Capturing the Dynamics of Homelessness through Ethnography and Mobile Technology

背景：某个晚上，大约有40，000名退伍军人无家可归，另有300，000人面临危险。许多 这些退伍军人有着复杂的健康和社会需求，他们经历着频繁的居住过渡 这可能会破坏医疗保健和治疗依从性。许多住房不稳定的人 经历频繁的住宅过渡，例如从过渡住房到庇护所，或从与 家人/朋友住在车里。这种转变造成的破坏可能会导致这一人口的 健康状况不佳，妨碍获得护理和坚持治疗。尽管有潜在的危害，但仍有一个 在这些过渡的详细背景知识方面存在重大差距，特别是从 个人经历他们-如他们的情绪，行为，地理运动， 社会抚养费填补这一空白将改善对退伍军人进出美国的轨迹的了解。 无家可归及其在获得保健和其他服务方面的日常障碍。需要采取新的办法。 研究表明，大多数无家可归的人都有移动的电话，而且越来越多的人使用移动电话。 它们是智能手机。这提供了以相对较低的成本收集接近实时信息的机会， 这将有助于提高对退伍军人在住房、健康、情绪和服务使用方面变化的理解。 意义/影响：退伍军人无家可归是我们国家最严重的失败之一， VA医疗保健和社会服务系统。健康状况很差，无家可归者的预期寿命为10至20岁。 比居住人口短20年。这里提出的工作将有助于VA的优先事项， 改善获得护理的机会，增加虚拟护理/远程医疗，并改善无家可归的退伍军人的健康状况。 创新：我们提出了被动和主动移动的电话数据收集的第一个重要测试， 无家可归的退伍军人，包括使用全球定位系统（GPS）定位和生态瞬间 评估（EMA），以提高对环境、移动性和服务距离的理解。这些方法 可以改变卫生服务研究人员如何从边缘化和隐藏的人那里收集数据， 人口。这些技术可以识别微时间事件的序列，例如， 从一种住房类型过渡到下一种住房类型之前（和之后）的事件和经历， 或导致错过医疗保健机会的事件（例如，错过预约）。 具体目标：本研究评估了从无家可归的退伍军人中收集智能手机数据的可行性。 目标1：描述无家可归退伍军人的实时生活体验，包括日常活动， 与服务的互动，以及使用形成性人种学方法的住宅过渡; 目标2：完善和定制智能手机数据收集方法; 目标3：进行为期4周的智能手机数据收集演示，以评估其可接受性， 退伍军人经历无家可归的可能性。整合定量（GPS、EMA、移动的调查， 医疗记录）和定性数据;识别住宅转换的不同模式（或类型学）;以及， 评估居住过渡、流动性、情绪、健康服务和依从性之间的关联。 方法：目标1中使用人种学访谈方法;目标2中使用焦点小组和可用性评估。 目标2;目标3中的智能手机数据收集。 下一步/实施：使用本研究的方法和结果，下一步将开发 在退伍军人住房状况迅速恶化的时间点采取干预措施， 稳定或健康，以防止重大住房中断和健康危机。干预措施还将有助于 增加获得护理和坚持治疗的机会。

Background: On a given night around 40,000 Veterans are homeless and another 300,000 are at risk. Many of these Veterans have complex health and social needs, and they experience frequent residential transitions which can disrupt access to healthcare and treatment adherence. Many persons who are housing unstable experience frequent residential transitions, such as from transitional housing to shelter, or from doubled up with family/friend to living out of a car. Disruptions caused by such transitions likely contribute to this population's poor health by interfering with access to care and treatment adherence. Despite the potential harm, there is a major gap in detailed, contextual knowledge of these transitions, especially from the perspective of the individuals experiencing them – such as their in-the-moment emotions, behaviors, geographic movements, and social support. Filling this gap would improve knowledge of Veterans' trajectories into and out of homelessness and their day-to-day barriers to health care and other services. New approaches are needed. Research has shown that most persons experiencing homelessness have mobile phones, and increasingly they are smartphones. This provides an opportunity to gather near real-time information, at relatively low cost, that would help improve understanding of Veterans' changes in housing, health, mood, and use of services. Significance/Impact: Homelessness among Veterans represents one of the worst failures of our national and VA health care and social service systems. Health is poor, and life expectancy for homeless persons is 10 to 20 years shorter than for housed populations. The work proposed here will contribute to VA priorities of improving access to care, increasing virtual care/telehealth, and improving the health of homeless Veterans. Innovation: We propose the first significant test of passive and active mobile phone data collection among homeless Veterans, including the use of global positioning system (GPS) location and ecological momentary assessment (EMA) to improve understanding of context, mobility, and distance to services. These methods can change how health services researchers think about collecting data from marginalized and hidden populations. These techniques can identify sequences of micro-temporal events, for example teasing apart the events and experiences that immediately precede (and follow) the transition from one housing type to the next, or the events that led to a missed healthcare opportunity (e.g. a missed appointment). Specific Aims: This study assesses the feasibility of smartphone data collection from homeless Veterans. Aim 1: Characterize the real-time lived experience of homeless Veterans, including day-to-day activities, interactions with services, and residential transitions using a formative ethnographic approach; Aim 2: Refine and tailor smartphone data collection methods; Aim 3: Conduct a 4-week demonstration of smartphone data collection to evaluate its acceptability and feasibility with Veterans experiencing homelessness. Integrate quantitative (GPS, EMA, mobile survey, medical records) and qualitative data; identify distinct patterns (or typologies) of residential transitions; and, assess associations among residential transitions, mobility, mood, health services, and adherence. Methodology: Ethnographic interview methods are used in Aim 1; focus groups and usability assessments in Aim 2; and smartphone data collection in Aim 3. Next Steps/Implementation: Using the methods and findings from this study, next steps will be to develop interventions to identify and intervene at timepoints when there is rapid deterioration in Veterans' housing stability or health to prevent major housing disruptions and health crises. Interventions will also contribute to enhancing access to care and adherence to treatments.