Regardless, our analyses demonstrate some measure of construct validity in that higher scores on both measures were linked to reporting mental health conditions in our study. Our measure of sexual orientation “outness” was only asked for gay-identified participants, and a general measure should be included in future studies. A nurse-administered structured interview was used to assess mental health diagnoses and current treatments to ensure these questions were more accurately understood and answered. Given the potential impact of social desirability and reporting bias , we used CASI to collect data regarding illicit substance use. However, we did not use drug testing to confirm or correct self-report data and likely underestimated the true prevalence of substances used . Despite these shortcomings, one of the strengths of our study is the use of RDS to overcome previous sampling shortfalls with GBM and produce a more accurate representation of the population parameters of these variables of interest for the GBM population of Metro Vancouver. Our study also adds new data regarding the detailed prevalence of substance use and mental health conditions among GBM populations in Canada filling a gap in currently available published literature. Finally, our work goes further to examine explicitly the relationship between substance use and mental health conditions among GBM identifying important relationships that have implications for counseling and public health services, interventions, and policy. The greater burden of mental health conditions and higher prevalence of substance use in GBM populations highlight the need for a more explicit focus on these issues in research and service provision.
Mental health specialists should be aware of the relationships with sexuality and substance use when working with GBM clients,rolling bench particularly issues regarding identity disclosure, number of sexual partners, and higher background community prevalence of substance use . Future research should seek to validate current measures and to confirm the relationship between substance use and mental health conditions, which has been demonstrated to produce a syndemic including suicidal ideation among GBM and HIV acquisition . Our study was based in a major metropolitan area, which may limit generalizability to GBM in rural or remote regions, whom are a population with distinct needs and challenges that should be further examined. In order to evaluate generalizability, additional research is needed to explore these issues among GBM populations in other urban and non-urban centers across Canada, particularly if these studies employ RDS or other more representative sampling methods. Given the role of social factors in mental well-being, future research should directly examine experiences of homophobia or heterosexism as possible precursors to substance use and/or mental health issues, along with potential mediators and protective factors. Examining demographic factors independent of one another may not reflect the diversity of experiences that exists among GBM. Using an intersectional approach, which looks at how multiple identities such as race, sexual orientation, and class, interact with one another to shape experiences , may also explain the distribution and experiences of mental health and substance use within diverse communities of GBM. In spite of experiences of marginalization and discrimination, many GBM do not go on to develop mental health conditions or engage in harmful substance use. Shilo, Antebi, and Mor found that factors such as support of family and friends, meaningful connections with the LGBT community, and having a steady partner, protect against developing poorer mental health in lesbian, gay, bisexual, queer, and questioning adults.
Thus, more focus on factors such as these that promote resiliency in GBM would be beneficial to include in future research on mental health and substance use in these populations. Compared with the Canadian population, GBM living in Metro Vancouver have increased levels of substance use and mental health conditions. The strong link between substance use and mental health among GBM has important implications for public health promotion programming and care service provision. A number of social determinants increase the likelihood of mental health diagnosis among GBM, including disclosure of sexuality, low income, and race/ethnicity. GBM living with HIV were significantly more likely to have a lifetime doctor-substance use disorder compared with HIVnegative GBM. Greater attention to these issues is needed across all health and social services given their disproportionate effect on GBM populations. Health promotion and interventions should address issues of substance use, mental health, and sexuality in unison and future research can help direct these efforts by examining possible precursors of these issues, which may be the result of discrimination, prejudice, and stigma.Tobacco use in the general population has declined substantially in the past three decades, but rates remain high in certain populations. The prevalence of tobacco use in the homeless population is 3 to 4 times that of the general population.Among homeless adults, tobacco-related chronic diseases including heart disease, cancer and chronic obstructive pulmonary disease are common and contribute significantly to the increased morbidity and mortality in this population.Among a clinic-based sample of homeless adults aged 50 and older, tobacco-attributable deaths accounted for 26% of the overall mortality and 54% of substance-related mortality.The health consequences of smoking occur disproportionately among older individuals because of the cumulative effects of long term smoking.Among older adults, tobacco-related chronic diseases, particularly chronic obstructive pulmonary disease and coronary heart disease, are among the most common reasons for emergency health care services and preventable hospitalizations.
Current tobacco use contributes significantly to all-cause mortality among older adults, suggesting that tobacco cessation at any age is likely to significantly reduce tobacco-related morbidity and mortality.In a nationally representative sample, older adults were less likely to quit smoking than younger adults because of reduced interest in quitting smoking, higher nicotine dependence, and lower support for smoke-free norms.This highlights the need for tobacco cessation interventions that address tobacco-related beliefs and practices among older adults. Over the past 2 decades, the median age of homeless adults increased from 37 years in 1990 to almost 50 years in 2010.Despite increased tobacco-related morbidity and mortality among older homeless adults, little is known about tobacco use and cessation behaviors in this population. Prior research on tobacco use in the homeless population has focused on younger adults, where the average age of study participants in previous studies was less than 44 years.The high prevalence of tobacco use and the increased burden of tobacco-related chronic diseases with aging underscore a need for studies that characterize tobacco use and cessation behaviors among older homeless adults in order to develop tobacco control interventions that address the unique needs of this population. We conducted a study of a cohort of homeless individuals aged 50 and older sampled from the community to examine rates of and factors associated with tobacco cessation. We hypothesized a priori that current smoking would be associated with symptoms of depression, substance use disorders, history of incarceration, and history of staying in shelters.We also hypothesized that persons who reported smoking heavily or having symptoms of depression at enrollment would be less likely to make a quit attempt at follow-up.The HOPE HOME Study is a longitudinal study of life course events, geriatric conditions, and their associations with health-related outcomes among older homeless adults. From July 2013 to June 2014, we enrolled a population-based sample of 350 homeless adults aged 50 years and older from homeless encampments, recycling centers,grow table overnight homeless shelters, and free and low-cost meal centers serving at least three meals a week in Oakland, California. Participants were eligible if they were English-speaking, aged 50 years and older, defined as homeless as outlined in the Homeless Emergency Assistance and Rapid Transition to Housing Act, and able to provide informed consent, as determined by a teach-back method.The University of California, San Francisco Institutional Review Board reviewed and approved all study protocols.The study included an enrollment visit and a follow-up visit at 6 months. Study interviews took place at a community-based site. After determining eligibility, study staff administered an in-depth structured enrollment interview and collected extensive contact information from participants. We asked participants to check in with study staff in person or by telephone each month. If participants missed two or more check-in visits, study staff reached out to participants using their contact information. From January 2014 to January 2015, we conducted 6-month follow-up visits with each of the participants who completed an enrollment interview. We gave participants gift cards to a major retailer for their participation: $5 for the screening interview, $20 for the enrollment interview, $5 for each month check-in, and $15 for the follow-up interview.We used previously validated questions on tobacco use at the enrollment and 6-month follow-up interviews. We asked participants whether they had ever smoked 100 cigarettes in their lifetime, and classified those who did as ever-smokers. We classified ever-smokers who reported smoking “every day or some days” as current smokers, and those who reported “not smoking at all” as former smokers. We asked current daily smokers to report the number of cigarettes smoked daily. For current non-daily smokers, we estimated average daily cigarette consumption based on self-reported numbers of cigarettes smoked on smoking days in the past 30 days. Participants reported how soon they had smoked their first cigarette after waking, which we dichotomized as greater or less than 30 minutes.
We asked current smokers about their intentions to quit smoking . We asked current smokers to report whether they had stopped smoking for 1 day or longer in the past 6 months because they were trying to quit smoking. We asked participants who responded affirmatively to making a quit attempt to report the length of their last quit attempt. We defined reporting a quit attempt in the past 6-months at the follow-up visit as the primary outcome variable. We determined the proportion of participants who were abstinent for 30 days and 90 days at the 6-month study visit using self-reported information on the length of the last quit attempt. At the 6-month follow-up visit, we obtained additional information from participants on their quitting behaviors.If participants reported having made a quit attempt during the past 6 months, we asked them to report the medications, strategies, and support system they had used during their last quit attempt. Participants reported whether they had used nicotine replacement therapy and/ or any of the US Food and Drug Administration -approved medications for smoking cessation during their last quit attempt. Participants reported whether they had used other strategies to quit smoking including gradually cutting back on cigarettes, switching to smokeless tobacco, other combustible tobacco , or electronic cigarettes, or giving up cigarettes all at once. Participants self-reported their use of a telephone quit line, group or one-on-one smoking cessation counseling, hypnosis or acupuncture, and other internet or family-based support for smoking cessation. Participants also reported whether they had received advice to quit cigarette smoking from their health care provider in the past 6 months, and whether they had acted on the advice to quit smoking.Participants self-reported age, gender and race/ethnicity at the enrollment visit. At the enrollment and follow-up interviews, participants reported whether they had spent any time in jail or prison in the past 6 months. At both visits, we gathered residential history of every place that the individual had stayed, by using a 6-month follow-back residential calendar.We categorized participants as having stayed in shelters if they reported staying in a homeless shelter for single adults or families during the past 6 months.We used questions derived from the World Health Organization’s Alcohol, Smoking, and Substance Involvement Screening Test to assess use of cannabis, cocaine, amphetamines, and opioids. We administered the WHO’s Alcohol Use Disorders Identification Test with a shortened time frame of the previous 6 months to assess risk and severity of alcohol use disorders. We categorized AUDIT scores of 8 or more as indicative of hazardous and harmful alcohol use or an alcohol disorder.To assess the prevalence of depressive symptomatology or significant distress, we administered the Center for Epidemiologic Studies Depression Scale .We used a standard threshold score of 16 or more to categorize depressive symptomatology or significant distress.In this cohort of older homeless adults, the prevalence of current smoking was at least 3 times higher than similarly aged members of the general population. The quit attempt and 30-day and 90-day abstinence rates were similar to that observed among older adults from a nationally representative sample of the general population.However the quit ratio , an indicator of successful quitting, was at least three times lower than the national average.Findings from our study confirm previous research that homeless adults are interested in quitting smoking,but are less successful compared to those who are not homeless.