Not getting by: Poverty management and homelessness in Miami

Urban inequality has emerged as one of the dominant themes of modern life and globalization. More than three million people experienced homelessness in the United States last year; in Miami-Dade, more than 15,000 individuals were homeless. Surviving extreme poverty, and exiting or avoiding homelessness, involves negotiating a complex mix of public and private assistance. However, a range of factors influence what types of help are available and how they can be accessed. Frequently, larger social structures determine which resource are available, leaving many choices entirely out of the individual's control. For single men, who are ineligible for many benefits, homelessness can be difficult to avoid and even harder to exit. My study seeks to better understand how adult, minority men living in extreme poverty in Miami-Dade negotiate their daily survival. Specific research questions address: Do black and Hispanic men who are homeless or at risk of homelessness have different personal characteristics and different experiences in avoiding or exiting homelessness? How does Miami's response to extreme poverty/homelessness, including availability of public benefits and public and private service organizations, either maximize or constrain the choices available to this population? And, what is the actual experience of single, adult men who are homeless or at risk of homelessness, in negotiating their daily survival? A mixed methods approach combines quantitative survey data from 7,605 homeless men, with qualitative data from 54 semi-structured interviews incorporating the visual ethnography techniques of Photo Elicitation Interviewing. Results show the differences experienced by black and Hispanic men who are poor and homeless in Miami. Findings also highlight how the community's official and unofficial responses to homelessness intersect with the actual experiences of the persons targeted by the policies and programs, challenging preconceived notions regarding the lives of persons living in extreme poverty. It adds to the existing body of literature by focusing on the urban Miami context, emphasizing disparities amongst racial and ethnic groups. Findings are intended to provide an empirically grounded thesis that humanizes the subjects and illuminates their personal experiences, helping to inform public policy around the needs of extremely poor populations.

Not Getting By: Poverty Management and Homelessness in Miami

Urban inequality has emerged as one of the dominant themes of modern life and globalization. More than three million people experienced homelessness in the United States last year; in Miami-Dade, more than 15,000 individuals were homeless. Surviving extreme poverty, and exiting or avoiding homelessness, involves negotiating a complex mix of public and private assistance. However, a range of factors influence what types of help are available and how they can be accessed. Frequently, larger social structures determine which resource are available, leaving many choices entirely out of the individual’s control. For single men, who are ineligible for many benefits, homelessness can be difficult to avoid and even harder to exit. My study seeks to better understand how adult, minority men living in extreme poverty in Miami-Dade negotiate their daily survival. Specific research questions address: Do black and Hispanic men who are homeless or at risk of homelessness have different personal characteristics and different experiences in avoiding or exiting homelessness? How does Miami’s response to extreme poverty/homelessness, including availability of public benefits and public and private service organizations, either maximize or constrain the choices available to this population? And, what is the actual experience of single, adult men who are homeless or at risk of homelessness, in negotiating their daily survival? A mixed methods approach combines quantitative survey data from 7,605 homeless men, with qualitative data from 54 semi-structured interviews incorporating the visual ethnography techniques of Photo Elicitation Interviewing. Results show the differences experienced by black and Hispanic men who are poor and homeless in Miami. Findings also highlight how the community’s official and unofficial responses to homelessness intersect with the actual experiences of the persons targeted by the policies and programs, challenging preconceived notions regarding the lives of persons living in extreme poverty. It adds to the existing body of literature by focusing on the urban Miami context, emphasizing disparities amongst racial and ethnic groups. Findings are intended to provide an empirically grounded thesis that humanizes the subjects and illuminates their personal experiences, helping to inform public policy around the needs of extremely poor populations.

Barriers and facilitators of a designated driver program

The general aim of designated driver programs is to reduce the level of drink driving by encouraging potential drivers to travel with a driver who has abstained from (or at least limited) consuming alcohol. Designated driver programs are quite widespread around the world, however a limited number have been rigorously evaluated. This paper reports the qualitative results from an evaluation of a designated driver program known as ‘Skipper’, in a provincial city in Queensland. Focus groups were conducted with 108 individuals from the intervention area. These focus groups aimed to assess the barriers and facilitators to the programs’ effectiveness by obtaining information about the patrons’ views on various aspects of the program, as well as designated driver and travelling after drinking more generally. A brief questionnaire was also given to participants in order to present responses in terms of the participants’ characteristics. Results suggest general support for the designated driver concept and the ‘Skipper’ program specifically. Facilitating factors reported by participants included the media coverage highlighting the risks associated with drink driving and the social acceptability of choosing not to drink. However, there was also some suggestion that the impact of the program was mainly to encourage those who already engage in designated driver behaviour to continue doing so, rather than encouraging the uptake of the behaviour among potential new users. Some of the suggested barriers to this kind of behaviour change include: social pressure to drink; alcohol dependency; and a failure to plan ahead.

Developing the Practice of Early Intervention into Youth Homelessness

The Australian government has found that early intervention services related to youth homelessness expanded through the Reconnect program have been found to be quite effective and successful. The main things that a good early intervention practice requires are highlighted.

Participatory approach to support community development of rural craftspeople

This paper presents a case study of the participatory project in the Jombang glass bead craft industry. Economic instability has brought significant business challenges in the community. The involvement of outsiders to collaborate with craftspeople in order to support business innovation as well as strengthen the social capital in the community is essential. However, facilitating a rural community to formulate and implement bottom-up planning needs an integrated approach. In this paper, we explain a participatory project in the rural craftspeople community that resulted in a collective action. The project aimed at uniting and empowering rural craftspeople focusing on the unique skills and knowledge of participants. There are some aspects influencing the success of collective action: the ability to understand the local political situation; the role of facilitators to respect and support the unique potential of craftspeople; and the economic benefit of the program.

Developing and evaluating interventions that are applicable and relevant to inpatients and those who care for them; a multiphase, pragmatic action research approach

Background Randomised controlled trials may be of limited use to evaluate the multidisciplinary and multimodal interventions required to effectively treat complex patients in routine clinical practice; pragmatic action research approaches may provide a suitable alternative. Methods A multiphase, pragmatic, action research based approach was developed to identify and overcome barriers to nutritional care in patients admitted to a metropolitan hospital hip-fracture unit. Results Four sequential action research cycles built upon baseline data including 614 acute hip-fracture inpatients and 30 purposefully sampled clinicians. Reports from Phase I identified barriers to nutrition screening and assessment. Phase II reported post-fracture protein-energy intakes and intake barriers. Phase III built on earlier results; an explanatory mixed-methods study expanded and explored additional barriers and facilitators to nutritional care. Subsequent changes to routine clinical practice were developed and implemented by the treating team between Phase III and IV. These were implemented as a new multidisciplinary, multimodal nutritional model of care. A quasi-experimental controlled, ‘before-and-after’ study was then used to compare the new model of care with an individualised nutritional care model. Engagement of the multidisciplinary team in a multiphase, pragmatic action research intervention doubled energy and protein intakes, tripled return home discharge rates, and effected a 75% reduction in nutritional deterioration during admission in a reflective cohort of hip-fracture inpatients. Conclusions This approach allowed research to be conducted as part of routine clinical practice, captured a more representative patient cohort than previously reported studies, and facilitated exploration of barriers and engagement of the multidisciplinary healthcare workers to identify and implement practical solutions. This study demonstrates substantially different findings to those previously reported, and is the first to demonstrate that multidisciplinary, multimodal nutrition care reduces intake barriers, delivers a higher proportional increase in protein and energy intake compared with baseline than other published intervention studies, and improves patient outcomes when compared with individualised nutrition care. The findings are considered highly relevant to clinical practice and have high translation validity. The authors strongly encourage the development of similar study designs to investigate complex health problems in elderly, multi-morbid patient populations as a way to evaluate and change clinical practice.

Barriers to entering affordable home ownership for young people: A preliminary study from university students’ perspectives

Over the last two decades, housing affordability has been a problem for young people, and identified as factor leading to youth homelessness. The National Youth Commission Inquiry into Youth Homelessness developed a roadmap for preventing this problem (National Youth Commission, 2008). The roadmap recommends increasing the supply of affordable housing for young people as an important strategy to reduce the risk of homelessness problems. In addition, understanding the barriers and the needs of young people is a significant part of the development of a national affordable housing strategy. This paper explores issues encountered by young people when they enter the housing market as first home buyers. A short survey was conducted to review the barriers to entry, classified by income levels, housing cost and availability of affordable housing. In the current competitive job market, young people have minimal work experience, relatively low job security and low income. In addition to these barriers, participants also suggested other barriers towards the purchase of their first home, such as lack of knowledge of legal issues and lack of government funding. This study suggests the need for both government and educational support for young people around housing choices and the development of financial strategies to manage barriers towards owning their first home.

The palliative care link nurse role in nursing homes: barriers and facilitators

Aim. This paper is a report of a study to explore link nurses' views and experiences regarding the development, barriers and facilitators to the implementation of the role in palliative care in the nursing home.
Background. The delivery of palliative care in nursing homes is widely advocated; one approach is to develop the link nurse role to cascade good practice and training to nurses and other care staff to enhance patient care.
Method. A descriptive qualitative study was conducted with a purposive sample of 14 link nurses from 10 nursing homes in Northern Ireland during 2006. Three focus groups, composed of all Registered Nurses currently acting as link nurses in their nursing homes participated, and the data were audio recorded, fully transcribed and content analysed.
Findings. The link nurse system shows potential to enhance palliative care within nursing homes. However, link nurses experienced a number of difficulties in implementing education programmes. Facilitators of the role included external support, monthly meetings, access to a resource file and peer support among link nurses themselves. Lack of management support, a transient workforce and lack of adequate preparation for link nurses were barriers to fulfilling this role.
Conclusion. Whilst palliative care link nurses can improve care for residents in nursing homes, consideration must be given to overcome the types of barriers identified in order to enable the link nurse system to function effectively. © 2008 The Authors.

Positioning Clinical Nurse Specialists and Nurse Practitioners as Change Champions to Implement a Pain Protocol in Long-Term Care

Pain management for older adults in long-term care (LTC) has been recognized as a problem internationally. The purpose of this study was to explore the role of a clinical nurse specialist (CNS) and nurse practitioner (NP) as change champions during the implementation of an evidence-based pain protocol in LTC. In this exploratory, multiple-case design study, we collected data from two LTC homes in Ontario, Canada. Three data sources were used: participant observation of an NP and a CNS for 18 hours each over a 3-week period; CNS and NP diaries recording strategies, barriers, and facilitators to the implementation process; and interviews with members of the interdisciplinary team to explore perceptions about the NP and CNS role in implementing the pain protocol. Data were analyzed using thematic content analysis. The NP and CNS used a variety of effective strategies to promote pain management changes in practice including educational outreach with team members, reminders to nursing staff to highlight the pain protocol and educate about practice changes, chart audits and feedback to the nursing staff, interdisciplinary working group meetings, ad hoc meetings with nursing staff, and resident assessment using advanced skills. The CNS and NP are ideal champions to implement pain management protocols and likely other quality improvement initiatives.

A realist literature review of transition to adult services by young people with life-limiting conditions in ireland.

Background As a result of improvements in care and treatment more young people with life-limiting conditions are now living beyond childhood, meaning they must make the transition from children's to adult services. The loss of long-standing relationships with providers of children's services combines with poor co-ordination of services to make this a daunting prospect for young people and their families. However, there is little evidence on transition services for young people with life limiting conditions, with few models of good practice in the literature.


Aims The purpose of this review was to determine the factors that promote or hinder the transition to adult services for young adults with life limiting conditions, and identify gaps to be addressed.


Methods A comprehensive search of the literature was undertaken using key terms, of the following databases; MEDLINE and the Cochrane Database of Systematic Reviews. 314 articles were sourced and inclusion and exclusion criteria were applied to highlight the most relevant literature.


Results Studies were reviewed using a realist review approach and three themes emerged from the literature. Barriers and facilitators to the transition process were identified associated with: 1. The patient 2. Parents/carers 3. The organisation.


Conclusion It is unclear from the literature what the specific factors are that promote or hinder the transition process for young adults with life limiting conditions who go through the transition from children's to adult services, therefore, research is required to identify the factors that promote and hinder the transition process in Ireland. This research is currently being carried out by the author as part of Doctoral studies. The three year full time Doctoral study commenced in January 2013 and is funded by the All Ireland Institute of Hospice and Palliative Care.

Caught in a 'spiral': barriers to healthy eating and dietary health promotion needs from the perspective of unemployed young people and their service providers

The number of young people in Europe who are not in education, employment or training (NEET) is increasing. Given that young people from disadvantaged backgrounds tend to have diets of poor nutritional quality, this exploratory study sought to understand barriers and facilitators to healthy eating and dietary health promotion needs of unemployed young people aged 16-20 years. Three focus group discussions were held with young people (n=14). Six individual interviews and one paired interview with service providers (n=7). Data were recorded, transcribed verbatim and thematically content analysed. Themes were then fitted to social cognitive theory (SCT). Despite understanding of the principles of healthy eating, a ‘spiral’ of interrelated social, economic and associated psychological problems was perceived to render food and health of little value and low priority for the young people. The story related by the young people and corroborated by the service providers was of a lack of personal and vicarious experience with food. External, environmental factors such as the proliferation and proximity of fast food outlets and the high perceived cost of ‘healthy’ compared to ‘junk’ food rendered the young people low in self-efficacy and perceived control to make healthier food choices. Agency was instead expressed through consumption of junk food and substance abuse. Both the young people and service providers agreed that for dietary health promotion efforts to succeed, social problems needed addressed and agency encouraged through (individual and collective) active engagement of the young people themselves.

The Meaning of Drug Use among Homeless Young People:A longitudinal pathways analysis

A strong link between drug use and homelessness has long since been documented in the international literature. However, much of the research has concentrated on the direction of the relationship between drug use and homelessness, seeking to establish drug use as a cause or consequence of homelessness, with far less attention to the intersection of drug and homeless ‘careers’. This paper examines the drug and homeless pathways of young people who are participants in a qualitative longitudinal study of homeless youth in Dublin, Ireland. The findings highlight downward drug transitions as associated with exiting homelessness and continued or escalated consumption as associated with remaining homeless. Analyses of the meanings young people attach to drug use over time reveal the importance of housing as an enabler to engaging with treatment and as assisting the process of becoming and remaining drug free. Young people who remained homeless did not accept their situations, as ‘acculturation’ accounts would suggest; rather, they aspired to changing their situations. However, they also face strong barriers to accessing housing which in turn hamper their efforts to address the matter of their drug use. The implications for how the homeless/drug use ‘nexus’ is conceptualised and understood, as well as implications for policy, are discussed.

Improving appropriate polypharmacy for older people in primary care: selecting components of an evidence-based intervention to target prescribing and dispensing.

Background
The use of multiple medicines (polypharmacy) is increasingly common in older people. Ensuring that patients receive the most appropriate combinations of medications (appropriate polypharmacy) is a significant challenge. The quality of evidence to support the effectiveness of interventions to improve appropriate polypharmacy is low. Systematic identification of mediators of behaviour change, using the Theoretical Domains Framework (TDF), provides a theoretically robust evidence base to inform intervention design. This study aimed to (1) identify key theoretical domains that were perceived to influence the prescribing and dispensing of appropriate polypharmacy to older patients by general practitioners (GPs) and community pharmacists, and (2) map domains to associated behaviour change techniques (BCTs) to include as components of an intervention to improve appropriate polypharmacy in older people in primary care.

Methods
Semi-structured interviews were conducted with members of each healthcare professional (HCP) group using tailored topic guides based on TDF version 1 (12 domains). Questions covering each domain explored HCPs’ perceptions of barriers and facilitators to ensuring the prescribing and dispensing of appropriate polypharmacy to older people. Interviews were audio-recorded and transcribed verbatim. Data analysis involved the framework method and content analysis. Key domains were identified and mapped to BCTs based on established methods and discussion within the research team.

Results
Thirty HCPs were interviewed (15 GPs, 15 pharmacists). Eight key domains were identified, perceived to influence prescribing and dispensing of appropriate polypharmacy: ‘Skills’, ‘Beliefs about capabilities’, ‘Beliefs about consequences’, ‘Environmental context and resources’, ‘Memory, attention and decision processes’, ‘Social/professional role and identity’, ‘Social influences’ and ‘Behavioural regulation’. Following mapping, four BCTs were selected for inclusion in an intervention for GPs or pharmacists: ‘Action planning’, ‘Prompts/cues’, ‘Modelling or demonstrating of behaviour’ and ‘Salience of consequences’. An additional BCT (‘Social support or encouragement’) was selected for inclusion in a community pharmacy-based intervention in order to address barriers relating to interprofessional working that were encountered by pharmacists.

Conclusions
Selected BCTs will be operationalised in a theory-based intervention to improve appropriate polypharmacy for older people, to be delivered in GP practice and community pharmacy settings. Future research will involve development and feasibility testing of this intervention.

Propiedades psicométricas de la versión al español del cuestionario “Barriers to Being Active Quiz”, entre estudiantes universitarios de Colombia

Objetivo: El cuestionario Barriers to Being Active Quiz (BBAQ), indaga las barreras para ser físicamente activo. El cuestionario fue traducido al español por el mismo equipo que desarrolló la versión inglésa original, pero carece de estudios de validez en la versión española. El objetivo de esta investigación fue evaluar las propiedades psicométricas del BBAQ (en la versión completa de 21 ítems), centrándose en la fiabilidad y validez. Material y métodos: Un total de 2.634 (1.462 mujeres y 1.172 varones; 18-30 años de edad) estudiantes universitarios completaron el cuestionario BBAQ-21. El alfa de Crombach se estimó como indicador de consistencia interna. El coeficiente de correlación intra-clase (CCI) y el grado de acuerdo se calcularon para evaluar la estabilidad temporal con un periodo de 7 días entre ambas administraciones como estimadores de la reproducibilidad. Se aplicó un análisis factorial exploratorio (AFE) y confirmatorio (AFC) para analizar la validez del BBAQ-21 ítems. Resultados: El BBAQ-21 mostró valores de un alfa de Cronbach entre 0,812 y 0,844 y un CCI entre el 0,46 y 0,87. El porcentaje de acuerdo por todos los conceptos individuales varió de 45 a 80%. El AFE determinó cuatro factores que explicaron el 52,90% de la varianza y el AFC mostró moderadas cargas factoriales. Conclusiones: Los resultados obtenidos en este cuestionario avalan la utilización de este instrumento con este tipo de muestra, desde el punto de vista de la fiabilidad y validez. El BBAQ-21 está disponible para evaluar las barreras para la actividad física en América Latina.

E-learning opens the door to the global community. Novice users experiences of e-learning in a Somali University

E-learning has become one of the primary ways of delivering education around the globe. In Somalia, which is a country torn within and from the global community by a prolonged civil war, University of Hargeisa has in collaboration with Dalarna University in Sweden adopted, for the first time, e-learning. This study explores barriers and facilitators to e-learning usage, experienced by students in Somalia’s higher education, using the University of Hargeisa as case study. Interviews were conducted with students to explore how University of Hargeisa’s novice users perceived elearning, and what factors positively and negatively affected their e-learning experiences. The Unified Theory of Acceptance and Use of Technology (UTAUT) model was used as a framework for interpreting the results. The findings show that, in general, the students have a very positive attitude towards e-learning, and they perceived that e-learning enhanced their educational experience. The communication aspect was found to be especially important for Somali students, as it facilitated a feeling of belonging to the global community of students and scholars and alleviated the war-torn country’s isolation. However, some socio-cultural aspects of students’ communities negatively affected their e-learning experience. This study ends with recommendations based on the empirical findings to promote the use and enhance the experience of e-learning in post conflict Somali educational institutions