# Presentation: 473535

## COMMUNICATING WITH PEOPLE COPING WITH DIMINISHED STATUS ABOUT PRESCRIPTION DRUGS AND HEALTH CARE:  AN EXAMPLE FROM HOMELESSNESSDAVID P. MOXLEY, UNIVERSITY OF OKLAHOMA 

## Background

- Leaving Homelessness Intervention Research Project
- Based in Detroit, Michigan
- Has been in existence for eight years
- Focuses on helping older African American women
- Incorporates multiple levels of helping
- Has multiple research and development aims
- Addresses its aims through participatory action research

## Research and Development Aims

- Document and understand the experience of homelessness among older African American women
- Develop and test those interventions
- Useful in helping participants decrease the debilitating effects of homelessness
- Useful in helping participants get out of homelessness
- Useful in helping participants stay out of homelessness
- Useful in helping participants improve their quality of life through intentional community development

## The Research and Development Process Incorporates Subprojects

- The subprojects are focused activities in which we work closely with participants to design and test interventions:
- Telling my story
- Multi-method assessment
- Group work for mobilizing protective factors
-  Advocacy for leaving homelessness
- Intentional community development
- Increasing public awareness through social action

## Health within the Project

- Means that participants possess adaptive resources to function effectively in the face of the exigencies and challenges they face daily
- Homelessness is a state of ill health
- It drains the adaptive resources of people
- It literally wears down adaptation, flexibility, and functioning
- Homelessness is a major threat to health and well being

## Diminished Status

- Diminished status is a critical coordinating concept within the project
- People who are homeless are located in situations in which their inherent value as human beings is degraded
- Such degradation sets in motion serious consequences that threaten health
- One set of consequences is the adaptation the person makes to homelessness in order to cope with her situation

## Diminished Status

- Weakens host resistance
- Increases risk
- Situates people in degraded environments
- Fosters susceptibility to trigger factors

## The Project Has Enabled Us to Identify Eight Pathways into Homelessness

- Narratives are loaded with information about the descent into homelessness
- Accidents, such as house fires, are frequent themes
- Health concerns that limit functioning are frequent themes
- Marital disruption is frequent theme

| Accidents |
| --- |
| Health Issues |
| Marital Disruption |
| Job Loss |
| Substance Use |
| Criminal Activity |
| Domestic Violence |
| Mental Illness |

## Photovoice

- We incorporate the use of photography among the participants so they can document the environmental and situational factors they experience

## Slide 10

## Slide 11

- Through Photovoice Participants Identify the Places they Trust

## Slide 13

## Slide 14

## Slide 15

- And through photovoice they can identify the places they do not trust

## Slide 17

## People coping with diminished status deal with multiple and serious issues that degrade health

- Serious
- Complex
- Conjunction between issues
- Scope
- Intractability
- Temporal nature (long lasting)
- Mediated bureaucratically
- Produce considerable distress
- Produce numerous hassles
- Efforts to resolve issues are often unproductive
- Limited control over the issues
- Exist within context of isolation or limited social support
- Result in demoralization

## CONSEQUENCES OF THE ISSUES

- Personal health consequences
- Depression
- Dampening control and mastery
- Victimization and trauma
- Helplessness
- Pronounced deprivation

## What Helpers Should Prepare For

- Serious deprivation
- Deprivation of basic living needs
- Demoralization
- Complex health issues influenced by social issues
- Dependency on the helper
- Considerable emotion
- Unresolved life experiences—such as trauma and violence

## What Helpers will Come to See

- Considerable resilience
- Hope in the future
- Aspirations for self and the other women
- Concern and compassion for other homeless
- Desire to take action
- Faith and spirituality
- Willingness to learn
- Desire to engage the worlds of education and work
- Numerous culinary, folk art, and practical skills
- Desire for opportunities

## Two types of narratives

- The narrative of plight
- The narrative of efficacy

## Typology of Intervention

- So far three types of intervention have proven useful

## Group Work

## The Project Incorporates Several Different Approaches to Group Work

- Cognitive approaches in which the women learn about how they think and how homelessness influences their thinking
- Experiential approaches in which the women take  action to resolve homelessness
- Mutual support options in which the women support one another

## Controlled Group Work Has Taught Us a Great Deal

- Each approach – cognitive, experiential, and support – contributes something different to the “leaving homelessness process.”
- By fostering general expectancies of success, personal problem solving, and confidence; the experiential approach appears more effective
- However, effect sizes are moderate.

## Advocacy

## Reactive Advocacy 

- It is reactive since it comes into play late in the homelessness experience.
- Assistance comes into play when the issue reaches a crisis point.
- But it is not difficult to anticipate issues
- The real challenge is to create proactive approaches that help people address their needs and receive the support they find useful.

## Proactive Advocacy

- Requires
- Early alert system
- Easily triggered by person.
- Considerable information and exchange of information about well-being of individuals
- Offers abundant and relevant education about rights.
- Helps people understand their health and protect their health
- And about how to navigate difficult situations
- In empowered ways

## Intentional Community Development

## Some Qualities of a Proactive Community

- Access to technical experts
- Small and personalized helping resources that truly represent the person
- Short links between the person and sources of help
- Prevention of the escalation of issues
- Quick resolution of serious issues that can disrupt living situation
- Sense of community and belonging
- Avenues for personal fulfillment

## But what does this have to do with communicating? 

- Practical issues with medication management
- Potential for limited access to food
- Loss of medication while on streets or moving around
- Degradation of containers
- Theft
- At points of transition the person may lose control of medication or even access to medication
- When entering jail
- When entering a shelter
- Inadequate storage or heroic efforts to store medication
- Control of caregivers, particularly nonfamily ones who are not likely health personnel

- All of these possibilities are consistent with the person’s loss of control over personhood and environment

## The adaptation the person makes can influence communication 

- Person communicating medication expectations or requirements may not possess credibility
- Helplessness can dampen receptivity to communication
- Focusing attention can be a challenge because of stress or nutritional inadequacy
- Loss of energy and vitality can reduce cognitive vigilance and therefore limit receptivity to information provision
- Person may not be direct recipient of communication because they are dependent on others for information
- Case management personnel
- Guardian
- Shelter personnel

## Important health practices

- Assist the person to secure medication on their person or in a trusted place
- Help the person fulfill nutritional needs in conjunction with medication
- Do inventory of medication and address the person’s understanding of each medication and its role in their self care
- Strengthening self-efficacy may improve receptivity to communication about self care
- Discuss medication management under supportive group conditions
- Understand the context in which the person uses and stores the medication