Voices of homeless alcoholics who frequent Bellevue Hospital: a qualitative study.

STUDY OBJECTIVE: We describe the evolution, environment, and psychosocial context of alcoholism from the perspective of chronically homeless, alcohol-dependent, frequent emergency department (ED) attendees. We use their words to explore how homelessness, health care, and other influences have contributed to the cause, progression, and management of their alcoholism. METHODS: We conducted detailed, semistructured, qualitative interviews, using a phenomenological approach with 20 chronically homeless, alcohol-dependent participants who had greater than 4 annual ED visits for 2 consecutive years at Bellevue Hospital in New York City. We used an administrative database and purposive sampling to obtain typical and atypical cases with diverse backgrounds. Interviews were audio recorded and transcribed verbatim. We triangulated interviews, field notes, and medical records. We used ATLAS.ti to code and determine themes, which we reviewed for agreement. We bracketed for researcher bias and maintained an audit trail. RESULTS: Interviews lasted an average of 50 minutes and yielded 800 pages of transcript. Fifty codes emerged, which were clustered into 4 broad themes: alcoholism, homelessness, health care, and the future. The participants' perspectives support a multifactorial process for the evolution of their alcoholism and its bidirectional reinforcing relationship with homelessness. Their self-efficacy and motivation for treatment is eroded by their progressive sense of hopelessness, which provides context for behaviors that reinforce stigma. CONCLUSION: Our study exposes concepts for further exploration in regard to the difficulty in engaging individuals who are incapable of envisioning a future. We hypothesize that a multidisciplinary harm reduction approach that integrates health and social services is achievable and would address their needs more effectively.

Resource-limited, collaborative pilot intervention for chronically homeless, alcohol-dependent frequent emergency department users.

We introduced case management and homeless outreach to chronically homeless, alcohol-dependent, frequent emergency department (ED) visitors using existing resources. We assessed the difference in differences of ED visits 6 months pre- and postintervention using a prospective, nonequivalent control group trial. Secondary outcomes included changes in hospitalizations and housing. The differences in differences between intervention and prospective patients and retrospective controls were -12.1 (95% CI = -22.1, -2.0) and -12.8 (95% CI = -26.1, 0.6) for ED visits and -8.5 (95% CI = -22.8, 5.8) and -19.0 (95% CI = -34.3, -3.6) for inpatient days, respectively. Eighteen participants accepted shelter; no controls were housed. Through intervention, ED use decreased and housing was achieved.

Inclusion of Adolescents in Clinical Trials for Sexually Transmitted Infections: A Review of Existing Registered Studies.

PURPOSE: Despite their heightened risk of sexually transmitted infections, minor adolescents (<18 years old) are often excluded from clinical trials. The results of trials of adults should not be assumed to generalize to minors. METHODS: Two public clinical trial registries were first searched using microbicide or PrEP with STD, STI, HIV, or HSV and with gel, ring, or film, and then searched using prevention/sexually transmitted diseases with gel. Studies were classified based on the information provided in the registry. RESULTS: The searches yielded 111 unique studies. Only 9.0% (n = 10) included minors. They were under-represented in Phase 0-II studies and over-represented in studies of individuals infected with human immunodeficiency virus. CONCLUSIONS: Minor adolescents should be included during all stages of development and before they have acquired an infection. Future studies should examine the challenges of including minor adolescents in trials and how to overcome these barriers.

Adolescents and Their Parents Differ on Descriptions of a Reproductive Health Study.

STUDY OBJECTIVE: To understand how adolescents and parents describe a sexually transmitted infection prevention study to a friend. DESIGN: Adolescents and parents participating in a study about willingness to participate in a hypothetical microbicide clinical trial were interviewed separately and asked to describe the clinical trial to a friend. Qualitative responses were written down verbatim and coded using a thematic framework analysis. SETTING: Adolescent medicine clinics in New York City. PARTICIPANTS: The participants consisted of adolescents, 14-17 years old, and a parent (n = 301 dyads) who spoke English or Spanish. Most adolescents (72%) identified as Hispanic and 65% reported minimal sexual experience (ie, nothing more than kissing). INTERVENTIONS: None. MAIN OUTCOME MEASURES: Qualitative responses were content coded for: (1) overall approach; (2) opinion rendered; and (3) details mentioned using thematic framework. The relationship of demographic characteristics, sexual history, and recruitment method to how adolescents and/or parents described the study was evaluated. RESULTS: Adolescents (n = 293) differed from parents (n = 298) in their overall approach to describing the study (P < .01) with more adolescents than parents providing a "purpose with detail" (54% adolescents vs 31% parents) and less providing a "commentary" description (6% adolescents vs 28% parents). Fewer adolescents (25% of n = 301) provided an opinion compared with parents (75% of n = 301; P < .01). A greater proportion of adolescents (70% adolescents, n = 206; vs 48% parents, n = 144) provided a detail (P < .01). Adolescents provided a greater number of details than parents (P < .01). CONCLUSION: Adolescents in this sample were more focused on the details of the study. Parents were focused on their impression of the study. Adolescents and parents might need to be approached differently about reproductive health studies.