Special Project

Understanding Adverse Childhood Experiences (ACEs) and Addressing Social-Mental Health Needs in Public Housing: A Case Study

Project Introduction

In working with the Resident Engagement team at the Chattanooga Housing Authority, it is clear that residents have many needs.  Some we can help with, others that we cannot help as much with.  My manager at Chattanooga Housing Authority aims to improve the services that we can provide to residents, so between knowing the goals that she would like to meet, along with my interest in the relevance of adverse childhood experiences for those living in public housing, the idea for this project came to life.

My special project at the Chattanooga Housing Authority, was a research study titled, “Understanding Adverse Childhood Experiences (ACEs) and Addressing Social-Mental Health Needs in Public Housing: A Case Study“, which was done by surveying residents at the Greenwood Terrace, Emerald Villages, Fairmount, Maple Hills, Oaks at Camden, Cromwell Hills, and Villages at Alton Park housing sites.  The participants were residents of these sites, aged 18 and older.

Social Issues

The social issues addressed in this research project include the prevalence of Adverse Childhood Experiences of residents who reside in public housing, the resident’s social-mental health needs, issues in public housing, and health equity and social justice.  The reasons for these issues being collectively addressed, are to gather a clear picture of the needs of the residents for CHA to better be able to address them, as well as to gather information on the prevalence of ACE’s to prepare for trauma-informed practice.  This project was initiated by me, with great help and support from Dr. Racovita, and the approval of management at Chattanooga Housing Authority’s central office and the help and support of my colleagues in the Resident Engagement Team and Chattanooga Housing Authority.

Adverse Childhood Experiences and Mental Health

Negative experiences during childhood, known as Adverse Childhood Experiences (ACEs), can result in adult vulnerability, affect health and opportunities in life, as well as play a role in adverse housing outcomes (Grey & Woodfine, 2018).  One study found that individuals living in public housing may experience poorer health outcomes than those residing in homes they own (Byrne et al., 2014). Another study that focused on older adults living in public housing showed that about one-third of participants in the study had four or more ACEs and that often substance abuse was an associated implication of ACE’s and public housing as well as poor mental and physical health outcomes (Larkin et al., 2017; Mersky et al., 2018).  Reasons for not seeking help for mental health issues include stigma, especially in minority populations, shame, embarrassment, and poverty (Young, 2015). However, the association between ACEs and living in public housing, whether generational or not, has not been researched. Additionally, the literature shows that public housing residents are at higher risks of experiencing poorer mental and physical health outcomes as mentioned above; therefore, it is imperative that an assessment of these needs as relate to ACEs in the context of public housing services be conducted to better understand the needed services for this population. The current survey seeks to assess the social and mental health needs of the residents, as well as housing and ADL needs that CHA may be in a position to assist with. The survey has been designed in conjunction with the CHA resident engagement team’s supervisor to ensure that it meets the needs of CHA as well as meeting the research goals.  

How This Relates to Chattanooga Housing Authority

The Chattanooga Housing Authority (CHA) manages approximately 2,300 low income apartments which house individuals, couples, and families (CHA-Managed Housing, n.d.). CHA provides case management, educational services, and some social engagement events through its resident engagement team. However, coming out of the COVID-19 pandemic there is a clear need for engaging the residents as a community. This may lead to better mental health outcomes. Additionally, there has been no survey such as this done previously with any of the housing sites managed by CHA. Therefore, this survey will add to the body of knowledge of the profession, as well as provide a trauma informed social worker lens for approaching housing residents, and their social and mental health needs.

The Research Project

The goals of this research were to identify the social, mental health, and physiological needs of the residents at these particular sites while also taking into consideration their ACE’s scores and generational and migration information.  The questionnaire, which can be found here, includes questions 6 about their physiological needs, 9 questions about their social needs, 3 questions related to stress, 3 questions related to anxiety, 3 questions related to depression and 3 questions related to bipolar disorder, and includes the full 10 questions ACES questionnaire.  The survey also asks about current health conditions and treatment they are receiving, and what assistance for mental health they would be interested in, as well as household and current, past, and generational living situations, and asks specific questions on what needs and services that they would like from the Chattanooga Housing Authority.

Framework

The theoretical framework that guided this project and my research was the Ecological Systems Theory.  The theory, and this research, looks at the various environmental influences that impact the individual’s development and well-being.  This includes the microsystem, which is the immediate environments that they interact with including their families and their neighbors and also includes their childhood, which is where the ACES scores are relevant, the mesosystem which may include Chattanooga Housing Authority and the services they offer the residents, the exosystem which includes the services in the community and the policies that affect the residents, the macrosystem which includes the societal perceptions of public housing, economic policies, and cultural norms, and lastly, the chronosystem which examines how situations change over time which particularly involves the aspects of my research regarding generational living in public housing and migration.

Participant Recruitment

Figure 1

Residents of the sites mentioned above were recruited using the flier in Figure 1.  Resident Engagement team staff members placed the fliers on residents’ doors and in some cases spoke to residents directly about the survey and its benefits to them and their community.  Due to an ARC grant, we were able to provide gift cards as an incentive to the first 150 participants of the survey.

 

Research Results

Demographics

There were 61 total respondents who had filled out the majority of the survey.  18 respondents (29.5%) were from the Villages at Alton Park, 13 respondents (21.3%) were from Cromwell, 8 respondents (13.1%) were from Greenwood Terrace, 7 respondents (11.5%) were from Emerald Villages, 2 respondents (3.3%) were from Maple Hills, 1 respondent (1.6%) were from Oaks at Camden, 1 respondent (1.6%) were not currently living at a CHA site (there information was still used for survey purposes since they still fall into the same demographics and socioeconomic status as the participants from the sites).  11 responses (18%) for site were missing.

The largest age group was ages 35 – 39, making up 16.4% of respondents, followed by 25 – 29, making up 13.1% of respondents, and then 30 – 34, making up 11.5% of respondents.  86.9% of respondents were female and 4.9% were male.  Regarding race, 75.4% of respondents were African American, 9.8% were Caucasian, and 6.6% selected other.  All responding participants selected that they were not Hispanic or Latino for ethnicity.  The majority of participants were unemployed (32.8%), followed by “other” (14.8%), which included write in responses that were mainly disabled or on SSI.  The majority of participants were single (62.3%) or divorced (9.8%).  Regarding education, the majority of participants had their High School diploma or GED (50.8%) followed by some High School but did not graduate (16.4%).  Detailed bar graphs showing all percentages of the responses can be found in the Appendix.

Most Relevant Needs

Food

  • 44.3% of participants selected that they “could use a little more help” or “need a lot more help” paying for food.
  • 34% of participants selected that they had trouble paying for food in the past 3 months.
  • 27.9% of participants selected that in the past 3 months they “often” or “very often” worried that food would run out before they were able to buy more.

Utilities

  • 49.2% of participants selected that they “could use a little more help” or “need a lot more help” paying for utilities.

Dental and Vision Needs

  • 49.2% of participants selected that they “could use a little more help” or “need a lot more help” paying for dental services.
  • 29.6% of participants selected that they “could use a little more help” or “need a lot more help” paying for vision services.

Finances

  • 41% of participants selected that they “could use a little more help” or “need a lot more help” with debt or loan repayment.
  • 31.1% of participants selected that they “could use a little more help” or “need a lot more help” managing finances.
  • 19.7% of participants selected that they have had trouble paying for debts in the past 3 months

Social Needs

  • 45.9% selected “disagree” or “strongly disagree” on the question, “I am comfortable reaching out to my neighbors for social support or assistance.”
  • 37.7% of participants selected “disagree” or “strongly disagree” on the question, “My social needs are adequately met at my housing site.”
  • 37.7% also selected “disagree” or “strongly disagree” on the question, “I am satisfied with the availability of common areas or spaces for socializing at my housing site.”
  • 36.1% of participants selected “disagree” or “strongly disagree” on the question, “My housing site provides opportunities for social interaction and engagement.”

Qualitative Responses on Social Needs

  • Two individuals wrote in responses that they are harassed and feel threatened by their neighbors.
  • No common spaces including no playground for children.
  • Transportation (Though on the questions about transportation, there was not a significant response to considering this a major issue).
  • More activities for both adults and children.
  • More sitting areas in the neighborhood.

Mental Health Needs

  • 32.8% of participants have received a diagnosis of anxiety and/or are receiving treatment for it.
  • 31.2% of participants have received a diagnosis of depression and/or are receiving treatment for it.
  • 9.9% of participants have received a diagnosis of more serious mental illnesses such as bipolar disorder or schizophrenia.
  • 9.8% of participants responded that they are currently receiving mental health counseling and 26.2% responded that they would be interested in receiving therapy or counseling.
    • The types of mental health services that they were most interested in were individual counseling (7%), education on mental health issues (4.9%), family counseling (3.3%), and “all of the above” (1.6%).

ACEs Scores

Adverse Childhood Experiences (ACEs) scores of 4 or higher are directly related to “toxic stress” and can lead to an increased risk of both mental health as well as medical issues, as well as life challenges such as financial and relationship problems.  It is important to use trauma-informed care in working with individuals with toxic stress and past childhood trauma to avoid re-traumatization.

  • 24.6% of participants had ACEs scores of 4 or higher
  • It may be safe to estimate this percentage (or higher) across all sites, which is still about a quarter of our residents, so I believe that it is important to focus on trauma-informed care for all residents.

Concerns with Current Living Situation

Below are the most significant general results on the participant’s current living situation.  I will break it down by site after the summary.

  • 37.7% of participants selected “disagree” or “strongly disagree” regarding if they felt that their housing site was safe.
  • 34.5% of participants selected “agree” or “strongly agree” that mold is an issue in their units.

Qualitative Responses on Events, Activities, and Services

  • Which past events or activities that they enjoyed
    • Fair/Carnival
    • Resource Fairs
    • Holiday Parties
    • Block Parties
  • Which events they would like to see in the future
    • Crafts
    • Block Parties
    • Cooking Classes
    • Holiday Parties
    • Resource Fair
    • Job Fairs
    • Playground for the Kids/Places for Kids to Play
    • Pool Opened Back Up
    • Family Game Nights
  • Which services they would like to see at the housing sites
    • Dental Services
    • Food Resources (including Food Boxes)
    • Mental Health
    • Clinics
    • Transportation Services
    • Conflict Resolution

Recommended services and interventions for the chattanooga housing authority based on this research

Recommendations for Food-Related Needs:

  • Several local organizations assist individuals in applying for SNAP benefits such as the Rural Health Association of Tennessee and other organizations. It may be beneficial to either bring representatives from organizations such as that to come in and talk to the residents and answer questions regarding applying for SNAP or create flyers to put up with contact information for those organizations.
  • Another option would be to create a Food Pantry that would be available to residents of CHA. This would be quite an endeavor, as there is a need for constant food drives and fundraising to ensure that there is enough food always available, amongst other hurdles.  However, if this is something that could be set up ever, it really would be beneficial in combating hunger and food insecurity at the housing sites.
  • Another option is making current services more frequent and available at all sites. When working at Gateway, I knew there was both the truck that had the little store in it that would come and park in front of Boynton, as well as the commodities that were delivered to residents.  I am not sure if that was just for senior sites or if it is available at all sites, but both of those could be beneficial to these residents with food insecurity.

Recommendations for Utility-Related Needs:

  • Resources for assistance with utilities seem to be ever-changing. The Resident Engagement team does a great job of keeping up with what resources are currently available.
  • There may be two reasons for this issue: There may currently not be enough utility resources available, or the residents don’t realize that Resident Engagement can assist with that sort of issue. It may be beneficial to make an updated flyer that lists the various services that Resident Engagement can help with, including referrals to organizations that assist with utilities.

Recommendations for Dental and Vision-Related Needs:

  • Partnering with free and low-cost clinics in the area to bring these services to our residents or at least to share the resources with the residents so that they know these services are available to them.
  • Those who are uninsured may also benefit from organizations such as the Rural Health Association of Tennessee which can inform them about available insurance benefits to them and assist them in signing up for those benefits. Though TennCare does not cover vision benefits, as of January 1, 2024, it does cover many dental benefits, so this could help those who need these types of benefits.

Recommendations for Financial-Related Needs:

  • It may be valuable to bring the services of an accountant, perhaps the one who works with FSS, to residents at the sites. This could either be done with him having either one-time or reoccurring classes with the residents on topics such as debt management or general financial planning, or by offering direct financial advisement services for them at the sites.
  • Alternatively, if he, or another advisor, would be unable to visit the sites, we could be active in sharing this resource and referral with residents. This may best done by posting or sharing flyers with them.  I hypothesize that many are struggling with debts and finances and may not necessarily come to Resident Engagement seeking help with this due to shame or pride, so sharing this resource in a way that allows them to pursue it themselves may be beneficial.  They also may not be aware if the Resident Engagement Team has resources may help address unique financial needs.

Recommendations for Social-Related Needs:

  • The results of the questions above as well as some of the qualitative questions below suggest that there is a need for more common areas at the sites. One suggestion would be creating new as well as improving old common areas at the sites.
  • There also seems to be the need to build more comradery between neighbors. Ways to improve this may include, again, better common areas where people want to spend time, community and cultural events, and addressing safety and security concerns.
  • Taking into consideration the lack of people feeling that they can reach out to their neighbors as well as those who were concerned with their safety due to being harassed by neighbors, it would be very beneficial to have an effective conflict management protocol/SOP in place (I am not sure if there is currently) to address tense situations such as this. This could best be put

    Figure 2

    together as a collaboration with Public Safety, a mental health professional such as a social worker or counselor specializing in conflict management, and site management.  I have created an evaluation for the conflict resolution protocol if CHA were to use it in the future.  The evaluation can be found here.  A policy brief to present this idea to CHA can be found in Figure 2.

Recommendations for Mental Health-Related Needs:

  • It would be great to partner with a mental health agency that could come on-site and provide counseling services to residents and share mental health education with residents.
  • If the above cannot occur, it would be important to provide residents with a list of available mental health resources, particularly practitioners who take TennCare or are low-cost.
  • It would also be important to provide residents with mental health-related information and work on reducing the mental health stigma that notoriously exists in the cultures of many of our residents.

Recommendations for Providing Trauma-Informed Care:

  • Having all staff participate in training on how trauma affects a person’s health and behavior, and how to provide trauma-informed care.
  • Integrating knowledge about trauma and adversity into policies, procedures, and practices.
  • Taking special care in working with residents who we know have experienced trauma.
  • Creating safe environments.

Recommendations for Assisting with Current Living Situation Concerns:

  • As mentioned above, a solid conflict resolution protocol would be essential in working out issues between neighbors.
  • Increased security at the housing sites including more cameras and police patrol, particularly after business hours.
  • Mold is an issue that occurs everywhere, and it most likely does not have anything to do with how CHA cares for or manages the units and more to do with people not knowing how to prevent mold. It would be recommended to educate residents on mold, what it looks like, what problems it can cause, and how it can be prevented and resolved, so they can learn to manage the mold problem in their units.

Additional General Recommendations:

  • A small percentage of participants selected that they have been victims of domestic violence. Even though it was a small percentage, it may be important to still spread awareness and share available resources to victims of domestic violence.  Many organizations place flyers in bathroom stalls with phone numbers to text if the person is a victim of domestic violence, since they may be able to text when they are alone in the bathroom away from their abuser.
  • On the medical condition questions, there wasn’t any overwhelming number of conditions, but the most prevalent one was high blood pressure. It may be beneficial to provide “Dinner with the Doctor” type programs at the sites, or available for residents to attend elsewhere, where residents can learn more about particular health conditions and how to manage them, as well as have a doctor available to answer questions.

Conclusions

Limitations

The limitations of this study were primarily the small percentage of respondents, despite the incentive of gift cards for participating.  Ways to improve this in future research might include using additional channels for recruitment such as sending emails to residents or door-to-door recruitment, as well as increasing the incentive amount.  Another limitation was that not all respondents fully completed the survey.  Ways to improve this in future research might include more in-depth questions in the areas that did not receive full attention and conducting focus groups at the sites to better understand residents’ unique situations and experiences.

Unexpected Outcomes

I had expected to actually see even higher ACEs scores, as well as have a higher need for mental health services.  The short 3-question each screening that I used to screen for possible anxiety, depression, and bipolar disorder, did not yield any significant results.

PResentation of the Results to The

Chattanooga Housing Authority

I put together the most significant information from this research study, as mentioned above, and presented it to the Resident Engagement Administrator and to the Director of Housing Operations in a report, which included bar graphs and tables visually representing much of the date, which can be seen here.

Presentation On “addressing social-mental health needs of public housing residents through the lens of internal migration” at the nineteenth international conference on interdisciplinary social studies in krakow, poland 

My special project research was accepted to be presented at the Nineteenth International Conference on Interdisciplinary Social Studies in Krakow, Poland which was a huge accomplishment for all the word that was done in this project. I in conjunction with Dr. Laura Racovita presented some of the findings from this study in a presentation titled “Addressing Social-Mental Health Needs of Public Housing Residents Through the Lens of Internal Migration” and the conference on Thursday, July 18, 2024.

 

 

The full presentation slides can be found here.

My attendance and presentation certificate can be found here.

 

 

Competencies

COMPETENCY 1: ETHICS & PROFESSIONALISM

  • I have used written skills in writing up the literature review, research questions, and recruitment materials as well as oral communication skills in discussing the research process with my colleagues and explaining the survey to the population taking the survey.
  • I have used both oral and written skills in designing the presentation slides and orally presenting the material to the audience at the conference.

COMPETENCY 2: HUMAN RIGHTS & JUSTICE

  • The content of the research study addresses such human rights needs such as food, transportation, medical care, mental health, and social needs.
  • Responses in this study had shown a need to conflict resolution between residents due to safety concerns, which I have advocated for in my recommendations and policy brief.
  • Sharing these finding at the conference helps to spread awareness of the human rights issues in Chattanooga, Tennessee, United States.

COMPETENCY 3: DIVERSITY

  • This research project respects and focuses on the diverse backgrounds and experiences of public housing residents, including their socioeconomic status, cultural backgrounds, and migration histories.  It uses the information regarding their diversity to focus on how the Chattanooga Housing Authority can focus on creating an inclusive environment for residents from a variety of backgrounds.

COMPETENCY 4: RESEARCH

  • Using my knowledge of Practice-Informed Research and Research-Informed Practice, I reviewed literature to determine the prevalence of ACES as well as mental health issues and social issues in public housing and to determine the need for this study.
  • Using my knowledge of Research-Informed Practice I conducted a research study on the residents of Chattanooga Housing Authority sites and used the results to inform the staff on the needs of these residents and to come up with programs to fill those needs.

COMPETENCY 5: POLICY

  • I designed a policy brief which advocates for a conflict resolution procedure to be put into place and used in instances of neighbor disputes and conflict.

COMPETENCY 6: ENGAGEMENT

  • During the beginning of this project, I engaged with leadership at the Chattanooga Housing Authority to get approval and finalize the research questions that I used in this survey.
  • I then engaged by getting approval for the research through Southern Adventist University’s IRB.
  • I engaged with residents at the sites by handing out the recruitment flyers, and explaining the importance of this research project to help provide services for them to improve their quality of life.

COMPETENCY 7: ASSESSMENT

  • Through using my knowledge of assessment, added into the survey questionnaire were questions relating to mental health, specifically stress, anxiety, depression, and bipolar disorder, as well as the ACES questionnaire, which can be found here.
  • Designing a needs assessment to measure the social, mental health, and physiological needs of the residents at the Chattanooga Housing Authority, which can be found here on the full survey.

COMPETENCY 8: INTERVENTION

  • With the presentation of these results to management at the Chattanooga Housing Authority, I have included several practical and evidence-based interventions as mentioned above.

COMPETENCY 9: EVALUATION

  • I have included a possible evaluation to be used if CHA were to adopt a conflict resolution protocol, as I mentioned.  The evaluation for this can be found here.