Capturing the Dynamics of Homelessness through Ethnography and Mobile Technology

背景：在一个晚上，大约有40,000名退伍军人无家可归，另有300,000人处于危险之中。许多 这些退伍军人中，有复杂的健康和社会需求，他们经历了频繁的住所转换 这可能会扰乱获得医疗保健和坚持治疗的机会。许多住房不稳定的人 经历频繁的住宅转变，例如从过渡性住房过渡到避难所，或从与 从家人/朋友到住在车里。这样的转变造成的干扰可能会导致这个人口的 妨碍获得护理和坚持治疗，从而导致健康状况不佳。尽管有潜在的危害，但有一个 在对这些过渡的详细背景知识方面存在重大差距，特别是从 体验它们的个人-例如他们的即时情绪、行为、地理运动和 社会支持。填补这一空白将提高对退伍军人进出轨迹的了解 无家可归者及其在卫生保健和其他服务方面的日常障碍。需要新的方法。 研究表明，大多数无家可归的人都有手机，而且越来越多 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的信息的机会， 这将有助于更好地了解退伍军人在住房、健康、情绪和服务使用方面的变化。 意义/影响：退伍军人中的无家可归者是我们国家和 退伍军人事务部医疗保健和社会服务体系。健康状况不佳，无家可归者的预期寿命为10%至10% 比居住人口短20年。这里建议的工作将有助于退伍军人管理局的优先事项 改善获得护理的机会，增加虚拟护理/远程保健，并改善无家可归退伍军人的健康状况。 创新：我们提出了被动和主动手机数据收集的第一个重大测试 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了解。这些方法 可以改变卫生服务研究人员从边缘化和隐蔽的人那里收集数据的方式 人口。这些技术可以识别微时间事件的序列，例如梳理 紧接在从一种住房类型过渡到另一种住房类型之前(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：这项研究评估了智能手机收集无家可归退伍军人数据的可行性。 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，以及使用形成性民族志方法的住宅转型； 目标2：改进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，以评估其可接受性和 退伍军人经历无家可归的可行性。集成定量(GPS、EMA、移动调查、 医疗记录)和定性数据；确定不同的居住过渡模式(或类型)；以及， 评估居住转变、流动性、情绪、健康服务和坚持性之间的关联。 方法：目标1采用人种学访谈方法；目标1采用焦点小组和可用性评估 AIM 2；以及AIM 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发现，下一步将制定 在退伍军人住房迅速恶化的时间点确定和干预的干预措施 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 加强获得护理的机会和坚持接受治疗。

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.