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Table 4 Characteristics of included studies (chronological order)

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

AuthorsCountrySubstanceSettingParticipant informationMethodsKey findings
Neale and Kennedy (2002) [67]UKDrugsHostels/drug agenciesN = 36; average age 25 years; 50% female; none in employment; many spent time in institutions; most marginally housed.Individual semi-structured interviews to explore experiences of and barriers to accessing services.
Analysis: Framework method.
Range of factors viewed as good practice in terms of services, with emphasis on staff attitudes and services offered.
Lee and Petersen (2009) [78]USAAlcohol and drugsDrop in centreN = 15; average age 43 years; 60% male; 60% Black; all homeless.Individual semi-structured interviews to explore experiences of treatment and marginalisation.
Analysis: Grounded theory
Positive outcomes in terms of demarginalisation; engagement; quality of life; social functioning; change in substance use; and articulation of future goals/plans.
Rayburn and Wright (2009) [80]USAAlcoholMen’s shelterN = 10; aged 40s–50s; all men experiencing homelessness/problem alcohol use; 80% Black; 50% completed high schoolLife history interviews to explore men’s moves from active addiction to recovery and process of becoming AA member.
Analysis: Variant of grounded theory
Participants experienced four types of barriers to sobriety/being part of AA when experiencing homelessness. These barriers were identification with AA; sponsorship; step work; and time constraints.
Rayburn and Wright (2010) [81]USAAlcoholMen’s shelterN =?; all men experiencing homelessness/problem alcohol useIndividual unstructured interviews exploring recovery and experience with AA.
Analysis: No detail
Study uncovered some ways homeless men achieve and maintain sobriety; adapting concepts of 12 step programmes to homeless men, shows need for flexible approach.
Burkey et al. (2011) [82]USAAlcohol and drugsResidential therapeutic community for menN = 10; all men; average age 43 years; all Black; all homeless.Individual semi-structured interviews to explore social ties in recovery from substance use.
Analysis: Miles and Huberman approach
Identified three types of social ties: family, recovery network and outside relationships: importance of relationships with peers, 12 step sponsors and counsellors, recovery network key; also relationships with healthcare professionals
Kidd et al. (2011) [83]CanadaAlcoholManaged Alcohol ProgramN = 1; male; aged 48 years, experiencing homelessness and had many failed attempts at abstinence.Individual semi-structured interviews at 3 time points with one man to develop case study of experiences.
Analysis: Grounded theory/narrative coding
Positive experience of MAP, strengths of staff (caring), benefits of alcohol administration, peaceful environment. Feeling at home, knowing residents.
Sznajder-Murray and Slesnick (2011) [84]USAAlcohol and drugsEmergency shelter for familiesN = 28; all women; average age 29 years; 61% Black; all had children (8 had children removed from custody, 3 currently pregnant); all residing in homeless shelter.Focus groups (×3) to explore needs and experiences of services.
Analysis: open and axial coding.
The women talked about how they had been treated differently to how they would like to be treated; highlighted particular issues for women/mothers who are homeless and using substances, particularly in terms of fear.
Collins et al. (2012a) [85]USAAlcoholProject based Housing FirstN = 17; average age 48 years; 40% white, 27% American Indian; many had experiences of treatment; all living in Housing First program.Individual interviews and observations to explore views of programme.
Analysis: Constant comparative method.
Harm reduction approach of the programme as a key factor in their attainment and maintenance of housing. Most did not see abstinence-based treatment as viable option. Harm reduction approach resulted in their successful reduction in drinking or abstinence in a way that abstinence-based treatments had not.
Collins et al. (2012b) [77]USAAlcoholProject based Housing FirstN = 17; average age 48 years; 40% white, 27% American Indian; many had experiences of treatment; all living in Housing First program.Individual interviews and observations to explore views of programme.
Analysis: Constant comparative method.
Study highlighted strengths and weaknesses of programme, including transitions into the programme, managing day-to-day life and community building.
Thickett and Bayley (2013) [88]UKAlcoholAlcohol service providerN = 12; all Polish street drinkers; 58% male; aged 33–62 years; all homeless/at risk of homelessness.Individual semi-structured interviews to explore experiences with services.
Analysis: Braun and Clarke’s thematic analysis.
Participants talked about positive and negative experience of treatment including social networks; social services; health services; homelessness services; specialist alcohol service provider; and barriers to service use.
Salem et al. (2013) [86]USAAlcohol and drugsResidential treatment facilityN = 14; all women; recently released from prison; average age 42 years; 79% Black; 79% had children; all homeless, living in residential treatment facility.Focus groups (×2) exploring experiences of challenges experienced in accessing treatment.
Analysis: Grounded theory.
Women talked about difficulties in accessing healthcare and other services; lack of support staff onsite; lack of education and criminal record made it difficult to get a job. Strategies to remain sober included feeling empowered, having a job, going to NA/AA meetings, having housing, job skills/education, aftercare program and support.
Baird et al. (2014) [87]USAAlcohol and drugsOutpatient programme for womenN = 10; all women; all homeless, living in shelter.Individual structured interviews to explore ways to maintain abstinence
Analysis: No detail.
Four main concerns identified by respondents: lack of communication between service providers; inconsistency in personnel during recovery; inconsistency in relapse policies; clients feeling ill prepared to live in the ‘real world’ after completion.
Neale and Stevenson (2014a) [69]UKAlcohol and drugsHostelsN = 30; average age 43 years; 83% male; 60% white; poly drug use common; most receiving some treatment; all homeless, living in hostels.Individual semi-structured interviews at 2 time points to explore experiences with computer assisted therapy intervention.
Analysis: Framework method.
Computer assisted therapy intervention for drug users in hostels viewed as beneficial in helping with substance use as well as wellbeing and improving skills/confidence. Negative issues were around structural barriers such as location of computers, quality and quantity of equipment.
Neale and Stevenson (2014b) [68]UKAlcohol and drugsHostelsN = 30; average age 43 years; 83% male; 60% white; poly drug use common; most receiving some treatment; all homeless, living in hostels.Individual semi-structured interviews at 2 time points to explore experiences with computer assisted therapy intervention
Analysis: Framework method.
Viewed programme positively, but mentor support was crucial. Need for good relationships with staff to help engage in programme. Also encouraged to have more open/honest conversations. Need for flexible approach. Use within context of therapeutic relationship crucial.
Evans et al. (2015) [70]CanadaAlcoholManaged Alcohol ProgramN = 10; all men; average age 51 years; all had many failed attempts at abstinence; all homeless, living in Managed Alcohol Program; within 1.5 years of study ending, 3 had died.Individual interviews and follow up focus group (×1) to explore experiences of program.
Analysis: No detail
Participants talked about importance of social belonging within programme, mutual support and relationships with support workers as important. Programme allowed increased awareness of alcohol and health and opportunity for self-management.
Clifasefi et al. (2016) [71]USAAlcoholHousing First programN = 44; 82% male; average age 53 years; 43% white; all had severe alcohol problems; all living in single site Housing First program.Individual semi-structured interviews and observations to explore experiences of program
Analysis: Constant comparative method
Participants reported issues with consistency in activities and services; expressed a desire for groups where they could learn about harm reduction; did not want focus to be on abstinence. Participants discussed an aversion to abstinence-based treatments with multiple failed attempts. Many indicated that abstinence was only achieved after entering service with harm reduction focus.
Collins et al. (2016) [33]USAAlcoholHousing agenciesN = 50; 84% male; average age 53 years; 46% white; all currently/formerly homeless.Individual semi-structured interviews to explore experiences of treatment and services.
Analysis: Content analysis.
Participants talked about experience of formalised, abstinence based approaches in terms of positives and negatives. Also experience of alternative, self-defined pathways that included basic needs; harm reduction counselling; meaningful activities; social networks; natural recovery.
McNeil et al. (2016) [74]CanadaDrugsHospitalsN = 30; 53% male; average age 45 years; 57% Indigenous; most had multiple hospitalisations due to drug use; all ‘structurally vulnerable’/at risk of homelessness.Individual semi-structured interviews to explore perspectives of hospital based harm reduction.
Analysis: Inductive and deductive approach.
Harm reduction approach in hospital settings would allow patients to complete their treatment for health problems and not have to be discharged early because of continued drug use; also mean safer use/risk reduction; harm reduction viewed as reducing stigma, being non-judgemental and having staff who understand/care.
Pauly et al. (2016) [73]CanadaAlcoholManaged Alcohol ProgramN = 7; 57% male; average age 42 years; all Indigenous; had all been in MAP for at least 1 year; experience of chronic homelessness, alcohol use and police contact.Individual semi-structured interviews to explore experiences of programme.
Analysis: Constant comparative approach.
MAP viewed as a place of safety, characterised by caring, respect, trust and non-judgemental attitude, with sense of home and opportunities to reconnect with family.
Perreault et al. (2016) [72]CanadaDrugsPeer-run day centre and housing unitsN = 13; 60% male; aged 30–60 years; half had Hepatitis C/mental health problem; all homeless, living in housing units.Individual semi-structured interviews and focus group (×1) to explore experiences of programme.
Analysis: Thematic analysis
Participants identified several issues in terms of satisfaction and dissatisfaction; length of time (3 years) too short and need for support in returning to education/work. Differences in opinion re. use of peers vs. professional staff.
Chatterjee et al. (2018) [75]USADrugsFamily sheltersN = 14; 79% female; average age 35 years; all part of families experiencing homelessness; 64% white; all had diagnosis of opioid use disorder; 86% in treatment.Individual interviews to explore experience of opioid use disorder and treatment when experiencing homelessness as a family.
Analysis: Immersion- crystallisation method
Study highlighted experiences of treatment, barriers and ideal treatment for those experiencing opioid use and homelessness as part of a family.
Crabtree et al. (2018) [76]CanadaAlcoholCommunitiesN = 85; no formal details collected but majority men; mostly white or Indigenous; aged 20–50 years; all homeless/at risk of homelessness.Weekly town hall meetings (×14), steering committee meetings (×7) and follow up focus groups (×4) to explore harm and harm reduction strategies among people who drink non-beverage alcohol.
Analysis: Interpretative description.
Participants identified harms and harm reduction strategies they employ, including sharing alcohol, pooling money to buy alcohol, diluting alcohol, drinking alone or with others and looking after one another. Proposed four harm reduction strategies - safe spaces, MAPs, peer based programs and educational programs.
Pauly et al. (2018) [79]CanadaAlcohol and drugsTransitional housing programmesN = 16; aged 32–52 years; 56% male; 81% white.Semi-structured individual interviews conducted to explore implementation of harm reduction in a transitional programme setting.
Analysis: Thematic analysis.
Study highlights challenges of settings with harm reduction and zero tolerance approaches to substance use. Harm reduction supplies were available but all substance use was prohibited on site. Despite zero tolerance approach, staff would turn blind eye to use onsite.