Voices of Homeless Alcoholics Who Frequent Bellevue Hospital: A Qualitative Study - 18/01/15

Doi : 10.1016/j.annemergmed.2014.05.025

Ryan P. McCormack, MD ^a,^⁎ , Lily F. Hoffman, MA ^a,^b, Michael Norman, BA ^a,^c, Lewis R. Goldfrank, MD ^a, Elizabeth M. Norman, PhD, RN ^a,^d
^a Department of Emergency Medicine, New York University School of Medicine, New York, NY
^b New York University Gallatin School of Individualized Study, New York, NY
^c Arthur L. Carter Journalism Institute, New York University College of Arts and Sciences, New York, NY
^d Department of Humanities and Social Sciences and Interdepartmental Research Studies, New York University Steinhardt School of Culture, Education, and Human Development, New York, NY

^∗Corresponding Author.

Abstract

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.

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Plan

Introduction

Materials and Methods

Study Design and Setting

Selection of Participants

Data Collection and Processing

Outcome Measures and Primary Data Analysis

Results

Limitations

Discussion

	Please see page 179 for the Editor’s Capsule Summary of this article.
	Supervising editor: David L. Schriger, MD, MPH
	Author contributions: RPM and EMN oversaw all aspects of the study. RPM, LFH, MN, and EMN developed the interview guide. LFH primarily conducted the interviews under the guidance of MN and EMN. RPM and LFH conducted other data collection. RPM, MN, and EMN conducted data analysis. RPM, LFG, MN, and EMN wrote, edited, and reviewed the article. RPM takes responsibility for the paper as a whole.
	Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article as per ICMJE conflict of interest guidelines (see www.icmje.org/). The authors have stated that no such relationships exist.
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