, Clark R, Moss AR. Emergency department use among the homeless and marginally housed: results from a community-based study. American journal of public health. 2002;92(5):778-784.

Kushel MB, Gupta R, Gee L, Haas JS. Housing instability and food insecurity as barriers to health care among low-income Americans. Journal of general internal medicine. 2006;21(1):71-77.

Ensign J, Panke A. Barriers and bridges to care: Voices of homeless female adolescent youth in Seattle, Washington, USA. Journal of advanced nursing. 2002;37(2):166-172.

Gelberg L, Andersen R. Physical Health and Medical Care in a Homeless Cohort. Rockville, MD: Agency for Health Care Policy and Research. 1991;1995.

Wood D, Valdez RB. Barriers to medical care for homeless families compared with housed poor families. American Journal of Diseases of Children. 1991;145(10):1109-1115.

Milburn N, D'ercole A. Homeless women: Moving toward a comprehensive model. American Psychologist. 1991;46(11):1161.

Robertson MJ, Cousineau MR. Health status and access to health services among the urban homeless. American Journal of Public Health. 1986;76(5):561-563.

Hatton DC, Kleffel D, Bennett S, Gaffrey EAN. Homeless women and children's access to health care: A paradox. Journal of Community Health Nursing. 2001;18(1):25-34.

Jezewski MA. Staying connected: The core of facilitating health care for homeless persons. Public Health Nursing. 1995;12(3):203-210.

Betty Da Silva R. Young homeless women encountered physical and individual barriers in obtaining health care. J Adv Nurs. 2002;37:166-172.

Lewis JH, . Andersen RM, Gelberg L. Health care for homeless women: Unmet needs and barriers to care. Journal of general internal medicine. 2003;18(11):921-928.

Abuse S. SAMHSA's working definition of trauma and guidance for trauma-informed approach. 2012.

Prescott L, Soares P, Konnath K, Bassuk E. A Long Journey Home A Guide for Creating Trauma–Informed Services for Mothers and Children Experiencing Homelessness. 2008.

Goering JM, Stebbins H, Siewert M. Promoting housing choice in HUD's rental assistance programs: Report to Congress. US Department of Housing and Urban Development, Office of Policy Development and Research; 1995.

Burt MR. Homelessness: Definitions and counts. Homelessness in America. 1996;15.

Sudman S, Sirken MG, Cowan CD. Sampling rare and elusive populations. Science. 1988;240(4855):991-996.

Hartley H, Rao J. Sampling with unequal probabilities and without replacement. The Annals of Mathematical Statistics. 1962:350-374.

StataCorp L. Stata multiple-imputation reference manual: release 13. Stata Manual. 2013;2013:1-367.

Bloom SL, Farragher B. Restoring sanctuary: A new operating system for trauma-informed systems of care. Oxford University Press; 2013.

Huckshorn K, LeBel JL. Trauma-informed care. Modern community mental health: An interdisciplinary approach. 2013:62-83.

Raja S, Hasnain M, Hoersch M, Gove-Yin S, Rajagopalan C. Trauma informed care in medicine. Family & community health. 2015;38(3):216-226.

Whitbeck LB, Armenta BE, Welch-Lazoritz ML. Borderline personality disorder and Axis I psychiatric and substance use disorders among women experiencing homelessness in three US cities. Social psychiatry and psychiatric epidemiology. 2015;50(8):1285-1291.

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Published

2019-11-08

Issue

Vol. 3 No. 3 (2019)

Section

Public Health

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