Eligible participants were at least 18 years of age and self-identified as unhoused. The a-priori goal was to survey up to 60 unhoused people in Santa Fe, New Mexico. Using convenience sampling, potential participants were approached in the community by the research team at congregate and non-congregate homeless shelters, at the public library, and at large with a street outreach team in Santa Fe, with permission of staff involved at each site. Those who participated provided informed consent and received a $20 gift card for their time.

The survey measured demographics, chronic medical and mental health conditions, substance use, healthcare utilization and barriers, and health and social service program priorities (Appendix). Data were collected December 2022 through April 2023. Most questions were close-ended and quantitative in nature, but participants had the option to provide open responses to some, including those related to perceptions of various harm reduction services. We chose to include these qualitative questions for more depth and understanding of the views of Santa Fe’s unhoused. Surveys were conducted in safe, private locations where participants were recruited and administered by the principal investigator (LB) who recorded anonymous responses in Qualtrics (Provo, UT) on a secure laptop.

This study was reviewed and approved by the University of New Mexico Institutional Review Board (#2205005755).

Descriptive and summary statistics included measures of central tendency (means and standard deviations [SD], medians, and interquartile ranges [IQRs], and frequencies) and 95% confidence Intervals (95% CI) were computed for point estimates using exact methods. Our approach to the data interpretation was based on an evaluation of the magnitude, direction, and precision of effect estimates rather than binary significance testing.

Most survey questions were close ended; open-ended questions asked about duration of time spent unhoused or unstably housed, education level, frequency of healthcare and mental healthcare access, and views about community harm reduction programs. Responses to all open-ended questions except those related to harm reduction programs were coded into quantitative categories or numbers and agreed upon by two members of the research team (HRB and LB; e.g., if someone responded “9th” to the question, “What is the last grade of school or college you completed?” this was categorized as “high school, no diploma”). Open responses to questions about MAPs and safe consumption sites were imported into NVivo 14 (Lumivero) for qualitative analysis. This software allowed us to better organize open responses into broad categories (themes) and quickly access related quotes. The senior qualitative methodologist (HRB) performed content analysis and ran a matrix query to examine distribution of quotes and codes, which was reviewed by the principal investigator (LB).

As shown in Table 1, 56 people participated in the survey (Appendix). Their ages ranged from 27 to 77 years (median 48.5, IQR 48.5, 60.25). More than half (58.9%, 95% CI: 45, 81.9) were male, non-Hispanic (57.1%, 95% CI: 43.2, 70.3), White (73.2%, 95% CI: 59.7, 84.8) and had received a high school diploma or equivalent (23.2%, 95% CI: 13.0, 36.4) or obtained some college education (39.3%, 95% CI: 26.5, 53.3). Their lifetime years unhoused or unstably housed ranged from less than one year to 63 years (median 4.0, IQR 4.0, 8.0).

Consistent with our first hypothesis, we found a high prevalence of diagnosed chronic medical conditions among Santa Fe’s unhoused. When asked whether they had been diagnosed with listed health conditions, mental health disorders predominated (Table 2; we did not ask about when diagnosis occurred or who provided it). Diagnosed post-traumatic stress disorder was reported by 58.9% (95% CI: 46.0, 71.8) of participants, as was “other” mental health disorder (58.9%, 95% CI: 46.0, 71.8), followed by major depression (57.1%, 95% CI: 43.2, 70.3). “Other” physical health disorders were reported by 55.4% (95% CI: 41.5, 68.7) of respondents, followed by hypertension (42.8 %, 95% CI: 29.7, 56.8) and chronic pain (41.1%, 95% CI: 28.1, 55.0). Diagnosed SUD prevalence reported by participants included tobacco (46.4%, 95% CI: 33.4, 59.5), alcohol (41.1%, 95% CI: 28.1, 55.0), cannabis (23.2%, 95% CI: 13.0, 36.4), opioid (21.4%, 95% CI: 11.6, 34.4), cocaine (21.4%, 95% CI: 11.6, 34.4), and methamphetamine (19.6%, 95% CI: 10.2, 32.4).

Regarding healthcare services (Table 2), participants reported they had been to a clinic or accessed healthcare services remotely for chronic medical conditions including SUD median of 2.0 (IQR 2.0, 4.5) times in the past year, and 0.0 (IQR 0.0, 2.5) for behavioral or mental health services. Healthcare barriers included transportation (70.9%, 95% CI: 57.1, 82.4), competing priorities (63.6%, 95% CI: 49.6, 76.2), communication with clinic to set up appointments (56.4%, 95% CI: 43.3, 69.7), stigma (49.1%, 95% CI: 35.4, 62.9), clinic hours of operation (34.6%, 95% CI: 22.2, 48.6), with participants able to choose more than one barrier (Table 2).

Of the 55 participants who responded to substance use questions, most (89.1%) said they used at least one of the following substances in the previous four weeks: alcohol (50.9%), methamphetamines (32.7%), prescription (12.7%) or street (23.6%) opioids, injected substances (9.1%), cannabis (56.4%), or tobacco (63.6%). When we looked at substance use at an individual level, only seven (12.7%) people said they had not used any of the listed substances in the past four weeks and 12 (21.8%) only used cannabis and/or tobacco. Not including cannabis and tobacco, 38.2% used at least two substances, 16.4% of whom used three or more.

Consistent with part of our second hypothesis, we found housing and food, but not healthcare, as top priorities among Santa Fe’s unhoused. When participants prioritized health and social service needs, long- and short-term housing were their highest priorities, followed by food and transportation assistance, noted across all respondents regardless of prevalent health conditions and current substance use. Other priorities presented included in decreasing ranked order; Medicaid assistance, primary care, emergency medical care, mental health services, workforce/employment services, Social Security assistance, peer support services, recreation assistance (“community centers”), legal services, education/school services, Medicare assistance, SUD treatment, and overdose prevention.

Our third hypothesis was partially supported in that we found positive, not mixed, support for community-based harm reduction programs such as managed alcohol programs and overdose prevention centers among Santa Fe’s unhoused. Most participants responded “yes” or “maybe” to the following questions (Table 4): Do you believe that your community would accept a managed alcohol program? (75.9%); Do you think other people experiencing homelessness would benefit from a managed alcohol program? (96.2%); and for those who use lots of alcohol AND other substances and/or stimulants, do you think your community should provide a safe place for people to use these substances? (85.5%). More than half (53.8%) of participants answered “no” to the question, from what you have learned or know about MAPs, do you think you would benefit from a managed alcohol program? (verbatim responses to these questions available upon request from authors).

In open responses to questions about MAPs, one participant said they were in favor because “a majority of us are alcoholics, and it’s unfair that others with [OUD] have Suboxone and methadone and we don’t have that option for alcohol.” Many other favorable perspectives span benefits and concern for others in the community. For example, one person said,

Concern for others included responses about how these programs would lead to decreased unsafe drinking practices, such as consumption of non-beverage alcohol (Lysol, hand-sanitizer, mouthwash) and homemade beverage alcohol (“liquor”). One negative response to whether Santa Fe would accept a managed alcohol program highlighted stigma:

Those who were in favor of overdose prevention centers had similar responses to those in favor of MAPs, related to increased individual and community safety and decreased crime. Seven participants mentioned decreased overdoses and/or overdose deaths, even from one participant who was opposed to overdose prevention centers: “No, because I think they would be abused. I do support supply of clean needles, though. I do think it could help reduce overdose and keep people steady after their fix. Good to have SUD treatment referrals on site.”

Concern for others and the community was again noted in several responses, such as, “I believe it would be beneficial to the community as well, would reduce sneaking around shelters to use, including people using blues [fentanyl] in shelter,” “Yes, given the number of people overdosing every day, that I’m witnessing. I’ve reversed at least three overdoses already here in Santa Fe. We’ve lost too many people, so much grief and fear,” and, “Yes, it would be beneficial for the community to have a designated site instead of using throughout the city, leaving needles around.”

Regardless of whether participants were in favor of these harm reduction programs, they had suggestions to make them successful. For example, there needs to be community and government support and funding, and they need to be well-managed. Potential users of these services need to feel safe and not fear getting arrested. Some suggested these programs should also provide wrap-around services such as, “a doctor and counselor on site, to get to root cause of problematic use” and “a navigation center [with a] housing-first model…” When asked about the location, most said it should be near or attached to a shelter or housing site, but other suggestions of location included a mobile unit or being attached to a treatment center, healthcare clinic, community center, church, or “co-located with a managed alcohol program navigation center.” Participants indicated facilitators for the success of a managed alcohol program or overdose prevention center including evidence of similar successful programs in other places around the world. They also mentioned the political (liberal) culture and smaller size of Santa Fe as being facilitators. Barriers to success for these community harm reduction programs highlighted access and transportation, with cultural or political issues, local stigma, negative attitudes, and fear for safety also mentioned.

This study has several limitations. While health insurance coverage is high in New Mexico following Medicaid expansion, we did not collect information about health insurance and cannot assume the same for this unhoused population (Keisler-Starkey et al., 2023). Additionally, the study had a relatively small sample size and used convenience sampling, which limits generalizability. As a pilot study however, we gained rich information through the mixed methods design and our participants. We also had a limited list of sociodemographic and health condition questions, leading to high prevalence of ambiguous “other” mental and physical health disorders, and we did not have other status information such as employment or history of incarceration. However, our standardized and brief list of sociodemographic and health conditions questions was intended to facilitate both greater survey completion and relatively brief administration (typically less than 35 minutes). Few people who were approached declined to participate, and many participants thanked the PI (LB) for giving them the opportunity to share their perspectives. Finally, this report is limited to descriptive results and further analyses of both quantitative and qualitative data will be hypothesis generating.

This examination of the health status, community service priorities, and harm reduction views of Santa Fe’s unhoused was needed for at least three important reasons: (1) giving voice to a vulnerable, poorly known, and largely unheard population; (2) highlighting urgent need for additional community harm reduction policy, programs, and practice; and (3) addressing significant gaps in New Mexico’s unhoused literature. New studies should consider a community-engaged participatory approach which includes the unhoused in the design, conduct, evaluation, and dissemination of programs to meet the needs of the unhoused. Community programs need program evaluations with re-defined “successful” outcomes to include changes to quality of life, program engagement, demarginalization, social functioning, substance use, and future goals and plans (Lee & Zerai, 2010) beyond current health and social service program outcome measures. A mixed methods program evaluation approach incorporating health equity and social justice lenses is recommended, which includes in-depth qualitative investigation to illuminate the often-unheard perspectives of the marginalized unhoused in the community.

This research may benefit communities working with people who are unhoused at local and state levels in New Mexico and the US including policy makers, social and health service providers, researchers, and advocates including the unhoused and their families. Organizations working with problematic substance use, overdose prevention, and harm reduction may benefit as well.

This research represents a call to action for communities throughout New Mexico -- beyond and including Santa Fe -- and the US to implement urgently needed additional community harm reduction policies and programs to better address the inequitable health status of growing numbers of vulnerable unhoused with chronic life-threatening medical conditions including SUDs and rising polysubstance use who live in risky, marginalizing, and dehumanizing environments.