https://orcid.org/0000-0001-9486-1191
Figures
Abstract
Background
Substance use contributes to poor health and increases the risk of mortality in the homeless population. This study assessed the prevalence and risk levels of substance use and associated factors among adults experiencing homelessness in Accra, Ghana.
Methods
305 adults currently experiencing sheltered and unsheltered homelessness in Accra aged ≥ 18 years were recruited. The World Health Organization’s (WHO) Alcohol, Smoking, and Substance Involvement Screening Test (ASSIST) was used to assess substance use risk levels. Association of high-risk substance use with sociodemographic, migration, homelessness, and health characteristics were assessed using logistic regression.
Results
Nearly three-quarters (71%, n = 216) of the sample had ever used a substance, almost all of whom engaged in ASSIST-defined moderate-risk (55%) or high-risk (40%) use. Survivors of physical or emotional violence (AOR = 3.54; 95% confidence interval [CI] 1.89–6.65, p<.001) and sexual violence (AOR = 3.94; 95%CI 1.85–8.39, p<.001) had significantly higher odds of engaging in high-risk substance use, particularly alcohol, cocaine, and cannabis. The likelihood of engaging in high-risk substance use was higher for men than women (AOR = 4.09; 95%CI 2.06–8.12, p<.001) but lower for those in the middle-income group compared to low-income (AOR = 3.94; 95%CI 1.85–8.39, p<.001).
Conclusions
Risky substance use was common among adults experiencing homelessness in Accra, and strongly associated with violent victimisation, gender, and income levels. The findings highlight the urgent need for effective and targeted preventive and health-risk reduction strategies to address risky substance use in the homeless population in Accra and similar cities within Ghana and sub-Sahara Africa with a high burden of homelessness.
Citation: Osei Asibey B, Marjadi B, Conroy E (2023) Alcohol, tobacco and drug use among adults experiencing homelessness in Accra, Ghana: A cross-sectional study of risk levels and associated factors. PLoS ONE 18(3): e0281107. https://doi.org/10.1371/journal.pone.0281107
Editor: Joel Msafiri Francis, University of the Witwatersrand, SOUTH AFRICA
Received: November 11, 2021; Accepted: January 16, 2023; Published: March 6, 2023
Copyright: © 2023 Osei Asibey et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Data Availability: All relevant data are within the paper and its Supporting information files.
Funding: The author(s) received no specific funding for this work.
Competing interests: The authors have declared that no competing interests exist.
Abbreviations: ASSIST, Alcohol, Smoking, and Substance Involvement Screening Test; AUDIT, Alcohol Use Disorder Identification Test; CIDI, Composite International Diagnostic Interview; DAST, Drug Abuse Screening Test; ETHOS, European Typology of Homelessness and Housing Exclusion; GLSS, Ghana Living Standard Survey; GSS, Ghana Statistical Service; ISSER, Institute of Statistical, Social and Economic Research; SSI, Specific Substance Involvement; UNODC, United Nations Office on Drugs and Crime; US, United States; WHO, World Health Organisation
Introduction
Homelessness affects a growing number of people worldwide, and the homeless population is susceptible to various health problems [1–3]. A critical issue regarding the health of people with experience of homelessness is substance use [4–7]. Among people experiencing homelessness, problematic substance use contributes to a high proportion of poor health and increased risk of mortality through overdoses, infectious diseases, and psychiatric conditions [8, 9]. For example, tobacco use contributes to respiratory conditions, cancers, and heart disease [10, 11], and risky use of alcohol is associated with digestive problems, ulcers, high blood pressure, anxiety and depression, and liver diseases [12, 13].
In Ghana, both homelessness [14, 15] and substance use [16–18] constitute significant public health problems. Urban homelessness has been increasing in Ghana for decades [14, 15]. There is no census data on homelessness, but estimates have varied between 100,000 to 120,000 [19, 20]. Homelessness prevalence is likely to be substantially underestimated in Ghana due to a narrow definition that only includes rooflessness or rough sleeping [21–23]. An unknown proportion of the estimated 39% of Ghana’s urban population (5.5 million people) living in slums [24] may be counted as homeless under a broader definition. Various studies in Ghana have revealed a high prevalence of alcohol and drug use in the general population. Ghana is among the leading consumers of illicit drugs: first in Africa and third in the world for marijuana, and first in Africa and 14th in the world for cocaine [25]. Alcohol, tobacco, methamphetamine, opioids, and other illicit drug categories are also highly consumed in Ghana [17, 26].
Despite the high prevalence of homelessness and substance use in Ghana, research on problematic substance use in the homeless population is scant. In fact, the only relevant study found was limited to street children aged up to 16 years [16]. Insufficient knowledge of substance use among the adult homeless population in Ghana is concerning since a large proportion of the homeless population in Ghanaian cities are adult urban migrants (both internal and external to Ghana) [23]. In addition, substance use in the Ghanaian general population is highly prevalent among adults aged 18 years or older in urban areas [17, 26]. Therefore, this study describes the spectrum of lifetime and recent substance use among adults with experience of homelessness in Ghana’s capital city, Accra. The study also reports the risk levels and examines factors associated with high-risk substance use. These analyses are important in helping policymakers and service providers tailor policies, treatment, and services to improve the health and well-being of people experiencing homelessness.
Methods
Study design and setting
The study was part of a larger cross-sectional community and facility-based research to explore homelessness as a public health phenomenon in Accra, Ghana and investigate the health and health service utilisation of people experiencing homelessness. This paper was based on the second of five empirical studies that included pathways to homelessness, substance use, health impacts of homelessness, social stigma and health care utilisation, and homelessness survival. Accra is Ghana’s capital, the most populous city, and the most popular destination for both internal and international migrants [23, 27]. The city has the largest housing deficit in Ghana and a high prevalence of homelessness [23]. The study was conducted in areas highly populated with people who sleep rough, squatters, and in crisis/emergency shelters and residential drug and alcohol rehabilitation facilities.
Study population
The study adopted the inclusive European Typology of Homelessness and Housing Exclusion (ETHOS) definition [28], where a person was considered as experiencing homelessness if they met at least one of the following conditions:
- Unsheltered homelessness:
- Sleep rough on the streets, marketplaces, abandoned vehicles and buildings, under bridges, verandas, and unauthorised places not designed for shelter.
- Reside in temporal/ non-conventional structures such as makeshift dwellings (slums, shacks, and squats) in extreme overcrowding and mostly under threat of eviction.
- Sheltered homelessness:
- Temporarily reside in a homeless shelter/crisis/emergency accommodation.
- Women living in a shelter because of the experience of domestic violence and where the period of stay is intended to be short-term.
- Has been admitted to a residential drug rehabilitation with an immediately preceding homelessness and no accommodation when discharged.
Due to the overwhelming predominance of the extended family system in the Ghanaian culture [29–31] where close and remote relatives commonly reside in compound housing style [32], living in conventional housing temporarily with relatives was not categorised as homelessness in this research. The 2000 and 2010 population and housing census reports showed that compound houses generally referred to as ‘family houses’ constituted 55% of the housing stock in urban Ghana [23].
A sample size of 200 was initially planned but 325 eligible individuals consented, out of which 305 (94%) completed the survey. Twenty individuals did not complete due to conflicting work and counselling appointments. Since there was no official data on homelessness in Ghana, the uncontrolled quota sampling technique [33, 34] was used to obtain a representation of sheltered and unsheltered homeless populations. This technique was adopted because it allows the researchers the freedom to choose sample group members according to their will and/or knowledge without any restrictions. Based on the lead researcher [BOA]’s knowledge and experience in working with the homeless population in Accra, and prior reports of the unsheltered homeless being the prevalent group in Ghana [14, 20], a greater number of eligible unsheltered homeless was sought as compared to the sheltered. The initial plan was to sample 70% unsheltered and 30% sheltered homeless persons, and the final sample consisted of 68% unsheltered and 32% sheltered persons. The total sample was deemed sufficient given the study purpose was to explore associations between the key predictors and the outcome without any hypothesis testing. Individuals were eligible if they were at least 18 years old and had at least six months’ experience of homelessness in Accra.
Procedure
Approvals were obtained from the Western Sydney University Human Research Ethics Committee, the Ghanaian Department of Social Development, and four community organisations that serve people experiencing homelessness in Accra. Respondents were recruited by trained research assistants experienced in public health research with vulnerable populations and fluent in local languages. For potential respondents in the streets and slums, their community leaders were contacted in advance to facilitate data collection. Respondents were recruited day and night during pre-existing outreach, health screening, and free meal programmes. The research team was introduced to the potential respondents, research information and consent were discussed, and consenting individuals were invited to pre-arranged community centres or playing grounds for participation. At the shelters, staff members introduced the research team to clients for information dissemination, consent, and participation.
To prevent exploitation, individuals with serious cognitive impairment, intellectual disability, and mental illness were excluded if the conditions limited capacity to consent. For such individuals, the capacity to provide consent was determined by social workers and shelter staff based on the seriousness of the health condition and prior experience of serious distress. Intoxicated individuals were only engaged when they had the ability to give informed consent. Three people judged as incapable to provide consent were excluded. To prevent coercion, community leaders, social workers, and shelter staff members were not involved in the consent process except when a person’s capacity to consent was questionable. Respondents had the opportunity to confirm or re-negotiate consent over time. That is participants who had already agreed to participate were asked of permission again prior to the start of the survey. Participants could change their decision to participate or withdraw their participation altogether based on changes in personal lives or availability of new information about the research.
Activities were conducted in either the local Ghanaian language (66%, n = 201) or English (34%, n = 104). The research assistants read the questions to respondents, recorded answers in electronic format, and then synchronised to the online software platform CANVAS (https://canvass.acspri.org.au) using android tablets. The survey lasted for 50 to 60 minutes, and respondents were reimbursed with mosquito repellent (valued at AU$5). All respondents could also check-in to any of the two partner alcohol and drug rehabilitation centres with the help of social workers free of charge. Community organisations provided timely referrals for mental health support for respondents who may experience psychological harm and distress. Two respondents experienced mild discomfort answering questions on discrimination and violence which led to a temporary pause of the survey.
Variables
Outcome variable: Alcohol and drug consumption.
Substance use risk levels were assessed using the ASSIST version 3.0, a tool to identify levels of risky substance use and related health risks [35]. The ASSIST consists of eight questions on lifetime and past three-month use of nine substances: tobacco, alcohol, cannabis, cocaine, amphetamine-type stimulants, inhalants, sedatives, hallucinogens, and opioids. For each substance used in the last three months, further questions assess the following: 1) frequency of use, 2) urges to use, 3) health, social, legal, or financial problems, 4) and interference with role responsibilities. The ASSIST also queries failed attempts to reduce substance use and whether someone ever expressed concern about use; a follow-up question determines if this occurred in the past three months or more than three months ago [7, 35].
A Specific Substance Involvement (SSI) score was calculated for each substance (range: 0–39, same for total scale) using standard ASSIST scoring procedures. Individual SSI scores were categorised into three risk levels: low, moderate, high (Table 1) [13]. An overall substance use risk variable was defined based on the highest risk level assigned for any substance.
The WHO-ASSIST has a test–retest reliability coefficient as high as 0.90 [36]. Although not used in any prior study in Ghana, the instrument has been used and validated with the sub-Saharan African countries like Nigeria, reporting internal correlation coefficients of greater than 0.7 [37].
Explanatory variables.
The following explanatory variables were selected based on previously published studies among persons experiencing homelessness in both developing and developed countries [5, 7, 38, 39]:
- Sociodemographic characteristics: Age, gender, education level, intimate relationship, employment status, and income levels.
- Migration and homelessness characteristics: Accra migration status (migrant/non-migrant). Homelessness characteristics included shelter status (sheltered/unsheltered). Sheltered homelessness refers to temporarily residing in a homeless shelter, crisis and emergency accommodations, and residential drug and alcohol rehabilitation facilities. Unsheltered homelessness, on the other hand, refers to roofless condition, such as the streets, marketplaces, alleys, abandoned vehicles, under bridges, verandas, and other places not designed for shelter. Total lifetime duration of homelessness was also measured (chronic- ≥1 year, non-chronic- <1 year).
- Experiences of stigmatisation: Assessed using a 12-item Social Stigma Scale to measure the experience of general stigma (10 items; scores ranged from 10–40) and self-blame (2 items; scores ranged from 2 to 8) [40]. Items are scored on the following 4-point Likert-type scale: strongly agree = 4, agree = 3, disagree = 2 and strongly disagree = 1. Higher scores imply higher levels of stigma and self-blame experienced. The Social Stigma Scale has an overall internal reliability of 0.87, with the subscales of self-blame and general stigma having Cronbach’s reliability coefficients of 0.78 and 0.89 respectively [40]. The scale has been used and validated with the homeless population in Ghana [41].
- Health characteristics: Self-reported experience or diagnosis of a range of physical and mental health conditions in the past three months. Presence of physical health problem (yes/no) or mental health problem (yes/no) was defined as having a positive response to at least one condition.
- Violence and abuse: measured using items from the Ghana Living Standard Survey (GLSS) Round 6 [15]. Three types of violence within the last six months were assessed in line with previously published studies among homeless and other impoverished people [42, 43]:
- Physical violence—defined as being hit, slapped, kicked, bitten, choked, twisted arm, kidnapped, struck with an object, pulled hair, spat on, urinated on, or the victim of a robbery with a weapon.
- Emotional violence—defined as any experience of threats, harassment, intimidation, controlling behaviour, insults, items seized, cruelty.
- Sexual violence—defined as holding, grabbing, and touching certain parts of a person in a manner that irritates or angers the person involved, and being forced to have sex of any kind.
To limit the influence of language barrier and allow participation by those who only spoke the local language, the survey questionnaire, including the ASSIST and the Social Stigma Scale was constructed in English, translated into Akan, and back-translated into English to ensure the actual meaning of items was preserved in the translation. As part of the back-translation, a list of culture-specific names of the diseases, common substances of abuse, and key terms were provided side-by-side their English names.
Statistical methods
Frequencies, percentages and medians were used to describe respondents’ characteristics and substance use risk levels (i.e. low, moderate, high). Logistic regression modelling was used to examine significant factors associated with high-risk substance use (ASSIST score ≥27). Factors included in the analyses were the socio-demographic characteristics, Accra migration and homelessness variables, social stigma, and self-reported physical and mental health problems. Two measures of violence (i.e. physical/emotional and sexual) were also included. Physical and emotional violence were merged into one measure (i.e. experience of physical or emotional violence, dichotomised as Yes = 1 and No = 0) due to high correlation (r = .96).
Separate multivariable logistic regression analyses were conducted for high-risk use of alcohol, cocaine, and cannabis due to their particularly high prevalence in both the general Ghanaian population and this study’s sample. Variable selection techniques consisted of two separate logistic regression analyses as follows:
- For each measure of high-risk substance use, a bivariate logistic regression was conducted separately for the explanatory variables.
- All variables with p-value ≤.25 in the bivariate analysis [44, 45] were included in the multivariable logistic regression. Variables were excluded as follows:
- Age, education, relationship status, and migration status were excluded from analysis of overall high-risk substance use.
- Age, education. relationship status, income, and shelter status were excluded from the analysis of high-risk alcohol use.
- Education, income, migration status, and shelter status were excluded from the analysis of high-risk alcohol use.
- Relationship status was excluded from the analysis of high-risk cocaine use.
However, self-blame (a sub-category of social stigma) and presence of mental health problem were included apriori in all analysis. International literature shows that that people engage in problematic substance use as a coping strategy for stress, trauma, and stigma from violence [46, 47]. Similarly, there is an established relationship with substance use in the homeless population [7].
Adjusted Odds Ratios (AORs) with 95% confidence intervals (CIs) were estimated as the measure of association between the explanatory and outcome variables. All statistical analyses were conducted in Stata version 14.0 (Stata Corp, College Station, TX, USA). All variables with a p-value≤.05 were considered significant. Multicollinearity was checked after the regressions. Interactions were examined between gender and various measures of violence, as well as between physical/emotional and sexual violence; none of them were statistically significant (S1 Table).
Results
Participants
The final sample size of 305 consisted of more men (61%) with a median age of 32 years (interquartile range [IQR] = 17 years; Table 3). Nearly three-quarters had, at best, a year 12 education; and most respondents (54%) were not in any intimate relationship. Those in relationships were legally or customarily married or in a consensual union. Most respondents identified themselves as employed (63%), commonly as street vendors, truck loaders or pushers, car washers, caterers, and cleaners. The median net monthly income was US$76.
Most respondents were urban migrants in the Accra city (78%), including non-Ghanaians. Two-thirds were unsheltered sleeping in streets, marketplaces, under bridges, and construction sites. Most respondents were considered chronically homeless (median homelessness duration = 5 years, IQR = 7 years, Table 3). More than three-quarters had experienced high levels of general stigma (median = 26, IQR = 9; range = 10–40) and self-blame (median = 5, IQR = 2; range = 2–8) due to homelessness. Self-reported physical and mental health problems were 72% and 87% respectively. Eye problems, blood pressure, dental problems, and respiratory problems were the top four physical health problems. Commonly reported mental health problems were tension and anxiety, depression, restlessness and gloominess, and suicidal thoughts. Emotional, physical, and sexual violence during the past six months were reported by 34%, 32%, and 19% of respondents respectively (Table 3).
Substance use prevalence and risk levels
Lifetime and recent substance use.
The lifetime prevalence of any substance use was 71% (n = 216) while 59% reported recent use (Fig 1). The substances most used were alcoholic beverages (65% lifetime, 48% recent), followed by tobacco products (53% lifetime, 27% recent), cannabis (52% lifetime, 29% recent), and cocaine (38% lifetime, 14% recent). Consumption of other illicit substances was low.
Risk related to substance use (WHO ASSIST-Defined).
Almost all the 216 respondents that had ever used substances were classified as engaging in risky substance use (95%) with 55% at moderate risk and 40% at high risk (Table 2). Moderate-risk use predominated for alcohol (64%), tobacco (56%) and cannabis (54%). For cocaine, high- and moderate-risk use were comparable (27% and 25%, respectively). For other illicit substances (hallucinogens, sedatives, inhalants, and opioids), most use was low-risk (69%-83%; Table 2).
Respondents’ demographic, migration and homelessness characteristics by highest specific substance involvement (SSI) score.
Bivariate analyses indicated substantial differences in respondents’ substance use risk levels based on socio-demographic, migration, and homelessness characteristics (Table 3). Moderate/high-risk substance users were significantly more likely to be men than women (80% vs 48%, p<.001), unemployed than employed (76% vs 62%, p<.050), and chronically versus recently homeless (70% vs 51%, p<.010). Moderate/high-risk substance users were also more likely to have experienced general stigma than not (72% vs 51%, p<.001), and have a physical health problem than not (72% vs 55%, p<.010). A higher proportion of survivors of physical violence (87% yes vs 58% no, p<.001), emotional violence (85% yes vs 58% no, p<.001), and sexual violence (86% yes vs 63% no, p<.001) had moderate/high-risk substance use. On the other hand, low-risk users or lifetime abstainers were significantly more likely to be women, homeless for less than a year, non-victims of violence, and had no experience of stigma. No significant differences were observed in substance use risk levels based on migration status, current shelter status, and self-reported mental health problems (Table 3).
Factors associated with a high-risk substance use.
Engaging in high-risk substance use was significantly associated with the experience of violence (Table 4). High-risk use of at least one substance was much more prevalent among survivors of sexual violence (AOR = 3.94; 95%CI 1.85–8.39, p<.001) and physical or emotional violence (AOR = 3.54; 95%CI 1.89–6.65, p<.001). In particular, physical or emotional violence survivors had higher odds of engaging in high-risk use of cocaine (AOR = 4.67; 95%CI 1.60–13.62; p = .005), alcohol (AOR = 3.42 95%CI 1.68–6.95, p<.001), and cannabis (AOR = 3.05; 95%CI 1.02–9.14; p = .050). Sexual violence survivors were nearly nine times more likely to have high-risk use of cocaine compared to non-victims (AOR = 8.82; 95%CI 2.83–27.52; p< .001).
Gender and income levels were also associated with substance use. The likelihood of engaging in high-risk use of at least one substance was significantly higher for men (AOR = 4.09; 95%CI 2.06–8.12, p<.001, Table 4), particularly for cocaine (AOR = 7.52; 95%CI 2.26–24.99, p = .001), cannabis (AOR = 4.23; 95%CI 1.23–14.58, p = .022), and alcohol (AOR = 2.75; 95%CI 1.30–5.84, p = .008). Individuals in the middle-income group had lower odds of high-risk use of at least one substance (AOR = .42; 95%CI 0.23–0.78, p = .006), particularly for cocaine (AOR = 0.21; 95%CI 0.07–0.62, p = .004). Stigmatisation and self-reported health problems did not have significant associations with high-risk substance use. Separate logistic regression analyses were attempted for sheltered and unsheltered respondents but were unsuccessful due to small sample sizes after separation.
Discussion
This study set out to explore risky substance use and associated factors in adults experiencing homelessness in Ghana’s capital, Accra. Substance use was highly prevalent and most use was at the level of moderate to high risk of harm. Experiences of violence, male gender and low-income status were associated with more risky substance use. Contrary to expectations, experiences of stigma and mental health problems were not statistically related to risky substance use.
The high prevalence of risky substance use in the sample may be expected given the easy access to alcohol and drugs in Ghanaian cities [48, 49]. Since the early 2000s Ghana has been an important international trafficking route for cocaine, cannabis, and heroin from Asia and South America to other African countries, United States, and Europe [50–52]. Alcohol and cannabis are locally produced and trafficked from Ghana to other African countries [53], and methamphetamine has been locally produced and transported to East Asia since 2009 [17, 53]. The production and/or trafficking of these substances has contributed to the establishment of a ready local market and a surge in domestic consumption [17], including consumption among vulnerable populations. Particularly, people experiencing homelessness in Ghanaian cities are mostly exposed to places of high drug activity with easy accessibility [17]. Low-income status may play a crucial role in people’s access and use of substances through engagement in sale and distribution to generate income [54].
It is noteworthy that close to a third of this study’s sample had never used any substance in their lifetime and 5% of all users were at low risk of harm despite their generally low-income status and exposure to high drug activity. Resilience factors such as self-esteem [55–57], intellectual ability [58–61], religiosity/spirituality [55, 62], and personal skills [55, 63, 64] may account for the non-use. Individual’s attitudes about substance use including fear of consequences (health, social, legal), personal and family norms, and lack of interest may also explain their non-use [65–67]. Future research should focus on non-engagement in substance use and associated factors among people who experience homelessness. Knowing the extent and reasons/factors associated with non-engagement in substance use or misuse could inform policies and interventions based on strength and resilience factors among people experiencing homelessness and other vulnerable populations.
The high prevalence and risky substance use in this Ghanaian study broadly agree with previous findings in Africa [68–71] and Western countries [4–7, 72–75]. Although generally high, differences in prevalence exist between the present study and previous research which may be explained by the differences in defining homelessness as well as substance use assessment tools. The present study included a broad homeless population consisting of unsheltered and sheltered people such as those undergoing rehabilitation. A previous study in Ghana and South Africa that used a narrow definition of unsheltered homelessness reported over 80% lifetime substance use [71]. Conversely, an American study [7] of people using homeless shelters and primary health care settings (where high drinking and drug use may be prohibited) reported a substantially lower prevalence. These differences in prevalence suggests that substance use may be higher among those experiencing rooflessness compared to other forms of homelessness. Unfortunately, comparisons between sheltered and unsheltered respondents in the present study could not be conducted due to the small sample sizes of the two subgroups. In terms of assessment tools, a Canadian study [5] that assessed problematic alcohol drinking and drug use using Alcohol Use Disorder Identification Test (AUDIT) and the Drug Abuse Screening Test (DAST) respectively reported substantially lower prevalence for alcohol (16%) but a similar prevalence for drugs (29%). However, it is noteworthy that the American study [7] that used ASSIST reported a substantially lower prevalence of problematic alcohol and drug use.
The finding that a high proportion of individuals engaged in risky substance use implies the experience of moderate to severe health problems and suggests the need for brief interventions and more intensive treatments [12]. More critical is the high proportion of people engaged in the risky use of more than one substance which suggests multiple and complex psychosocial risks requiring integrated treatment [17, 66, 76]. While abstinence-based interventions through rehabilitation are important [17, 77], outpatient rehabilitation detoxification services (which are mostly available in Accra) may be unsuitable for people experiencing homelessness. Ghanaian homeless individuals have to return to places of high drug activity, peer influence, violence, and other traumatic conditions that may cause relapse and treatment dropout. Residential rehabilitation may therefore be more suitable for people experiencing homelessness particularly for survivors of violence and youth under gang pressure [78, 79]. Unfortunately, the number of residential rehabilitation facilities in Accra is woefully inadequate [17]. A small number of non-governmental organisations and religious bodies have established small-scale residential rehabilitation programmes targeting the homeless population, but the need for consent from a relative and separation from children prevents migrants and women with children from accessing services. Relaxing these requirements would help urban migrants and women with children–who constitute the majority of the homeless population in Accra–to access services. Equally critical is the inadequate aftercare programmes such as rehousing and income generating activities for residential rehabilitation patients upon discharge. Absence of such programmes implies a likely return to homelessness and subsequent relapse. Linking supportive housing services [80, 81] and skills training [82, 83] to substance use treatments are recommended. A few faith-based rehabilitation programmes in Accra offer clients opportunities to earn a decent income upon discharge through vocational training, education, sports, and peer-mentorship, while some clients are assisted to reunite with their families. Government investment in such initiatives would help increase the capacities of rehabilitation centres to admit more clients experiencing homelessness, and to help successful clients transition into stable housing through income-earning activities.
Also important are targeted harm-reduction interventions that assist people to identify and address specific factors behind their substance use, reduce usage rates, and stop harmful practices such as needle sharing even if they are not motivated to abstain [13, 17, 84]. Embedding such approaches into the government and donor agencies’ strategies is important particularly for the homeless population who may engage in risky substance use to cope with the poor environment, experiences of stigmatisation and isolation, and stress [42, 85–90]. Prior studies have recommended harm-reduction interventions through counselling, education, and peer support on self-help strategies for reducing substance use and other harmful practices [91]. The community organisations and rehabilitation centres in Accra and other Ghanaian cities could expand their periodic outreach, health screening, and meal programmes in the streets and slums to accommodate such strategies.
High levels of violence found in this study are consistent with other studies of homeless populations in Africa [68, 70, 92, 93] and Western countries [42, 94–97]. The multivariable analysis indicated that recent violence among people experiencing homelessness was related to risky substance use, as has been reported in Africa [69, 70], United States [42, 43, 90, 98] and Europe [86]. The association between risky substance use and violence may reflect the systemic violence inherent in the criminal networks involved in drug distribution, including enforcing debt payment and settling disputes between dealers and users, and among dealers (who are also mostly users) [99–102].
Along with the finding of the male gender associated with high-risk substance use, which confirms prior findings [7, 72, 103], the association between substance use and violence may also be attributed to substance use as a coping strategy for violence. This strategy includes using drugs to establish street reputation as ‘hard core’ and to gain entry into street gangs for protection against violence [73, 104]; using depressants to self-medicate injuries and ongoing pain from violence [85, 87, 89, 90, 105]; and consuming alcohol, cocaine, and opioids to appear tough and fearless and to prepare for fights [42, 85–87, 90]. Due to sample size issues, this study was unable to examine gender differences in relation to violence and substance use, but previous research have reported women’s problematic substance use as a coping strategy for stress and trauma from violence [46, 47]. Meanwhile, women’s lower odds of engaging in high-risk substance use in this study could be attributed to substantial under-reporting due to the greater social stigma for women’s substance use. Women experience a high burden of criticism and widespread condemnation for engaging in substance use in many Ghanaian and African cultures [17, 106] which is often spoken about using the language of religion and perception of ungodliness [17]. For example, a qualitative study in Kenya reports that women who inject drugs experience gender-based stigma in societies and in healthcare settings because drug use ran contrary to gendered norms of behaviour [106]. One study demonstrated a higher prevalence of substance use among women compared to men [107], although the finding may have been confounded by younger age among women.
There were limitations in the conduct of this study. The sample’s representativeness of the homeless population in Ghana could not be assessed due to the absence of data on the size and characteristics of the homeless population and the single-city sampling. Despite its non-random nature possible bias, and limited generalisability, the use of uncontrolled quota sampling allowed sampling from key sub-groups of the homeless population. Although accurate proportion of the various sub-groups was not possible due to unknown sizes, the uncontrolled quota sampling achieved some level of representativeness. The small sample from a single city also make also makes it difficult to make broad inferences about the findings from this study to the larger homeless population in Ghana. The study’s use of self-reported data, including the assessment of risky substance use may introduce reporting bias and provision of socially desirable answers, given that most of the substances studied are illegal in Ghana. However, respondents were assured the researchers were under no legal obligation to report their engagement in substance use, and the respondents openly talked about their substance use experiences. Despite these limitations, this study makes a substantial contribution to the scarce research on substance use among adults experiencing homelessness in an African context. Adopting an inclusive definition of homelessness and assessment of substance use risk levels have expanded knowledge, as previous African studies only assessed the prevalence and types of substance use among street dwellers.
Conclusions
This study demonstrates a high prevalence of risky substance use among adults experiencing homelessness in Accra, and the increased probability of engaging in high-risk substance use for survivors of violence, men, and low-income individuals. The findings highlight the need to provide targeted interventions to address risky substance use among the adult homeless population in the city. Interventions should take into consideration the complexity of what it means to be homeless in Ghana and Africa as a whole.
Supporting information
S1 Table. Logistic regression with interaction terms.
https://doi.org/10.1371/journal.pone.0281107.s001
(DOCX)
Acknowledgments
The authors sincerely thank the Department of Social Welfare and Community Organisations working with people experiencing homelessness in Accra for approving the data collection. We also thank the social workers and community leaders in the streets and slums for their assistance in contacting potential participants. Special thanks to the respondents for their interest and participation.
References
- 1. Adkins EC, Zalta AK, Boley RA, Glover A, Karnik NS, Schueller SM. Exploring the potential of technology-based mental health services for homeless youth: A qualitative study. Psychol Serv. 2017;14(2):238. pmid:28481610
- 2. Tobey M, Manasson J, Decarlo K, Ciraldo-Maryniuk K, Gaeta JM, Wilson E. Homeless individuals approaching the end of life: symptoms and attitudes. J Pain Symptom Manage. 2017;53(4):738–44. pmid:28042064
- 3. Klop HT, De Veer AJ, Van Dongen SI, Francke AL, Rietjens JA, Onwuteaka-Philipsen BD. Palliative care for homeless people: a systematic review of the concerns, care needs and preferences, and the barriers and facilitators for providing palliative care. BMC Palliat Care. 2018;17(1):1–16. pmid:29690870
- 4.
Conroy E, Burns L., Wilson S. Alcohol use disorder and cognitive impairment among older homeless persons. Foundation for Alcohol Research & Education. 2013. https://fare.org.au/alcohol-use-disorder-and-cognitive-impairment-among-older-homeless-persons-implications-for-service-delivery/
- 5. Palepu A, Gadermann A, Hubley AM, Farrell S, Gogosis E, Aubry T, et al. Substance use and access to health care and addiction treatment among homeless and vulnerably housed persons in three Canadian cities. PLoS One. 2013;8(10):e75133. pmid:24124470
- 6. Spicer B, Smith DI, Conroy E, Flatau PR, Burns L. Mental illness and housing outcomes among a sample of homeless men in an Australian urban centre. Aust N Z J Psychiatry. 2015;49(5):471–80. pmid:25526944
- 7. Stringfellow EJ, Kim TW, Gordon AJ, Pollio DE, Grucza RA, Austin EL, et al. Substance use among persons with homeless experience in primary care. Subst. Abuse. 2016;37(4):534–41. pmid:26914448
- 8. Galea S, Vlahov D. Social determinants and the health of drug users: socioeconomic status, homelessness, and incarceration. Public Health Rep. 2002;117(Suppl 1):S135. pmid:12435837
- 9. Grinman MN, Chiu S, Redelmeier DA, Levinson W, Kiss A, Tolomiczenko G, et al. Drug problems among homeless individuals in Toronto, Canada: prevalence, drugs of choice, and relation to health status. BMC Public Health. 2010;10(1):1–7.
- 10. Blazer DG, Wu L-T. Patterns of tobacco use and tobacco-related psychiatric morbidity and substance use among middle-aged and older adults in the United States. Aging Ment Health 2012;16(3):296–304. pmid:22292514
- 11. Wipfli H, Samet J, Therapeutics. Global economic and health benefits of tobacco control: part 2. Clin. Pharm. Therap. 2009;86(3):272–80.
- 12. Humeniuk R, Ali R, Babor T, Souza‐Formigoni MLO, de Lacerda RB, Ling W, et al. A randomized controlled trial of a brief intervention for illicit drugs linked to the Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) in clients recruited from primary health‐care settings in four countries. Addiction. 2012;107(5):957–66. pmid:22126102
- 13.
Humeniuk R, Henry-Edwards S, Ali R, Poznyak V, Monteiro MG, Organization WH. The Alcohol, Smoking and Substance Involvement Screening Test (ASSIST): manual for use in primary care. 2010. Report No.: 9522727083.
- 14.
Obeng-Odoom F. Homelessness, poverty, and unemployment: The Ghanaian case. In Thompson SJ. Homelessness, Poverty and Unemployment. New York: Nova Science Publishers; 2012. p. 149–165.
- 15.
Ghana Statistical Service. Ghana Living Standard Survey Round 6. Ghana Statistical Service 2014. https://www.statsghana.gov.gh/gssmain/fileUpload/Living%20conditions/GLSS6_Main%20Report.pdf
- 16. Asante KO, Meyer-Weitz A, Petersen I. Substance use and risky sexual behaviours among street connected children and youth in Accra, Ghana. Subst. Abuse Treat. Prev. Policy 2014;9(1):1–9.
- 17.
Bird L. Domestic Drug Consumption in Ghana. An Under-Reported Phenomenon. Global Initiative Against Transnational Organized Crime. 2019. https://globalinitiative.net/analysis/drug-policy-ghana/
- 18. Doku D. Substance use and risky sexual behaviours among sexually experienced Ghanaian youth. BMC Public Health. 2012;12(1):1–7. pmid:22839700
- 19. Debrah YA. Promoting the informal sector as a source of gainful employment in developing countries: insights from Ghana. Int. J. Hum. Resour. Manag. 2007;18(6):1063–84.
- 20.
Dwumoh K. Homelessness in Ghana, Is it my Problem? 2013 April 3 [cited 17 July 2020]. In Ghanaweb [Internet]. Accra. https://www.ghanaweb.com/GhanaHomePage/NewsArchive/Homelessness-in-Ghana-Is-it-myProblem-269760.
- 21. Tipple G, Speak S. Definitions of homelessness in developing countries. Habitat Int. 2005;29(2):337–52.
- 22.
Ghana Statistical Service. 2010 Population and Housing Census: National Analytical Report. Accra: Ghana Statistical Service 2013. https://www.environmentandurbanization.org/2010-population-housing-census-national-analytical-report-ghana
- 23.
Ghana Statistical Service. Ghana Population and Housing Census: Housing in Ghana. Accra Ghana Statistical Service 2014. http://www.statsghana.gov.gh/docfiles/2010phc/Mono/Housing%20in%20Ghana.pdf
- 24.
Asad A. 5 Facts about Homelessness in Ghana. 2020 September 11 [cited 17 August 2021]. In The Borgen Project Blogs. https://borgenproject.org/homelessness-in-ghana/
- 25.
United Nations Office on Drugs and Crime. Wolrd Drug Report 2017: Executive Summary and Policy Implications United Nations Office on Drugs and Crime 2017. https://www.unodc.org/wdr2017/field/Booklet_1_EXSUM.pdf
- 26. Yawson AE, Baddoo A, Hagan-Seneadza NA, Calys-Tagoe B, Hewlett S, Dako-Gyeke P, et al. Tobacco use in older adults in Ghana: sociodemographic characteristics, health risks and subjective wellbeing. BMC Public Health. 2013;13(1):1–8. pmid:24138966
- 27.
Grant R. Globalizing city: The urban and economic transformation of Accra, Ghana: Syracuse University Press; 2009.
- 28. Amore K, Baker M, Howden-Chapman P. The ETHOS definition and classification of homelessness: an analysis. European Journal of Homelessness. 2011;5(2).
- 29. Danso-Wiredu EY, Poku A. Family Compound Housing System Losing Its Value in Ghana: A Threat to Future Housing of the Poor. Hous. Policy Debate. 2020;30(6):1016–32.
- 30. Gabrielli G, Paterno A, Sacco P. Living arrangements in sub-Saharan Africa between modernization and ethnicity. Afr. Popul. Stud. 2018;32(2).
- 31. Agyemang FO, Asamoah PKB, Obodai J. Changing family systems in Ghana and its effects on access to urban rental housing: a study of the Offinso Municipality. J Hous Built Environ. 2018;33(4):893–916.
- 32. Oppong C. Globalization and the disruption of mothercare. Afr. Res. Rev. 2001;17(1):25–47.
- 33.
Saunders M, Lewis P. & Thornhill A. Research Methods for Business Students, 6th edition. London, UK: Pearson Education Limited; 2012.
- 34. Yang K, Banamah A. Quota sampling as an alternative to probability sampling? An experimental study. Sociol. Res. Online. 2014;19(1):56–66.
- 35.
World Health Organization. The ASSIST project-Alcohol, Smoking and Substance Involvement Screening Test. 2018. Avaiable from https://www.who.int/publications/i/item/978924159938-2
- 36. World Health Organization (WHO) Assist Working Group. The alcohol, smoking and substance involvement screening test (ASSIST): development, reliability and feasibility. Addiction. 2002;97(9):1183–94. pmid:12199834
- 37. Onifade PO, Bello AO, Abiodun O, Sotunsa JO, Ladipo OA. Psychometric properties of alcohol smoking and substance involvement screening test (Assist V3. 0) among university students. J Addict Behav Ther Rehab. 2014;3(3):2–7.
- 38. Gomez R, Thompson SJ, Barczyk AN. Factors associated with substance use among homeless young adults. Subst. Abuse 2010;31(1):24–34. pmid:20391267
- 39. Tyler Kort-Butler LA, Swendener A. The effect of victimization, mental health, and protective factors on crime and illicit drug use among homeless young adults. Violence Vict. 2014;29(2):348–62. pmid:24834752
- 40. Kidd S. Youth homelessness and social stigma. J Youth Adolesc. 2007;36(3):291–9. pmid:27519028
- 41. Oppong Asante K, Onyeaka H. The mediating role of social support in the relationship between stigma and emotional distress among homeless adolescents in Ghana. Psychol Health Med. 2021:1–9. pmid:33559489
- 42. Riley ED, Cohen J, Knight KR, Decker A, Marson K, Shumway M. Recent violence in a community-based sample of homeless and unstably housed women with high levels of psychiatric comorbidity. Am J Public Health. 2014;104(9):1657–63. pmid:25033127
- 43. Wenzel SL, Leake BD, Gelberg L. Risk factors for major violence among homeless women. J. Interpers. Violence 2001;16(8):739–52.
- 44. Bursac Z, Gauss CH, Williams DK, Hosmer DW. Purposeful selection of variables in logistic regression. Source Code Biol Med. 2008;3(1):1–8. pmid:19087314
- 45. Hillyer MH, Taylor FGR, Proudman CJ, Edwards GB, Smith JE, French NP. Case control study to identify risk factors for simple colonic obstruction and distension colic in horses. Equine Vet J. 2002;34(5):455–63. pmid:12358047
- 46. Bungay V, Johnson JL, Varcoe C, Boyd S. Women’s health and use of crack cocaine in context: Structural and ‘everyday’violence. Int J Drug Policy. 2010;21(4):321–9.
- 47. Haile K, Umer H, Ayano G, Fejo E, Fanta T. A qualitative exploration of substance misuse among homeless women in Addis Ababa, Ethiopia. BMC Psychiatry. 2020;20:1–9.
- 48. Hormenu T, Hagan Jnr JE, Schack T. Predictors of alcohol consumption among in-school adolescents in the Central Region of Ghana: A baseline information for developing cognitive-behavioural interventions. PloS one 2018;13(11):e0207093. pmid:30419048
- 49. Owusu-Dabo E, Lewis S, McNeill A, Gilmore A, Britton J. Smoking uptake and prevalence in Ghana. Tob Control. 2009;18(5):365–70. pmid:19581276
- 50. Akyeampong E. Diaspora and drug trafficking in West Africa: a case study of Ghana. Afr. Aff. 2005;104(416):429–47.
- 51. Aning K, Pokoo J. Understanding the nature and threats of drug trafficking to national and regional security in West Africa. Stability: International Journal of Security Development 2014;3(1).
- 52. Ellis S. West Africa’s international drug trade. Afr. Aff. 2009;108(431):171–96.
- 53.
United Nations Office on Drugs and Crime. West Africa: 2012 ATS situation report. United Nations Office on Drug and Crime; 2012. https://www.unodc.org/documents/scientific/ATS_West_Africa_final_2012.pdf
- 54. Valdez A, Kaplan C. Conditions that increase drug market involvement: The invitational edge and the case of Mexicans in South Texas. J Drug Iss. 2007;37(4):893–917. pmid:21218142
- 55. Currie CL, Wild TC, Schopflocher DP, Laing L, Veugelers P. Illicit and prescription drug problems among urban Aboriginal adults in Canada: the role of traditional culture in protection and resilience. Soc. Sci. Med. 2013;88:1–9. pmid:23702204
- 56. Turner MG, Hartman JL, Exum ML, Cullen FT. Examining the cumulative effects of protective factors: Resiliency among a national sample of high-risk youths. J Offender Rehabil. 2007;46(1–2):81–111.
- 57. Kidd S, Golan S. Resilience in homeless youth: The key role of self‐esteem. Am J Orthopsychiatry. 2008;78(2):163–72. pmid:18954180
- 58. Benda BB. Discriminators of suicide thoughts and attempts among homeless veterans who abuse substances. Suicide Life Threat Behav. 2003;33(4):430–42. pmid:14695057
- 59. Hollen P, Tyc V, Shannon S, Donnangelo S, Hobbie W, Hudson M, et al. Factors related to decision making and substance use in adolescent survivors of childhood cancer: a presenting clinical profile. J Cancer Surviv. 2013;7(3):500–10. pmid:23712611
- 60. Rosenblum A, Magura S, Fong C, Cleland C, Norwood C, Casella D, et al. Substance use among young adolescents in HIV-affected families: Resiliency, peer deviance, and family functioning. Subst. Use Misuse 2005;40(5):581–603. pmid:15887592
- 61. Sirikantraporn S, Mateu-Gelabert P, Friedman SR, Sandoval M, Torruella RAJSu, misuse. Resilience among IDUs: planning strategies to help injection drug users to protect themselves and others from HIV/HCV infections. Subst. Use Misuse 2012;47(10):1125–33. pmid:22574849
- 62. Okamoto SK, Helm S, Po’a-Kekuawela Ko, Chin CI, Nebre . Community risk and resiliency factors related to drug use of rural Native Hawaiian youth: An exploratory study. J Ethn Subst Abuse. 2009;8(2):163–77. pmid:19459123
- 63. Alavijeh M, Matin B, Jalilian F, Hamzeh B, Haghighi M, Ahmadpanah M, et al. Relapse preventative intervention among Iranian addicts based on theory of planned behavior results. Res. J. Appl. Sci. 2016;11(4):138–43.
- 64. Carrico AW, Gómez W, Siever MD, Discepola MV, Dilworth SE, Moskowitz JT. Pilot randomized controlled trial of an integrative intervention with methamphetamine-using men who have sex with men. Arch Sex Behav. 2015;44(7):1861–7. pmid:26123068
- 65. Davis SJ, Spillman S. Reasons for drug abstention: A study of drug use and resilience. J Psychoactive Drugs. 2011;43(1):14–9. pmid:21615003
- 66. Andreas JB, Lauritzen G, Nordfjærn T. Co-occurrence between mental distress and poly-drug use: a ten year prospective study of patients from substance abuse treatment. Addict. Behav. 2015;48:71–8. pmid:26004857
- 67. Gilliard-Matthews S, Stevens R, Medina M. ‘If drugs does that to you, then I don’t want it.’Resiliency among non-marijuana using adolescents. J. Youth Stud. 2016;19(9):1237–58.
- 68. Moyo U, Patel L, Ross E. Homelessness and mental illness in Hillbrow, South Africa: A situation analysis. Soc. Work Soc. Sci. Rev. 2015;51(1):1–21.
- 69. Swahn M, Melissa H, Jane P. Alcohol and drug use and other high-risk behaviors among youth in the slums of Kampala, Uganda: Perceptions and contexts obtained through focus groups. Int J Alcohol Drug Res. 2014;3(4):289–95.
- 70. Swahn M, Culbreth R, Tumwesigye NM, Topalli V, Wright E, Kasirye R. Problem drinking, alcohol-related violence, and homelessness among youth living in the slums of Kampala, Uganda. Int J Environ Res Public Health 2018;15(6):1061. pmid:29882915
- 71. Asante KO, Nefale MT. Substance use among street-connected children and adolescents in Ghana and South Africa: a cross-country comparison study. Behav. Sci. 2021;11(3):28. pmid:33673464
- 72. Santa Maria DM, Narendorf SC, Cross MB. Prevalence and correlates of substance use in homeless youth and young adults. J. Addict. Nurs. 2018;29(1):23–31. pmid:29505458
- 73. Johnson G, Chamberlain C. Homelessness and substance abuse: Which comes first? Aust Social Work. 2008;61(4):342–56.
- 74. Raven MC, Carrier ER, Lee J, Billings JC, Marr M, Gourevitch MN. Substance use treatment barriers for patients with frequent hospital admissions. J Subst Abuse Treat. 2010;38(1):22–30. pmid:19540700
- 75. Spinelli MA, Ponath C, Tieu L, Hurstak EE, Guzman D, Kushel M. Factors associated with substance use in older homeless adults: Results from the HOPE HOME study. Subst. Abuse. 2017;38(1):88–94. pmid:27897965
- 76. Kertesz SG, Khodneva Y, Richman J, Tucker JA, Safford MM, Jones B, et al. Trajectories of drug use and mortality outcomes among adults followed over 18 years. J Gen Intern Med. 2012;27(7):808–16. pmid:22274889
- 77. Turner B, Deane FP. Length of stay as a predictor of reliable change in psychological recovery and well being following residential substance abuse treatment. Int. J. Ther. Communities. 2016; 37(3): 112–120.
- 78. Mericle AA, Miles J, Cacciola J, Howell J. Adherence to the social model approach in Philadelphia recovery homes. Int. j. self help self care 2014;8(2).
- 79. Polcin D, Mericle A, Howell J, Sheridan D, Christensen J. Maximizing social model principles in residential recovery settings. J Psychoactive Drugs. 2014;46(5):436–43. pmid:25364996
- 80. Collins SE, Malone DK, Clifasefi SL, Ginzler JA, Garner MD, Burlingham B, et al. Project-based Housing First for chronically homeless individuals with alcohol problems: Within-subjects analyses of 2-year alcohol trajectories. Am J Public Health. 2012;102(3):511–9. pmid:22390516
- 81. Kisely SR, Parker JK, Campbell LA, Karabanow J, Hughes JM, Gahagan J. Health impacts of supportive housing for homeless youth: A pilot study. Public Health. 2008;122(10):1089. pmid:18617200
- 82. Sereta BN, Amimo FA, Ouma P, Ondimu TO. An assessment of effectiveness of drug rehabilitation programs in Kisii County-Kenya. J Health Edu Res Dev. 2016; 4(1): 1–20.
- 83. Adams-Guppy JR, Guppy A. A systematic review of interventions for homeless alcohol-abusing adults. Drugs: Educ. Prev. Policy 2016;23(1):15–30.
- 84. Hawk KF, Vaca FE, D’Onofrio G. Focus: Addiction: Reducing fatal opioid overdose: Prevention, treatment and harm reduction strategies. Yale J. Biol. Med. 2015;88(3):235.
- 85. Chakraborty T, Mukherjee A, Rachapalli SR, Saha S. Stigma of sexual violence and women’s decision to work. World Dev. 2018;103:226–38.
- 86. Fernandez‐Montalvo J, Lopez‐Goñi JJ, Azanza P, Cacho R. Gender differences in drug‐addicted patients in a clinical treatment center of Spain. Am. J. Addict. 2014;23(4):399–406. pmid:24961362
- 87. Kennedy AC, Prock KA. “I still feel like I am not normal”: A review of the role of stigma and stigmatization among female survivors of child sexual abuse, sexual assault, and intimate partner violence. Trauma, Violence, Abuse. 2018;19(5):512–27. pmid:27803311
- 88. Riley ED, Shumway M, Knight KR, Guzman D, Cohen J, Weiser SD. Risk factors for stimulant use among homeless and unstably housed adult women. Drug alcohol depend. 2015;153:173–9. pmid:26070454
- 89. Springer KW, Sheridan J, Kuo D, Carnes M. Long-term physical and mental health consequences of childhood physical abuse: Results from a large population-based sample of men and women. Child Abuse Neglect. 2007;31(5):517–30. pmid:17532465
- 90. Tyler , Gervais SJ, Davidson MM. The relationship between victimization and substance use among homeless and runaway female adolescents. J. Interpers. Violence. 2013;28(3):474–93. pmid:22935946
- 91. Tatarsky A, Marlatt GA. State of the art in harm reduction psychotherapy: An emerging treatment for substance misuse. J Clin Psychol. 2010;66(2):117–22. pmid:20049922
- 92. Hills F, Meyer-Weitz A, Asante KO. The lived experiences of street children in Durban, South Africa: Violence, substance use, and resilience. Int J Qual Stud Health Well-being. 2016;11(1):30302. pmid:27291160
- 93. Lyons M, Swahn MH, Whitaker D, Brown JR, Kasper J, Culbreth R. Associations of lifetime prevalence of homelessness with risky sex, sexual victimization, depressive symptoms, and suicidality among youth in Kampala, Uganda. Int Soc Work. 2017:0020872819847753.
- 94. Slesnick N, Erdem G, Collins J, Patton R, Buettner C. Prevalence of intimate partner violence reported by homeless youth in Columbus, Ohio. J. Interpers. Violence. 2010;25(9):1579–93. pmid:20056815
- 95. Larney S, Conroy E, Mills KL, Burns L, Teesson M. Factors associated with violent victimisation among homeless adults in Sydney, Australia. Aust. N. Z. J. Public Health 2009;33(4):347–51. pmid:19689595
- 96. Hudson AL, Wright K, Bhattacharya D, Sinha K, Nyamathi A, Marfisee M. Correlates of adult assault among homeless women. J Health Care Poor Underserved 2010;21(4):1250–62. pmid:21099076
- 97. Tyler KA, Wright JD. Homelessness and sexual assault. Handbook of sexual assault and sexual assault prevention 2019:693–707.
- 98. Wenzel SL, Leake BD, Gelberg L. Health of homeless women with recent experience of rape. J Gen Intern Med. 2000;15(4):265–8. pmid:10760002
- 99. Kuhns JB III. The dynamic nature of the drug use/serious violence relationship: a multi-causal approach. Violence Vict. 2005;20(4):433–54. pmid:16250410
- 100. Stretesky PB, Pogrebin MR. Gang-related gun violence: Socialization, identity, and self. J. Contemp. Ethnogr. 2007;36(1):85–114.
- 101. May T, Hough M. Drug markets and distribution systems. Addict Res Theory. 2004;12(6):549–63.
- 102. Affinnih YH. Pilot study of the relationship between drug misuse and violence among drug addicts in Greater Accra, Ghana: the south of Saharan Africa case. Subst Use Misuse. 2005;40(6):813–22. pmid:15974141
- 103. Hadland SE, Marshall BD, Kerr T, Qi J, Montaner JS, Wood E. Depressive symptoms and patterns of drug use among street youth. J Adolesc Health. 2011;48(6):585–90. pmid:21575818
- 104. Didenko E, Pankratz N. Substance use: Pathways to homelessness? Or a way of adapting to street life. Visions: BC’s Mental Health and Addictions Journa. 2007;4(1):9–10.
- 105. Dunnegan SW. Violence, trauma and substance abuse. J Psychoactive Drugs. 1997;29(4):345–51. pmid:9460028
- 106. Mburu G, Ayon S, Tsai AC, Ndimbii J, Wang B, Strathdee S, et al. "Who has ever loved a drug addict? It’s a lie. They think a ’teja’ is as bad person": multiple stigmas faced by women who inject drugs in coastal Kenya. Harm Reduct. J. 2018;15(1):29-. pmid:29801494
- 107. Geissler LJ, Bormann CA, Kwiatkowski CF, Braucht GN, Reichardt CS. Women, homelessness, and substance abuse: Moving beyond the stereotypes. Psychol Women Q. 1995;19(1):65–83.