International Journal of Drug Policy - 2014

Volume 25 Issue 3 May 2014

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Page 56 of 153

K.R. Knight et al. / International Journal of Drug Policy 25 (2014) 556–561 557 1988; Hanrahan, Luchins, Savage, & Goldman, 2001; Nagy, Fisher, & Tessler, 1998), there is a need to understand how housing policies shape specific built environments, which in turn impact women at risk for poor mental health outcomes and substance abuse. This paper analyzes the role of place, specifically single room occupancy (SRO) hotel rooms, in exacerbating and ameliorating negative men- tal health outcomes for substance using, urban poor women. Urban housing environments have received increasing atten- tion as sites that can both contribute to health and produce harm (Freudenberg, Galea, & Vlahov, 2005; Northridge, Sclar, & Biswas, 2003; Vlahov et al., 2007), and there is growing evidence linking the built environment to mental health (Evans, 2003; Frumkin, 2003; Halpern, 1995; Parr, 2000). Contributing factors include neigh- borhood conditions (Cohen et al., 2003; Dalgard & Tambs, 1997; Johnson, Ladd, & Ludwig, 2002; Leventhal & Brooks-Gunn, 2000; Wandersman & Nation, 1998), poor housing quality (Evans, Wells, & Moch, 2003; Freeman, 1984), crowding and lack of privacy (Baum & Paulus, 1987; Evans & Lepore, 1993; Wener & Keys, 1988), and noise (Stansfeld, 1993), which negatively impact depression (Galea et al., 2005; Weich et al., 2002), social support (Evans & Lepore, 1993; McCarthy & Saegert, 1979) and recovery from cognitive fatigue and stress (Frumkin, 2001; Ulrich, 1991). Living in an SRO, when compared to living in other housing envi- ronments, has been associated with higher rates of HIV infection, emergency room use, recent incarceration, having been physi- cally assaulted, crack cocaine smoking, and cocaine, heroin, and methamphetamine injection (Evans & Strathdee, 2006; Shannon, Ishida, Lai, & Tyndall, 2006). Further, Lazarus, Chettiar, Deering, Nabess, and Shannon (2011) demonstrate that the specific organi- zation and management of SROs creates a gendered vulnerability to violence and sexual risk taking among women. Political-economic theories which account for the role place (Bourgois & Schonberg, 2009; Fullilove, 2013; Popay et al., 2003; Rabinow, 2003) have included an analysis of the structural-level policies responsible for the creation of built environments through the use of public funds. Drawing from this example, we adapt Rhodes (2002, 2009) "risk environment" framework to argue that SROs can operate as "men- tal health risk environments" for urban poor women. Consistent with the risk environment framework (Rhodes, Singer, Bourgois, Friedman, & Strathdee, 2005; Rhodes et al., 2012), our analysis examines the interplay between: (1) housing policies addressing comorbid substance use and mental illness as a macro-level fac- tor shaping the built environments of SROs, (2) meso-level factors such as the management of social relationships within SROs, includ- ing drug/sex economy involvement, and (3) micro-level individual behaviors related to drug use and trauma management enacted within SROs. Our application of the risk environment framework to SROs offers potential contributions in the areas of theory, methodol- ogy, and health policy. Theoretically, our analysis foregrounds how specific constructions of urban space may exacerbate women's co-occurring mental health issues and substance use. Methodolog- ically, we employ qualitative methods to examine the relationship between space, drug use, and mental health to reveal the link- ages between housing policies, the socio-structural organization of urban built environments and everyday behaviors. In terms of health policy, our analysis highlights the importance of consid- ering comorbidity in housing policy for active substance users, particularly the role of trauma-sensitive housing environments for unstably housed women who use illicit drugs. Methods Our participants were recruited from a larger epidemiological study, the "Shelter, Health and Drug Outcomes among Women" (SHADOW), a cohort study of homeless and unstably housed women living in San Francisco (Riley et al., 2007). A qualitative sub-sample (n = 30) was selected from the larger SHADOW cohort. Consistent with qualitative study designs, the sample was not representative of the larger cohort (Silverman & Marvasti, 2008). Rather, we purposefully sampled (Coyne, 1997; Higginbottom, 2004) women illustrative of a set of issues (recent physical and/or sexual victimization, unprotected sex, and needle sharing) previ- ously described in the epidemiological literature to be relevant to unstably housed women (Coughlin, 2011). Women in the sub- sample underwent a separate consent process and took part in approximately hour-long taped interviews with trained qualita- tive researchers (Knight, Lopez, and Cohen). During the interviews, participants were asked to describe their current and past living situations, current and past drug use, mental health (including experiences with diagnosis and psychiatric medications), sexual and friendship relationships, and experiences with violence and trauma. Participants completed a baseline, one-year, and 18-month follow up interview and were reimbursed $15 for each interview completed. All study procedures were approved by the Institu- tional Review Board at the University of California, San Francisco. In addition, the first author (Knight) conducted an independent, four-year (2007–2010) ethnographic study which included inter- views with housing and health policy-makers in San Francisco and a photo-ethnographic study of a variety of SRO hotel rooms. Over 500 photographs were taken during this timeframe in 25 different SRO hotels in San Francisco. Transcribed audio-recorded interviews from each study under- went a similar two-phase analysis, consistent with methods the authors have employed in several previous qualitative studies (Comfort, Grinstead, McCartney, Bourgois, & Knight, 2005; Knight et al., 1996, 2005). In phase one, the team of four analysts (three of whom were the interviewers) used grounded theory method- ologies (Strauss & Corbin, 1990) to construct memo summaries of each interview, which included basic background information, current circumstances, notable events and quotations, and analyst impressions and interpretations. Because previous research (Chan, Dennis, & Funk, 2008; Cohen et al., 2009; Hopper et al., 1997; Kushel et al., 2003; Luhrmann, 2008) indicated a potential relationship between lifetime histories of traumatic exposure, housing instabil- ity, current living situations, and sexual and drug use behaviors, we sought to keep narratives "intact" in the initial data analysis phase. The interview transcript and summaries were then discussed at a 2-h meeting devoted to analyzing each participant's interview. The team identified each narrative's micro, meso, and macro fac- tors for analysis. After the initial group analysis process, the team developed a preliminary codebook, which was amended through- out data collection. In phase two of analysis, interview transcripts were coded and entered into a qualitative data management soft- ware program (, to produce aggregate data for the entire qualitative sample. For the purposes of this analysis, memoed summaries and multiple aggregate sections of coded data (e.g., codes for housing, trauma, mental health, neighborhood) were analyzed. Photo-ethnographic data were coded by location, type of hotel, and date. Results Macro-level factors: housing policies shape SRO built environments in San Francisco The widespread implementation of mental health deinstitu- tionalization policies which took place in the 1970s and 1980s in California was not accompanied by structured housing plans for the uptake of mentally ill persons now residing in the community (Lamb, 1984). Thus, community reintegration of adults with dis- abling mental illnesses created a housing need, which was largely

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