Motivation to stop substance use and psychological and environmental characteristics of homeless women

Characteristics associated with wanting to permanently quit their alcohol, cocaine or heroine use were examined in 748 homeless women. Only a third of Latinas wanted to stop using alcohol; they were also at relatively high risk for continued heroine use. Recognition that their substance use was an extremely serious problem was a consistent predictor of wanting to quit substance use. Other important predictors of desiring to quit two substances included not hanging out with other drug users, lifetime hospitalization for drug use and recent substance use treatment. Findings from this study may be helpful for selecting relative good candidates for the limited number of substance abuse treatment slots available for homeless women and providing supplementary assistance to those already in treatment. D 2004 Published by Elsevier Ltd.


Introduction
Substance use can increase homeless women's risk for diseases such as Acquired Immunodeficiency Syndrome (AIDS) and Hepatitis B and C (Nyamathi et al., 2002); predispose them to victimization and unintended pregnancy (Nyamathi, Wenzel, Lesser, Flaskerud, and Leake (2001); and prevent them from exiting their homeless state (Zierler & Krieger, 1997). Thus, motivation to quit substance use is a crucial psychosocial characteristic of homeless women. This study identified factors associated with homeless women's motivation to quit using alcohol, cocaine, and heroin.

Method
Women in this study were drawn from a purposive sample of 1325 homeless women residing in 1 of 47 traditional or sober living shelters or contacted through street outreach in Los Angeles. Data were collected between 1994 and 1996. Women were eligible if homeless and 18 or over. A homeless woman was defined as one who had spent the previous night in a shelter, hotel, motel, or home of a relative or friend and was uncertain as to her residence in the next 60 days or who stated that she did not have a home or house of her own in which to reside. Among the original sample, 748 (56%) of the women had used alcohol, cocaine, or heroin in the past year. Data provided by these 748 women were used in this study.

Measures
Motivation to quit substance use was assessed by asking the women about their goals with respect to use. Respondents were asked to select one of seven goals ranging from ''I don't have a clear goal in mind'' to ''I want to quit using [substance] once and for all and to be totally abstinent.'' This last goal was used to indicate motivation to quit.
Sociodemographic predictors tested in this analyses were age, ethnicity, education, usual living place in the past month, whether respondents had ever been incarcerated for drug or alcohol offenses, receipt of public benefits, and number of homeless episodes in their lifetime. Closeness of the family during childhood was measured by a single item with a five-point response set ranging from very close to not close at all.
Substance use initiation was examined in terms of individuals who played an important role in the process. Respondents were asked whether the following persons had been particularly influential in their decision to use alcohol or drugs: friends or peers, a boyfriend or husband, themselves, their mother or father, and other relatives.
Perceived severity of substance use problems was measured by a single item. Women were asked to rate how serious they thought their alcohol/drug problem had become on a Likert scale ranging from (1) not at all serious to (5) extremely serious.
Barriers to action were assessed by several measures. First, the women were asked (1) whether they were hanging out or living with others involved in drugs, and (2) whether three specific factors that had been identified in previous qualitative analyses (Nyamathi Bayley, Anderson, Keenan, & Leake, 1999) would influence them to continue using drugs or alcohol. These factors were the following: enjoying the fun/socializing, forgetting about their problems, and enjoying the high. An index of reasons to continue substance use was formed by summing the number of ''yes'' responses.
Additional barriers included the percent of their lifetime spent using each substance and whether their substance use was heavy enough to suggest abuse/dependence. Heavy substance use was defined as daily use in the past 6 months. Daily drug and/or alcohol use over an extended period strongly suggests physiological or psychological dependence and has been found to be associated with a variety of social problems (Anglin & Hser, 1990).
Benefits of action were assessed by the women's perceived negative effects of their substance use. Specifically, the women were asked whether or not their alcohol/drug problem had negatively affected their lives by causing them to experience the following: lose everything, mess up their life, have poor health, lose their family or friends, become sick, become depressed, have sex for money or drugs, become moody or angry, or become sleepy. Positive responses to these potentially detrimental results of substance use, which had previously been identified in qualitative analyses (Nyamathi et al., 1999), were summed to form an index of negative substance use impacts.
Health-related cues to action included physical and mental health status, self-esteem, active coping, life satisfaction, social support, and utilization of health services. Respondents were asked to rate their physical health on a five-point scale from excellent to poor. This item has been used in a number of health surveys as a valid overall indicator of physical health (Aday, 1991). Mental health was measured by the five-item Mental Health Index (Stewart, Hays, & Ware, 1988). Active coping was measured by a 17-item instrument used in the Medical Outcomes Study (Ware & Sherbourne, 1992). Life satisfaction was measured by a single item. The women were shown a series of faces and asked to select the face that came closest to how they felt about life in general. Possible responses on a seven-point scale ranged from (1) delighted to (7) terrible. Social support in childhood was assessed by asking women who had most negatively influenced their attitudes and behaviors when they were adolescents. Current social support was measured by five items used in the RAND Course of Homelessness Study (Burnam & Koegel, 1989). Self-esteem was measured by a revised version of the Coopersmith Self Esteem Inventory (1967). Health services utilization was assessed by items inquiring about recent use of both preventive health services and substance abuse services.

Results
The women had a mean age of 33 (S.D. = 8.8) and a mean education of 11 years (S.D. = 2.4). About half (52%) were African-American, 31% were Latina, and 17% were White or others (6 identified with other racial/ethnic groups). Almost one third (31%) used alcohol only; 32% reported alcohol and cocaine use; 12% reported use of alcohol, cocaine, and heroin; and 11% reported cocaine use only. Relatively few (4%) reported using heroin only. Among women using cocaine, 72% scored high on motivation to quit (i.e., wanted to quit completely and permanently). The figures for heroin and alcohol use were 62% and 56%, respectively.
A number of factors were significantly related to homeless women's motivation to quit ( P < .01 for odds ratios). Several were associated with wanting to quit at least two of the three substances. These were the following: perceiving substance use as a serious problem (OR = 3.56 for alcohol users and 4.13 for heroin users), fewer perceived benefits of use (OR = 0.80 for alcohol users and 0.75 for cocaine users), not hanging out or living with drug users (OR = 0.46 for alcohol users and 0.40 for cocaine users), lifetime drug hospitalization (OR = 2.15 for cocaine users and 6.01 for heroin users), and recent substance abuse treatment (OR = 1.72 for alcohol users and 2.19 for cocaine users). Women who reported a greater number of preventive health screens (OR = 1.31 for alcohol users), high family intimacy in childhood (OR = 1.66 for heroin users), and more education (OR = 1,16 for cocaine users) were more motivated to quit. Moreover, daily substance use was negatively related to motivation to quit (OR = 0.24) among heroin users and unrelated to motivation to quit among either alcohol or cocaine users.
Finally, one third of the Latinas wanted to stop alcohol use compared to over 60% of African-American and Caucasian women. Similarly, only 53% of the Latinas versus 80% of the other two ethnic groups stated that they had an interest in quitting heroin use.

Discussion
These findings are consistent with research indicating that motivation to quit is often more closely associated with subjective recognition of substance use problems than with objective indicators of such problems (e.g., Carroll & Rounsaville, 1992). Hanging out or living with a drug-using partner or others who use drugs may be among the life circumstances most difficult for a homeless woman to change. She may have strong emotional ties to her partner or friends, and their drug use may signal the woman's immersion in a wider social context of dangerous or chaotic lifestyles. The results of this study indicate that women not associated with drug-using others were more likely to want to quit substance use. They may, in addition, find it less difficult to abstain inasmuch as they are not tempted by the presence of drugs in their immediate environment. On the other hand, abstinence support for women whose partners or friends do use drugs may require special training in resistance skills and other strategies by which the influence of their drug-using support sources can be lessened.
Additional results underscore the importance of social marginality in that women who were receiving preventive health screens (alcohol users), high family intimacy in childhood ( heroin users), and more education (cocaine users) were more motivated to quit. Thus, women whose motivation to quit is low may be chronically disconnected from conventional formal and informal sources of help and may find it difficult to interact successfully and comfortably in conventional health care and other social settings. Moreover, as Latinas may be at greater risk for continued substance use than women in other groups, further studies need to be conducted to better understand these factors and test effective interventions targeting this group.
Quitting alcohol or drugs can be very difficult for any substance user, especially for a homeless woman entrenched in a subculture of negative influences and preoccupied with daily survival. Results from this study can be used to improve the likelihood that homeless women will enter and benefit from substance abuse treatment. By identifying homeless female substance users highly motivated to stop use and facilitating both referral of these women for substance abuse treatment and their successful early engagement in treatment, we may make more cost-effective use of available treatment slots. Conversely, it is also important to identify homeless women with low motivation to abstain from substance use so that appropriate interventions, including pretreatment motivational intervention, can be targeted to them.