Spirituality and homelessness

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Spirituality affects both mental and physical health outcomes in the general United States population across different ethnic groups. [1] Because of the nuanced definitions of spirituality and religiosity, the literature on spirituality is not consistent in definitions or measures resulting in a lack of coherence. However, taken as a whole, research tends to show that the effect of spirituality is positive, associated with better health outcomes. [1] [2] For those who engage in spirituality, it may serve as a buffer from negative life events, often moderating the relationship between negative life experiences and levels of anxiety or depression. [3] The exception is when negative spiritual coping is practiced. This type of coping has negative health implications.

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The homeless are a vulnerable population that experiences the moderating effect of spirituality; spirituality plays a role in their emotional and mental capacity to handle challenges they face and practice health-promoting behaviors. For the homeless who practice spirituality as a positive coping mechanism, it often improves their life and is cited as a source of strength and comfort in qualitative research.

Spirituality

Definition

Spirituality does not have a clear definition, though it is generally regarded as the search for and experience of the sacred, meaning God, a higher power, or something of divine nature. [4] [5] Spirituality is characterized as something experienced personally, an individualized process that involves personal or private beliefs. [4] [6] [7] However, it may involve the values of community and relationship, or an emphasis on the connectedness of people. Spirituality often emphasizes the integration of mind, body and spirit, and it can provide a sense of purpose or life significance. [6] [7]

There is considerable overlap in the definitions of religion and spirituality and, for this reason, they are often used interchangeably in the literature. [4] Religion, like spirituality, can provide people a sense of purpose or meaning through personal beliefs. The main distinguishing factor between religion and spirituality is that religion is generally practiced collectively with some type of structural or institutional reinforcement. [4] [5] [7] Both terms are multi-faceted and are typically measured along similar dimensions. [1] Common dimensions of spirituality/religion as defined by the National Institute of Healthcare Research and NIA/Fetzer Institute are as follows: [1] [4] [5]

These dimensions are simply two examples of measures used in the literature on spirituality. Because of the nebulous definition of spirituality in the literature, measures are not consistent across different studies resulting in a lack of coherence in the literature. However, there is a consensus in research done on spirituality that it influences health. This effect is generally positive with the exception of negative spiritual coping.

Effect on physical health

Spiritual wellbeing has been associated with positive physical health outcomes in research. [1] [2] [5] Spirituality reduces the likelihood of illness and is strongly related to increased longevity. [5] For example, it lowers the rate of heart disease, cirrhosis, emphysema, stroke, kidney failure, cancer mortality, overall mortality. [1] Spirituality also decreases blood pressure and cholesterol levels. [1] If someone does become ill or must endure surgery, they are likely to have a better recovery. [5] These effects may vary depending on the strictness of behavioral codes associated with a religion, the intensity of the person's practice of spirituality, and whether or not their spiritual experience is a positive one. [1] [5] If someone uses negative spiritual coping, the positive health benefits will not happen and the individual's health may be influenced negatively (see religious/spiritual coping section). [1]

Effect on mental health

Spirituality tends to improve mental health. [1] [5] Spirituality is associated with lower rates of suicide, anxiety disorders, and depression. [1] [5] In regards to depression, individuals who are more spiritually involved are more likely to recover. [1] In a review of forty-three studies, Rew and Wong (2006) found that religiosity and spirituality are important correlates of adolescent health with 84% of the literature indicating a positive correlation. [8] Spirituality also reduces the likelihood of drug/alcohol dependency or abuse and is associated with a more effective recovery from abuse/dependence. [1] While spirituality generally improves mental health, for individuals who use harmful forms of religious coping, spirituality is "correlated with impaired mental health and poorer resolution of negative life events." [1]

Religious/spiritual coping

There are two types of spiritual coping, positive and negative. Positive spiritual coping manifests itself as a strong relationship with God, seeking support from the community and a higher power, looking for meaning in life and helping others. [9] [10] Most people who practice spirituality engage in positive spiritual coping which is associated with improved mental and physical health. [9] [10]

Negative spiritual coping, a pattern distinct from positive spiritual coping, has negative health implications. Negative spiritual coping involves deferring all responsibility to God, feeling abandoned by God or blaming God for difficulties. [10] It often manifests itself as a less secure relationship with God, an ominous worldview and general spiritual discontent. [9] For those who engage in negative spiritual coping, it is related to significantly poorer physical and mental health outcomes as well as higher mortality. [10] In a study done by Pargament (1998), negative spiritual coping had differing negative health implications among different populations. For citizens of Oklahoma City who experienced the federal building bombing, it was associated with more post-traumatic stress disorder symptoms and higher levels of callousness. For college students, negative spiritual coping was associated with higher levels of emotional distress and poorer physical health. For hospital patients with physical ailments, negative spiritual coping was associated with higher levels of depression and lower quality of life. [9]

Role of spirituality in the lives of homeless people

A homeless person is an individual without a consistent, fixed nighttime residence or someone whose nighttime residence is a supervised shelter that provides temporary housing. [11] Homelessness is a chronic stressor producing reduced wellbeing. [12] Homeless populations are a vulnerable population experiencing a higher prevalence of mental and physical health problems as well as victimization and increased mortality rates. [11] Spirituality is one method some homeless individuals use to cope with their position of high vulnerability. Runquist and Reed (2007) found that spiritual perspective correlated positively with measures of wellbeing among the sample of homeless individuals surveyed and that measures of wellbeing correlated positively with self-rated health status. [11] Social capital resulting from spirituality or religion, according to Irwin (2008), is a critical factor to wellbeing among homeless populations. It increases the resource base of the individual enabling them to cope with their situation in healthier ways. [12]

Youth

Youth, typically defined as people between the ages of twelve and twenty-four, make up a large portion of the homeless population. [13] As they are a transient population, it is difficult to get an accurate count of homeless youth; the number is commonly thought to be somewhere between 1.3 and 2 million. [14] [15] [16] These youth have higher rates of mental health disorders, suicide, and drug/alcohol dependency due to the high amount of stressors in their lives. [15]

Spirituality is one of many coping mechanisms homeless youth employ in order to manage life on the streets as well as techniques such as avoidant coping, use of alcohol, interpersonal skills, problem-focused coping and self-reliance. [13] [15] Spirituality as a coping mechanism often serves as positive force in the lives of homeless youth. [13] [15] [16] Kidd (2003) surveyed 80 street youth on the topic of coping and found that spirituality gave meaning to suffering, enabling the youth to process negative emotion and retain some hope. [15] In interviews done by Lindsey et al. (2000), spirituality served as a resource to youth and empowered those engaged in spirituality to redirect their lives in a healthy manner. [16] A theme across multiple studies the coping mechanisms of homeless youth is that their beliefs act as a source of strength and comfort; many attribute their ability to survive to the direct intervention of a higher power or to their faith. [13] [15] [16] One individual in a group discussion conducted by Bender (2007) commented on his engagement with the divine as a source of comfort and survival saying, "The man upstairs is what helps me. Just knowing that he's there. There may be times when I feel like he's not there, but he's helping me out slowly." [13]

These positive effects of spirituality appear largely in qualitative work, meaning that the youth themselves associate spirituality with improved coping and better mental health. Youth who do not engage in spirituality thus do not use it as a coping mechanism and do not comment on it. There are no examples of negative religious coping among the youth in the studies cited. However, a quantitative study conducted by Kidd and Carroll revealed that spirituality was not associated with a lower suicide risk in homeless youth. [17]

Homeless man Homeless (8329924557).jpg
Homeless man

Men

For homeless men, specifically those suffering from a substance abuse problem or who are in crisis, spirituality often serves as a positive coping mechanism, giving meaning to life and is tied to a sense of peace. [18] [6] However, positive spiritual coping lessens in its effectiveness the longer someone is homeless and is not as effective for homeless men with mental health problems as for those who are alcohol/drug dependent or in crisis. [18] Many homeless men attribute their ability to get sober to their spirituality, though this may be a product of the spiritual nature of programs like Alcoholics Anonymous. [6] In a study done by Brush and McGee (2000) surveying homeless men in a shelter for recovery, 78% of the respondents commented on how their spiritual views influence their decisions and two-thirds agreed or strongly agreed "to seeking spiritual guidance in daily life experiences." [6]

Women

Women are the fastest growing segment of the homeless population, making up an estimated 32% of the population. [2] [4] [7] [19] Many of these women are single mothers. [4] African American women are disproportionately represented among homeless populations as a result of their increased vulnerability to socioeconomic structures. [2] Homeless women, irrespective of ethnicity, tend to have more health problems than the general public including higher rates of substance abuse and mental health issues, as well as prior victimization. [2] [7]

Spirituality is used as a coping mechanism by many women of various ethnicities to deal with the stress of being homeless and/or to recover from substance abuse. [4] [19] It serves as a source of emotional support as well as a motivating force for women to take care of themselves and their families in a healthy way. [7] [19] Many accredit God with their survival and ability to be clean, looking to their spirituality to guide them in parenting. [19] In a study by Shuler (1994), 42% of homeless women surveyed said their beliefs gave them strength and helped them survive. [20] For the women who considered prayer an effective coping mechanism, they experienced considerably less worries and depressive symptoms. [20] Increased spirituality is associated with less substance abuse; for women who do not use drugs or alcohol, religious/moral beliefs are often the basis of their decision. [7] [21] Higher levels of spirituality is also associated with a lowered risk of depression and suicide among homeless women as well as increased health-promoting behaviors. [7] [19]

African-American women

Research shows that African Americans as a population, especially women, tend to have higher levels of religious involvement and deep ties to faith and spirituality. [2] [22] This is the case for homeless African American women as well; spirituality plays a larger role as a coping mechanism for African American homeless women than other women. [2] Douglas et al. (2008) found that homeless African American women placed a higher importance on spirituality and that lower rates of spiritual well-being among African American homeless mothers resulted in higher anxiety, increased trauma, punitive parenting and child behavioral issues. A study done by Washington et al. (2009) in which older African American homeless women were interviewed found that spirituality was an important asset for these women. Through their faith, they felt empowered to take control of their lives. [22] These women's experience of spirituality also had a mediating effect on their worries and concerns. [22]

Related Research Articles

The meaning of spirituality has developed and expanded over time, and various meanings can be found alongside each other. Traditionally, spirituality referred to a religious process of re-formation which "aims to recover the original shape of man", oriented at "the image of God" as exemplified by the founders and sacred texts of the religions of the world. The term was used within early Christianity to refer to a life oriented toward the Holy Spirit and broadened during the Late Middle Ages to include mental aspects of life.

Psychology of religion consists of the application of psychological methods and interpretive frameworks to the diverse contents of religious traditions as well as to both religious and irreligious individuals. The various methods and frameworks can be summarized according to the classic distinction between the natural-scientific and human-scientific approaches. The first cluster amounts to objective, quantitative, and preferably experimental procedures for testing hypotheses about causal connections among the objects of one's study. In contrast, the human-scientific approach accesses the human world of experience using qualitative, phenomenological, and interpretive methods. This approach aims to discern meaningful, rather than causal, connections among the phenomena one seeks to understand.

The study of religiosity and intelligence explores the link between religiosity and intelligence or educational level. Religiosity and intelligence are both complex topics that include diverse variables, and the interactions among those variables are not always well understood. For instance, intelligence is often defined differently by different researchers; also, all scores from intelligence tests are only estimates of intelligence, because one cannot achieve concrete measurements of intelligence due to the concept’s abstract nature. Religiosity is also complex, in that it involves wide variations of interactions of religious beliefs, practices, behaviors, and affiliations, across a diverse array of cultures.

Gender is correlated with the prevalence of certain mental disorders, including depression, anxiety and somatic complaints. For example, women are more likely to be diagnosed with major depression, while men are more likely to be diagnosed with substance abuse and antisocial personality disorder. There are no marked gender differences in the diagnosis rates of disorders like schizophrenia and bipolar disorder. Men are at risk to suffer from post-traumatic stress disorder (PTSD) due to past violent experiences such as accidents, wars and witnessing death, and women are diagnosed with PTSD at higher rates due to experiences with sexual assault, rape and child sexual abuse. Nonbinary or genderqueer identification describes people who do not identify as either male or female. People who identify as nonbinary or gender queer show increased risk for depression, anxiety and post-traumatic stress disorder. People who identify as transgender demonstrate increased risk for depression, anxiety, and post-traumatic stress disorder.

Secular spirituality is the adherence to a spiritual philosophy without adherence to a religion. Secular spirituality emphasizes the inner peace of the individual, rather than a relationship with the divine. Secular spirituality is made up of the search for meaning outside of a religious institution; it considers one's relationship with the self, others, nature, and whatever else one considers to be the ultimate. Often, the goal of secular spirituality is living happily and/or helping others.

<span class="mw-page-title-main">Temptation</span> Desire to engage in short-term urges for enjoyment that threatens long-term goals

Temptation is a desire to engage in short-term urges for enjoyment that threatens long-term goals. In the context of some religions, temptation is the inclination to sin. Temptation also describes the coaxing or inducing a person into committing such an act, by manipulation or otherwise of curiosity, desire or fear of loss something important to a person.

In psychology, posttraumatic growth (PTG) is positive psychological change experienced as a result of struggling with highly challenging, highly stressful life circumstances. These circumstances represent significant challenges to the adaptive resources of the individual, and pose significant challenges to the individual's way of understanding the world and their place in it. Posttraumatic growth involves "life-changing" psychological shifts in thinking and relating to the world and the self, that contribute to a personal process of change, that is deeply meaningful.

<i>Handbook of Religion and Health</i>

Handbook of Religion and Health is a scholarly book about the relation of spirituality and religion with physical and mental health. Written by Harold G. Koenig, Michael E. McCullough, and David B. Larson, the book was published in the United States in 2001. The book has been discussed in magazines and reviewed in professional journals.

<i>Multidimensional Measurement of Religiousness/Spirituality for Use in Health Research</i>

Multidimensional Measurement of Religiousness/Spirituality for Use in Health Research is a report, originally published in 1999, by a Fetzer Institute / National Institute on Aging working group on the measurement of religion and spirituality. A revised version with a new preface was published in 2003. The book presents a series of 12 self-report questionnaire measures, each focused on a particular aspect of religiousness or spirituality, along with reviews of underlying theory and supporting research. The book's purpose is to provide validated measures of spiritual and religious factors in health research. The book includes the Brief Multidimensional Measure of Religiousness/Spirituality (BMMRS), a practical measure with selected items from the 12 previous chapters.

Scholarly studies have investigated the effects of religion on health. The World Health Organization (WHO) discerns four dimensions of health, namely physical, social, mental, and spiritual health. Having a religious belief may have both positive and negative impacts on health and morbidity.

Most scientists agree that religiosity is not an independent personality trait, despite there being some commonality between their characteristics. Religiosity and personality traits both relate to one's feelings, thoughts, and behaviors. However, unlike for personality, one's level of religiosity is often measured by the presence or lack of belief in and relationship with a higher power, certain lifestyles or behaviors adopted for a higher power, and a sense of belonging with other followers of one's religion. Additionally, personality traits tend to follow a normal distribution, such that the majority of individuals' scores for a personality trait will be concentrated towards the middle, rather than being extremely high or low. Distributions for religiosity, however, follow a non-normal distribution, such that there are more individuals who score particularly high or low on religiosity scales.

One of the most common ways that people cope with trauma is through the comfort found in religious or spiritual practices. Psychologists of religion have performed multiple studies to measure the positive and negative effects of this coping style. Leading researchers have split religious coping into two categories: positive religious coping and negative religious coping. Individuals who use positive religious coping are likely to seek spiritual support and look for meaning in a traumatic situation. Negative religious coping expresses conflict, question, and doubt regarding issues of God and faith.

The relationship between religion and schizophrenia is of particular interest to psychiatrists because of the similarities between religious experiences and psychotic episodes; religious experiences often involve auditory and/or visual phenomena, and those with schizophrenia commonly report hallucinations and delusions that may resemble the events found within a religious experience. In general, religion has been found to have "both a protective and a risk increasing effect" for schizophrenia.

<span class="mw-page-title-main">Homelessness and mental health</span>

In a study in Western societies, homeless people have a higher prevalence of mental illness when compared to the general population. They also are more likely to suffer from alcoholism and drug dependency. It is estimated that 20–25% of homeless people, compared with 6% of the non-homeless, have severe mental illness. Others estimate that up to one-third of the homeless have a mental illness. In January 2015, the most extensive survey ever undertaken found 564,708 people were homeless on a given night in the United States. Depending on the age group in question and how homelessness is defined, the consensus estimate as of 2014 was that, at minimum, 25% of the American homeless—140,000 individuals—were seriously mentally ill at any given point in time. 45% percent of the homeless—250,000 individuals—had any mental illness. More would be labeled homeless if these were annual counts rather than point-in-time counts. Being chronically homeless also means that people with mental illnesses are more likely to experience catastrophic health crises requiring medical intervention or resulting in institutionalization within the criminal justice system. Majority of the homeless population do not have a mental illness. Although there is no correlation between homelessness and mental health, those who are dealing with homelessness are struggling with psychological and emotional distress. The Substance Abuse and Mental Health Services Administration conducted a study and found that in 2010, 26.2 percent of sheltered homeless people had a severe mental illness.

The Filipino American identity comprises principles from both the Philippines and the United States. Although the meaning of identity differs from one individual to another, the fundamental factors are the same. History, genetics, socio-economic status, culture, and education are all indirect factors that influences the identity of an ethnic group; thus, they are also reflective of a group's health beliefs and practices.

Well-being is a multifaceted topic studied in psychology, especially positive psychology. Biologically, well-being is highly influenced by endogenous molecules that impact happiness and euphoria in organisms, often referred to as "well-being related markers". Related concepts are eudaimonia, happiness, flourishing, quality of life, contentment, and meaningful life.

Suicide awareness is a proactive effort to raise awareness around suicidal behaviors. It is focused on reducing social stigmas and ambiguity by bringing attention to suicide statistically and sociologically, and by encouraging positive dialogue and engagement to prevent suicide. Suicide awareness is linked to suicide prevention as both address suicide education and the dissemination of information to ultimately decrease the rate of suicide. Awareness is the first stage that can ease the need for prevention. Awareness signifies a fundamental consciousness of the threat, while prevention focuses on stopping the act. Suicide awareness is not a medical engagement but a combination of medical, social, emotional and financial counseling. Suicide awareness in adolescents focuses on the age group between 10–24 years, beginning with the onset of puberty.

Suicide among Native Americans in the United States, both attempted and completed, is more prevalent than in any other racial or ethnic group in the United States. Among American youths specifically, Native American youths also show higher rates of suicide than American youths of other races. Despite making up only 0.9% of the total United States population, American Indians and Alaska Natives (AIANs) are a significantly heterogeneous group, with 560 federally recognized tribes, more than 200 non-federally recognized tribes, more than 300 languages spoken, and one half or more of them living in urban areas. Suicide rates are likewise variable within AIAN communities. Reported rates range from 0 to 150 per 100,000 members of the population for different groups. Native American men are more likely to commit suicide than Native American women, but Native American women show a higher prevalence of suicidal behaviors. Interpersonal relationships, community environment, spirituality, mental healthcare, and alcohol abuse interventions are among subjects of studies about the effectiveness of suicide prevention efforts. David Lester calls attention to the existence and importance of theories of suicide developed by indigenous peoples themselves, and notes that they "can challenge traditional Western theories of suicide." Studies by Olson and Wahab as well as Doll and Brady report that the Indian Health Service has lacked the resources needed to sufficiently address mental health problems in Native American communities. The most complete records of suicide among Native Americans in the United States are reported by the Indian Health Service.

The role of spirituality in health care has received significant research attention due to its benefits for patients and health care professionals. Integrating spirituality in healthcare can enhance healthcare professionals' ability to communicate effectively with patients and families. It can also have a positive impact on the health and well-being of patients due to its potential to enhance patients' ability to cope with illness and achieve better physical and mental health outcomes. As per 2014, more than 70 medical schools in the United States offer courses on spirituality and medicine. The Association of American Medical Colleges has co-sponsored, with the National Institute for Healthcare Research, four conferences, on curricular development in spirituality and medicine since 1997.

People who are LGBT are significantly more likely than those who are not to experience depression, PTSD, and generalized anxiety disorder.

References

  1. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 Seybold, Kevin S., and Peter C. Hill. "The Role of Religion and Spirituality in Mental and Physical Health." Current Directions in Psychological Science 10(2001):21-24.
  2. 1 2 3 4 5 6 7 Douglas, Amber N., Sherlyn Jimenez, Hsiu-Ju Lin, and Linda K. Frisman. "Ethnic Differences in the Effects of Spiritual Well-Being on Long-Term Psychological and Behavioral Outcomes Within a Sample of Homeless Women." Cultural Diversity and Ethnic Minority Psychology 14(2008):344-352.
  3. ↑ Young, J. Scott, Craig S. Cashwell, and Julia Shcherbakova. "The Moderating Relationship of Spirituality on Negative Life Events and Psychological Adjustment." Counseling and Values 45(2000):49-55.
  4. 1 2 3 4 5 6 7 8 Hodge, David R., Stephanie E. Moser, and Michael S. Shafer. “Spirituality and Mental Health Among Homeless Mothers.” Social Work Research 36(2012):1-12.
  5. 1 2 3 4 5 6 7 8 9 George, Linda K., David B. Larson, Harold G. Koenig, and Michael E. Mccullough. "Spirituality and Health: What We Know, What We Need to Know." Journal of Social and Clinical Psychology 19(2000):102-116.
  6. 1 2 3 4 5 Brush, Barbara L., and Eileen M. McGee. “Evaluating the Spiritual Perspectives of Homeless Men in Recovery.” Applied Nursing Research 13(2000):181-186.
  7. 1 2 3 4 5 6 7 8 Hurlbut, Jene M., Leslie K. Robbins, and Mary M. Hoke. “Correlations Between Spirituality and Health-Promoting Behaviors Among Sheltered Homeless Women.” Journal of Community Health Nursing 28(2011):81-91.
  8. ↑ Rew, Lynn, and Y. Joel Wong. "A Systematic Review of Associations Among Religiosity/Spirituality and Adolescent Health Attitudes and Behaviors." Journal of Adolescent Health 38(2006):433-442.
  9. 1 2 3 4 Pargament, Kenneth I., Bruce W. Smith, Harold G. Koening, and Lisa Perez. "Patterns of Positive and Negative Religious Coping with Major Life Stressors." Journal for the Scientific Study of Religion 37(1998): 710-724.
  10. 1 2 3 4 Wachholtz, Amy B., Michelle J. Pearce, Harold Koenig. "Exploring the Relationship between Spirituality, Coping, and Pain." Journal of Behavioral Medicine 30(2007):311-318.
  11. 1 2 3 Runquist, Jennifer J., and Pamela G. Reed. "Self-Transcendence and Well-Being in Homeless Adults." Journal of Holistic Nursing 25(2007):5-13.
  12. 1 2 Irwin, Jay, Mark LaGory, Ferris Ritchey, and Kevin Fitzpatrick. "Social Assets and Mental Distress Among the Homeless: Exploring the Roles of Social Support and Other Forms of Social Capital on Depression." Social Science and Medicine 67(2008): 1935-1943.
  13. 1 2 3 4 5 Bender, Kimberly, Sanna J. Thompson, Holly McManus, Janet Lantry and Patrick M. Flynn. "Capacity for Survival: Exploring Strengths of Homeless Street Youth." Child Youth Care Forum 36(2007):25-42.
  14. ↑ Ferguson, Kristin M., Qiaobing Wu, Grace Dyrness, and Donna Spruijt-Metz. "Perceptions of Faith and Outcomes in Faith-based Programs for Homeless Youth: A Grounded Theory Approach." Journal of Social Service Research 33(2007):25-42.
  15. 1 2 3 4 5 6 Kidd, Sean A. "Street Youth: Coping and Interventions." Child and Adolescent Social Work Journal 20(2003):235-260.
  16. 1 2 3 4 Lindsey, Elizabeth W., David Kurtz, Sara Jarvis, Nancy R. Williams, and Lary Nackerud. "How Runaway and Homeless Youth Navigate Troubled Waters: Personal Strengths and Resources." Child and Adolescent Social Work Journal 17(2000):115-142.
  17. ↑ Kidd, Sean A., and Michelle R. Carroll. "Coping and Suicidality Among Homeless Youth." Journal of Adolescence 30(2007):283-296.
  18. 1 2 Murray, Ruth Beckmann. "Stressors and Coping Strategies of Homeless Men." Journal of Psychosocial Nursing and Mental Health Services 34(1996):16-22.
  19. 1 2 3 4 5 Greene, Jeanie Ahearn, Kim Ball, John R. Belcher, and Catherine McAlphine. "Substance Abuse, Homelessness, Developmental Decision-Making and Spirituality: A Women's Health Issue." Journal of Social Work Practice in the Addictions 3(2003):39-54.
  20. 1 2 Shuler, Pamela A., Lillian Gelberg, and Marie Brown. "The Effects of Spiritual/Religious Practices on Psychological Well-Being Among Inner City Homeless Women." Nurse Practitioner Forum 5(1994):106-113.
  21. ↑ Nyamathi, Adeline, Linda Bayley, Nancy Anderson, Colleen Keenan, and Barbara Leake. "Perceived Factors Influencing the Initiation of Drug and Alcohol Use Among Homeless Women and Reported Consequences of Use." Women and Health 29(1999):99-114.
  22. 1 2 3 Washington, Olivia G. M., David P. Moxley, Lois Garriott, Jennifer P. Weinberger. "Five Dimensions of Faith and Spirituality of Older African American Women Transitioning Out of Homelessness." Journal of Religious Health 48(2009):431-444.
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