The comparison group of 216 families was enrolled from never-homeless families headed by women who were receiving Aid to Families with Dependent Children and who came to the Worcester Department of Public Welfare (DPW). To obtain a sample of low-income housed women, interviewers were stationed at the DPW office on rotating days of the week. Most of the women we recruited were coming to the DPW for a redetermination of their benefit eligibility, which requires a face-to-face appointment every 6 months.
We approached 395 housed women to take part in the study; 148 refused to participate, and 31 women did not complete the interview series. Those who refused to participate were similar to study participants with respect to age, marital status, and number of children. The housed women who refused to participate were less likely to have graduated from high school. The 31 women who did not complete the interviews were less likely to have completed high school but were otherwise similar.8
Data Collection
Information from homeless women and their families was collected during 3 or 4 interview sessions lasting a total of approximately 10 hours. The multisession format was used to reduce respondent fatigue and to allow time for the interviewers and respondents to develop a relationship. Informed consent was obtained before the initial interview. Homeless women were interviewed in a private room at the shelter; the comparison group of housed women were interviewed in their homes or at a community-based project office. The women received a $10 voucher redeemable at local stores for participation in each interview session.
During the interviews we gathered comprehensive demographic, income, and housing information. Whenever possible, we chose standardized interview instruments on the basis of their previous use with low-income and minority populations. We used existing Spanish versions of standardized instruments when they were available. All other questions were translated into Spanish by bilingual and bicultural translators. Because of the sensitive nature of some of the questions, our interviewers were women who earned a bachelor’s or master’s degree in an applied field, such as social work or psychology.
Using the modified Personal History Form,20 an instrument designed for use with homeless and low-income persons, we collected information about housing, income, education, jobs, and family life events. The Personal Assessment of Social Supports21 was used to determine the mother’s support and resource base. Study participants were asked to name as many as 7 people who played a role in their lives and the quality of the relationships they had with those people.
We used the New York Assessment Instrument for Women (NYAIW)22 to gather information about the mother’s lifetime experiences of physical and sexual victimization. The NYAIW includes established measures of intimate violence. We assessed the context of violent acts using the Conflict Tactics Scale.22 We determined lifetime prevalence of selected mental health and substance use disorders, including mood disorders, anxiety disorders, posttraumatic stress disorders, somatoform disorders, eating disorders, and alcohol and other drug abuse or dependence, using the nonpatient version of the structured clinical interview from the Diagnostic and Statistical Manual of Mental Disorders, 3rd Edition, Revised (DSM-III-R).23 Emotional distress was assessed using the Symptom Checklist 90-R global severity index,24 which provides a summary score that reflects the number of symptoms of distress in the last 7 days and their intensity across 9 symptom groups. We measured emotional strengths with the 10-item Rosenberg Self-Esteem Scale,25 and we assessed negative feelings about the future using the 20-item Beck Hopelessness Scale.26
We gathered substance use information using a series of questions specific to alcohol, cocaine, and other drugs. Frequent alcohol use was defined as consumption of 3 or more drinks every day or nearly every day during the last 2 years for housed mothers and in the 2 years before becoming homeless for the homeless mothers. Frequent use of marijuana, cocaine, heroin, or sedatives was defined as using the substance at least 3 or 4 times a month in the same time frame as specified for the measure of alcohol use. We also asked each respondent if she had ever used an intravenous drug.
Using questions from the National Health Interview Survey (NHIS),27 we asked women whether they had ever received a diagnosis of selected medical conditions and if they still suffered from the condition. Sexually transmitted diseases included gonorrhea, syphilis, herpes, chlamydia, pelvic infection, genital warts, and HIV/AIDS.
We asked women questions related to HIV knowledge, self-perception of risk, and risk practices for HIV infection. We assessed HIV knowledge using 18 questions taken from the NHIS28 and scored them according to the number of correct responses. Women with less than 15 correct responses were scored as having poor HIV knowledge. We also asked the women if they perceived their HIV risk to be nonexistent, low, medium, or high. We recorded sexual practices, including age at time of first sexual contact, number of lifetime partners, number of partners in the last 6 months, amount of unprotected sex within the past 6 months, and any partners with HIV or a history of intravenous drug use. The primary study outcome—high HIV-risk behavior—was assessed using criteria from previous studies.29-32 Women who responded affirmatively to any of the following factors were defined as being at high risk for HIV infection: history of intravenous drug use, a sexual partner who was either HIV-positive or an intravenous drug user, having ever had a sexually transmitted disease, or having had multiple partners in the last 6 months with whom they did not use a condom on at least one occasion. Additional questions included whether they had made changes in their sexual practices because of the threat of HIV, and if they experienced any barriers to condom use. We also questioned women about HIV testing.