The Power, Capacity, and Resiliency of Women in Substance Use Disorder Recovery to Overcome Multiple and Complex Housing Transitions

Round 1

Reviewer 1 Report

Social Science

Mauscript #socsci-2890357

Title:

The Power, Capacity, and Resiliency of Women in Drug Addiction Recovery to Overcome Multiple and Complex Housing Transitions

Overall:

An important topic that you present with excellent writing, theoretical frameworks, conceptual arguments, and engaging findings that are well organized and strongly supported. I have provided extensive suggestions to improve the methods section, and would also like the authors to engage more with existing literature in the discussion section.

One final and important point is in regards to the terminology of addiction used in this paper. I would like the authors to use stigmatizing language.. For example, replacing the word addiction with substance misuse or substance use disorder, and also replacing the word relapse with “return to use.” See here for additional context and guidelines: https://nida.nih.gov/nidamed-medical-health-professionals/health-professions-education/words-matter-terms-to-use-avoid-when-talking-about-addiction

I look forward to reviewing your revision, as I believe your contribution on the gendered implications of housing and recovery are essential additions to the literatre.

Abstract:

Consider adding the interview N.

Introduction:

Ln. 35- if the focus of your research and resulting implications is centered on the UK, I would suggest adding a few words at the beginning to make that explicit.

Lns. 35- 39 are impactful, but this gets a bit lost in its current run on form.

The section on gendered housing pathways would benefit from a brief mention of the literature which finds that women with children tend to fear and avoid treatment spaces because of consequences, such as family separation. Also- many recovery spaces require women to leave their families and children, which is another substantial barrier. It is important to acknowledge there that the numbers of women that need treatment are often under estimated because of these factors. You allude to this point in Ls. 78+, but an explicit mention of the implications of gender and treatment entry would be a valuable addition.

I am surprised that this section does not mention the impact of intimate partner violence on housing instability. I would like to see this added in your revision.

Good points on the potential limitations of recovery networks and capital.

Lns. 140-143 include important points, but need more explicit explanation and detail to make the point more clearly.

Ln. 160-161- there is additional and more current research to cite here in addition to Grella, 2008.

Ln. 166- 167: your sample is largely white (be consistent with either capitalizing or not), yet in the introduction you state that this research fills a gap in a field dominated by research on the experience of white males. I would suggested tempering your initial statement given your sample.

Methods:

This section needs more detail to convince readers that all research procedures were methodologically sound.

·      Did the authors receive permission from an ethical review board? Please state.

·      Were participants compensated?

·      Please elaborate on and cite how exactly the qualitative thematic analysis was conducted.

·      Ln. 196+ you are referring to “member checking”- reference and cite.

·      Did only one person analyze the data? If so, what was your approach to ensure the trustworthiness of the data?

·      Why (and how) were interviews transcribed during interviews- I would imagine this to be distracting, and would like some detail on why interviews were not transcribed after the interviews were complete.

·      Please add a brief discussion that draws on the qualitative constructs of reliable data collection and analysis (trustworthiness, credibility, etc.)

·      Please add a brief discussion to address author reflexivity.

·      A review of these guidelines on presenting QDA would be useful for the author/s: https://cdn.elsevier.com/promis_misc/ISSM_COREQ_Checklist.pdf

·      I am unclear what the authors mean with this statement: Qualitative thematic analysis was carried out on the interview transcripts in relation 190 to transitions in the accommodation of the sample using a recovery capital framework.

o   Please clarify, and also explain how a recovery capital framework was applied to the analysis

Results

Your findings are important and compelling. I didn’t find the thematic titles to be particularly compelling, which diminished the importance of the findings. Perhaps if

in your introductory paragraph you added a sentence that presents a high-level list of the themes you identified and will be presenting, this might help to orient the reader and provide more detailed context to the findings. Alternatively, you might consider adding a brief introductory sentence to each thematic sub-heading to better explain what the theme is about. Regardless of which approach you use, adding a list of what themes you are presenting at the start of this section would be helpful.

Ln. 214- please reword for clarity and active voice.

With the initial mention of Zoe please indicate with a footnote if pseudonyms were given to all participants (or not, and if not- why not).

Review guidelines for consistency on use of italics for quoted material.

I would consider separating violence out from the mothering theme because violence and vulnerability is experienced by many women.

Discussion

Consider renaming to “Discussion and Conclusion” or add a separate conclusion section.

The authors do an excellent job of reflecting on the collection of findings. However, this section is missing a more detailed integration of existing literature, and how the findings align with, contrast to, and complement the existing and established body of research on this topic.

Author Response

Dear Reviewer,

Many thanks for taking the time to read and review my article. It is much appreciated.

Thank you for your positive comments regarding the article and its merits.

I agree fully with your suggestions for amendments, and I have made all of the amendments that you suggested in your review.  I feel the article is much improved as a result.

Specifically, I have:

Removed the word ‘addiction’ from the article and used the phrase substance use disorder.  I have also removed the word ‘relapse’ with return to use as suggested following your comments that:

 “One final and important point is in regards to the terminology of addiction used in this paper. I would like the authors to use stigmatizing language.. For example, replacing the word addiction with substance misuse or substance use disorder, and also replacing the word relapse with “return to use.” See here for additional context and guidelines: https://nida.nih.gov/nidamed-medical-health-professionals/health-professions-education/words-matter-terms-to-use-avoid-when-talking-about-addiction

The phrases addiction and relapse remain in the text only if they have been used in the direct quotations from members of the sample.

Abstract:

I have added the number of participants used for the article in the abstract on page 1.

Introduction:

I have made it clear that this is a UK study in the abstract (see page 1) and in the introduction (see paragraph 3 under the heading ‘Introduction’, as you helpfully suggested to make this explicit.

Lns. 35- 39 I have revised these sentences to remove the run on form and made sure the wording is clearer and more impactful.

I have added new content in Paragraph 2 and the final paragraph in the section ‘Gendered Pathways’ on page 2 address your comments in relation to “The section on gendered housing pathways would benefit from a brief mention of the literature which finds that women with children tend to fear and avoid treatment spaces because of consequences, such as family separation. Also- many recovery spaces require women to leave their families and children, which is another substantial barrier. It is important to acknowledge there that the numbers of women that need treatment are often under estimated because of these factors. You allude to this point in Ls. 78+, but an explicit mention of the implications of gender and treatment entry would be a valuable addition.”

I have added new content relating to IPV and impact on housing in Paragraph 3 and 4 of the  ‘Gendered Housing Pathways’ section on page 3 address your comments in relation to  “I am surprised that this section does not mention the impact of intimate partner violence on housing instability. I would like to see this added in your revision.”

I have made the points more explicit and detailed to address your comment “ Lns. 140-143 include important points, but need more explicit explanation and detail to make the point more clearly.”

Additional and more current research has been added to this point to address your comment  “Ln. 160-161- there is additional and more current research to cite here in addition to Grella, 2008.

Capitals have now been consistently used for the term ‘White’ throughout the paper.  And I have removed the phrase ‘White middle aged males’ from the sentence that you referred to below that read ‘White, middle aged males’.  This was confusing as the point I was wanted to make related to gender only especially given the focus of the paper being on women. This phrase was confusing and so I have amended it to simply state ‘males’ to address your comments:  

“Ln. 166- 167: your sample is largely white (be consistent with either capitalizing or not), yet in the introduction you state that this research fills a gap in a field dominated by research on the experience of white males. I would suggested tempering your initial statement given your sample.

Methods:

The methods section has been re-written to include more detail and clarity as to the methods and procedures used. 

It now clarifies that ethical approval board permission was given.  See paragraph 2 of methods and materials section.

It clarifies that participants were not compensated financially or otherwise for their participation. See paragraph 2 of methods and materials section.

I have elaborated on and cite how exactly the qualitative thematic analysis was conducted. See the penultimate paragraph of methods and materials section.

I have referenced and cited “member checking” as a feature of the process. See final paragraph of methods and materials section.

The approach for analysis and who was involved at different stages is now clarified and explained more fully.  See the penultimate paragraph of methods and materials section.

The wording relating to the transcription was confusing and lacked detail.  This has now been clarified to make clear that notes were taken during interview but transcription occurred after interview. See paragraph 3 of the methods and materials section.

A brief discussion on the qualitative constructs of reliable data collection and analysis (trustworthiness, credibility, etc.) have been added and signposted throughout the methods and materials section.

A note addressing author reflexivity has been added – see penultimate paragraph of methods and materials section.

I have now clarified and explained more fully the statement: “Qualitative thematic analysis was carried out on the interview transcripts in relation 190 to transitions in the accommodation of the sample using a recovery capital framework.” And how this was applied to the analysis – see the penultimate paragraph in the methods section.

I noted in the methods section that pseudonyms were given to all participants quoted in the results section to ensure anonymity.

Results:

In the introductory paragraph in the results section on page 9, I have added a couple of sentences that presents a list of the themes I identified and will be presenting to help to orient the reader and provide more detailed context to the findings. In addition, I also added a brief introductory sentence to each thematic sub-heading to better explain what the theme is about.

I reworded Ln. 214- for clarity and active voice.

All quoted material is now in italics in the results section.

I have separated violence out from the mothering theme as suggested.  This has it’s own sub-heading.  As I reviewed the content for this new sub-theme it was clear that the reason why the women ended their relationship from a violent partner was not for their own safety but for the sake of their children.  The new heading is entitled ‘Ending a negative, substance using and/or violent relationship to protect children’.

Discussion section:

I have separated out the discussion and conclusion and added the heading ‘Conclusion to signify this.

I have made a more detailed integration of existing literature within the discussion section linking the reflections to other studies in the field.  This section also contains lots more links and citations to literature.

Many thanks again for your comments.

Reviewer 2 Report

Thank you for asking me to review this paper. I found it clear, well-written and easy to follow. I especially appreciated the use of 'recovery capital' and 'CHIME' as analytical frameworks. These were both new to me and I found them useful in providing the rich analysis completed in this paper. Tracing the changes in housing and how that relates to self-esteem, relationships and community development, though  known anecdotally, is more clearly illuminated in this work. Indeed, I believe more research exploring this association could be very fruitful. 

I think the paper could benefit from a review as noted below. Other than that, I think the paper is ready for publication.

Thank you!

Just needs a minor review for repetition of words close together such as "whilst" and "complex".  Also incorrect use of plural, "respondent" and "participant" on page 7.  Also in abstract, there is a missing noun, "various forms of housing..." Suggest it might read, " housing instability" or "housing insecurity".

Author Response

Dear Reviewer,

Many thanks for taking the time to read and review my article. It is much appreciated.

Thank you for your positive comments regarding the article and its merits.

I have made all of the amendments that you suggested in your review.

Specifically, I have removed repetition of words close together e.g. whilst and complex.  I have corrected use of respondent and participant.  Finally, I have inserted the noun in the sentence relating to housing in the abstract.

Many thanks again for your comments.

Reviewer 3 Report

This is an interesting and potentially important paper on a very relevant subject: how people get out of drug addiction, and the many ways in which this is different for women compared to men. However, there are a number of issues that require revision.

First, for me there is gap between the theoretical framework and the results of the interviews. The theoretical framework is rather general in terms of social, personal and community capital. On the other hand, the interviews illustrate the crucial role of three rather concrete factors: bad (i.e. abusive and/or substance-using) partners, the motivational force of motherhood, and the importance of being removed from an environment where substance use is common. And those factors seem to be governed more by chance than by anything else. My feeling is that the theoretical framework did not much to put the findings in a wider perspective. (Incidentally, I find it strange to put pregnancy and motherhood under the heading of social capital.) For the same reason, some of the policy recommendations in the Discussion seemed to me to be disconnected from the findings. E.g. it is stated that “Housing policy also needs to address the shortage of safe, secure, quality and affordable housing in the UK”. This is no doubt true in general, but for addiction recovery it seems less crucial if, as noted a few paragraphs above: “It was not always the accommodation type or duration of residence that determined the safety, stability or security of the accommodation, or the nature of the experience whilst residing there”. I am not sure that this issue is easy to remedy, but rewriting the Discussion with these points in mind might help.

Second, we need to know more about the sample. A “stratified sampling method” is mentioned: stratified in what way? And, more importantly, how were the participants in the study recruited? Also, in qualitative studies it is common to have a list of the people interviewed, with some relevant information, e.g. their ages, how long they have been in recovery, whether they have children. (Incidentally, it should be mentioned earlier in the Introduction and in the Abstract that this is a UK study.)

Third, despite the life-course perspective, the situation of addiction comes out as a kind of zero-point: everything that happened before that is erased and does not affect what happens later. Recovery capital is something that is built up from scratch. Some remarks may be sufficient to rectify this impression.

Some sentences appear unfinished or lack a main verb.

Author Response

Dear Reviewer,

Many thanks for taking the time to read and review my article. It is much appreciated.

Thank you for your positive comments regarding the article and its merits.

I have made all the amendments that you suggested in your review.

The theoretical section has had a general re-write to create greater alignment and congruence between the issues raised in the findings and the literature.  The reason for the application of the recovery capital framework was to try to situate the housing transitions into a wider context of personal, social and community capital.  The approach in the literature is typically to focus on a single issue in relation to housing e.g. gender, violence and so on.  Whereas the aim of this paper was to apply the recovery capital framework to the analysis to attempt to consider a broader range of issues relating to the 3 recovery capital life domains.  As it transpired in the findings, most of the transitions related to issues of social capital, as you helpfully highlighted which ten perhaps limited the scope for discussion or broader issues.   See the third and final paragraph of the introduction that addresses your comment:

“First, for me there is gap between the theoretical framework and the results of the interviews. The theoretical framework is rather general in terms of social, personal and community capital. On the other hand, the interviews illustrate the crucial role of three rather concrete factors: bad (i.e. abusive and/or substance-using) partners, the motivational force of motherhood, and the importance of being removed from an environment where substance use is common. And those factors seem to be governed more by chance than by anything else. My feeling is that the theoretical framework did not much to put the findings in a wider perspective.” 

The 3 factors you identified in your comment above have also been more clearly and explicitly discussed in the discussion section also.

The Discussion section has been re-written.   It is now more focused on discussing the implications of the findings. In addition, the housing policy comment you mention has been removed from the recommendations section of the discussion section for this reason.  New recommendations have been added that align with the findings to address your comment:

“For the same reason, some of the policy recommendations in the Discussion seemed to me to be disconnected from the findings. E.g. it is stated that “Housing policy also needs to address the shortage of safe, secure, quality and affordable housing in the UK”. This is no doubt true in general, but for addiction recovery it seems less crucial if, as noted a few paragraphs above: “It was not always the accommodation type or duration of residence that determined the safety, stability or security of the accommodation, or the nature of the experience whilst residing there”. I am not sure that this issue is easy to remedy, but rewriting the Discussion with these points in mind might help.”

The methods section has been re-written to add more detail and explanation generally and specifically to address the sampling section (it was stratified for gender), and recruitment processes relating to the REC-PATH study and criteria for selection to address your comment “Second, we need to know more about the sample. A “stratified sampling method” is mentioned: stratified in what way? And, more importantly, how were the participants in the study recruited?” See para 3 of the methods and materials section.

A table has been added on page 6 providing the details you mentioned relating to the sample as per your comment “Also, in qualitative studies it is common to have a list of the people interviewed, with some relevant information, e.g. their ages, how long they have been in recovery, whether they have children.”

In relation to your comment “(Incidentally, I find it strange to put pregnancy and motherhood under the heading of social capital.)”  The reason that pregnancy and motherhood is placed under the heading of social capital is that it relates to the strength and power of the relationship the women had with their babies and children.  I have made this more explicit in the text and how the pull of these relationships led to a series of positive changes. 

The abstract and introduction now state that this is a UK study as per your comment “(Incidentally, it should be mentioned earlier in the Introduction and in the Abstract that this is a UK study.)”

The last paragraph under the heading ‘A long-term dynamic and nuanced process of change’ on Page 4 has been added to incorporate your helpful comment “Third, despite the life-course perspective, the situation of addiction comes out as a kind of zero-point: everything that happened before that is erased and does not affect what happens later. Recovery capital is something that is built up from scratch. Some remarks may be sufficient to rectify this impression.”

A final edit to the paper has eradicated the issues highlighted by your comment “Some sentences appear unfinished or lack a main verb.”

Many thanks again for your comments. 

Round 2

Reviewer 3 Report

Many thanks for this really thorough revision, which has addressed my comments much more adequately than I had expected.