Unprotected sex of homeless women living in Los Angeles county: an investigation of the multiple levels of risk

Because We Love You (BeWeL): A protocol for a randomized controlled trial of two brief interventions focused on social and cultural connectedness to reduce risk for suicide and substance misuse in young Alaska Native people

Background

Suicide among young people in Alaska Native (AN) communities was nearly unheard of through the establishment of statehood in 1959, but in the 1970s, AN suicide rates began to double every five years, with most of the increase due to suicide among 15 to 25-year-olds. From 1960-1995, the suicide rate increased by approximately 500% during this period of rapid, imposed social transition. For example, families were forced to live in settlements and children were sent to boarding schools. These disruptions increased conditions associated with suicide risk (e.g., substance use disorders, cultural disconnection), and challenged the community-level social safety net of youth protective factors that might have moderated effects of these traumas. The present study addresses the significant gap in culturally appropriate evidence-based programming to address suicide prevention among AN young people as part of aftercare. Our key research questions and methodology have been informed by AN stakeholders, and the intervention approach is Indigenous-led.

Methods

Our interventions are targeted toward Alaska Native young people ages 14-24 who present with suicide attempt, ideation, or associated risk behaviors, including alcohol-related injury in the Yukon-Kuskokwim region or the Interior. In a randomized controlled trial, 14-24-year-old AN individuals will receive either BeWeL (n = 185), which comprises a 45-minute virtual cultural talk addressing family and ancestral strengths and increasing protective factors, or BeWeL plus motivational interviewing with social networks, which includes an additional 15 minutes focused on discussion of the individual's social networks (n = 185). We will evaluate intervention effects on primary outcomes of suicide-intent risk, depression, anxiety, frequency of alcohol use, and alcohol consequences. Some of our secondary outcomes include individual and community protective factors, social networks, and awareness of connectedness.

Discussion

This project has the potential to expand the range and effectiveness of suicide prevention services for AN young people and will help meet the need in Alaska to link clinical behavioral health services to AN community-based networks, and to engage local cultural resources in aftercare for individuals at risk for suicide. Findings have potential to provide practical information to advance the field of suicide prevention and enhance protective factors and resiliency among this population.

Trial registration

ClinicalTrials.gov Identifier: NCT05360888.

Reproductive justice for unhoused women: An integrative review of the literature

This review examines the reproductive health experiences of unhoused women and youth. Guided by the reproductive justice framework, this review examines barriers to accessing contraception, medical abortion, and prenatal care while homeless. Twenty-one articles were identified through keyword searches in Google Scholar, Ebscohost Academic Search Premier, and PsycINFO. In included articles, barriers were identified at the individual, relational, and contextual levels. Findings from this scoping review illustrate the need to examine multiple levels of analysis when seeking to improve access to family planning services for individuals experiencing homelessness. Included literature suggests an overabundance of research documenting barriers to contraceptive care relative to the literature examining abortion and prenatal care experiences and a scarcity of research examining barriers to reproductive justice among unhoused individuals who do not identify as women.

A Network Analysis of the Relationship Between Mental and Physical Health in Unsheltered Homeless Persons in Los Angeles County

Homelessness is a public health crisis both nationally, in the United States, and internationally. Nevertheless, due to the hidden vulnerabilities of persons who are without shelter, little is known about their experiences during periods of homelessness. The present research adopts a network approach that conceptualizes how the major risk factors of homelessness interact, namely substance abuse problems, poor mental health, disability, and exposure to physical or sexual violence by an intimate partner. Our analysis draws on a large demographic survey of over 5,000 unsheltered homeless persons conducted in 2017 by the Los Angeles Homeless Services Authority. We estimated a network structure for 12 survey items tapping individual risk using the graphical least absolute shrinkage and selection operator algorithm. We then examined network centrality metrics and implemented a community detection algorithm to detect communities in the network. Our results indicated that mental illness and intimate partner violence (IPV) are central measures that connect all other mental and physical health variables together and that post-traumatic stress disorder and IPV are both highly affected by changes in any part of the network and, in turn, affect changes in other parts of the network. A community detection analysis derived four communities characterized by disability, sexual victimization and health, substance use, and mental health issues. Finally, a directed acyclic graph revealed that drug abuse and physical disability were key drivers of the overall system. We conclude with a discussion of the major implications of our findings and suggest how our results might inform programs aimed at homelessness prevention and intervention.

Restructuring personal networks with a Motivational Interviewing social network intervention to assist the transition out of homelessness: A randomized control pilot study

BACKGROUND

Social relationships play a key role in both substance use and homelessness. Transitioning out of homelessness often requires reduction in substance use as well as changes in social networks. A social network-based behavior change intervention that targets changes personal social networks may assist the transition out of homelessness. Most behavior change interventions that incorporate social networks assume a static network. However, people experiencing homelessness who transition into housing programs that use a harm reduction approach experience many changes in their social networks during this transition. Changes may include disconnecting from street-based network contacts, re-connecting with former network contacts, and exposure to new network members who actively engage in substance use. An intervention that helps people transitioning out of homelessness make positive alterations to their social networks may compliment traditional harm reduction housing program services.

METHODS

We conducted a pilot randomized controlled trial (RCT) of an innovative Social Network Intervention (MI-SNI), which combines network visualization and Motivational Interviewing to assist adults transitioning out of homelessness. The MI-SNI provides feedback to new residents about their social environments and is designed to motivate residents to make positive changes in both their individual behavior and their personal network. In a sample of 41 adult housing program residents with past year risky substance use, we examined whether participants randomized to receive a MI-SNI showed greater changes in their personal networks over 3 months compared to those receiving usual care.

RESULTS

There were significant differences in the networks of the MI-SNI group compared to the group receiving usual care at follow-up, controlling for baseline network characteristics. The MI-SNI group had greater reductions in the proportion of their network members who influenced alcohol or other drug use (AOD) use, such as drinking partners, and more frequently changed their relationships in the direction of lower AOD risk with network members who were retained in their networks across waves.

CONCLUSIONS

This study is the first pilot test of a MI-SNI customized for assisting the transition out of homelessness to test for personal network changes. Results indicate that MI-SNIs can have a positive impact on short-term network changes and thus may serve as a useful adjunct to behavioral change interventions. These findings suggest that a MI-SNI approach may help individuals experiencing homelessness and risky AOD use positively restructure their social networks while transitioning into supportive housing. These promising results suggest the need for a larger RCT test of this innovative intervention approach.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02140359.

Integrating traditional practices and social network visualization to prevent substance use: study protocol for a randomized controlled trial among urban Native American emerging adults

BACKGROUND

Nonmedical use of prescription opioids (defined as taking opioid medications for hedonic effects or in a manner other than prescribed) and the use of heroin have emerged in recent years as major public health concerns in the United States. Of particular concern is the prevalence of opioid use among emerging adults (ages 18-25), as this is a developmental period of heightened vulnerability and critical social, neurological, and psychological development. Data from 2015 show that American Indian/Alaska Native (AI/AN) people have the highest rates of diagnosis for opioid use disorders (OUDs). One recent study found that the overdose death rate among urban-dwelling AI/AN individuals was 1.4 times higher compared to those living in rural areas. To date, there are no evidence-based prevention programs addressing opioid use among urban AI/AN emerging adults that integrate culturally-appropriate strategies with evidence-based treatment. Traditions and Connections for Urban Native Americans (TACUNA) builds on our prior work with AI/AN communities across California to develop and evaluate culturally appropriate programming to address opioid, alcohol, and cannabis use among urban AI/AN emerging adults.

METHODS/DESIGN

In a randomized controlled trial, 18-25 year old urban AI/AN emerging adults will receive either TACUNA (n = 185), which comprises three virtual workshops utilizing motivational interviewing, social network visualization, and integrating traditional practices and a wellness circle, or one virtual culturally sensitive opioid education workshop (n = 185). We will evaluate intervention effects on primary outcomes of frequency of opioid, alcohol, and cannabis use, as well as secondary outcomes of social network characteristics and cultural connectedness, over a 12-month period.

DISCUSSION

This project has the potential to expand the range and effectiveness of opioid, alcohol, and cannabis services for urban AI/AN emerging adults by addressing the opioid epidemic and use of other substances at both the community and individual level. In addition, it provides important culturally grounded conceptual and practical information to advance the field of substance use interventions and enhance resiliency among this population.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT04617938. Registered October 26, 2020 https://clinicaltrials.gov/ct2/show/record/NCT04617938 .

Longitudinal effects of social network changes on drinking outcomes for individuals with a first-time DUI

BACKGROUND

Social networks are important predictors of alcohol-related outcomes, especially among those with a DUI where riskier social networks are associated with increased risk of drinking and driving. Social networks are increasingly a target for intervention; however, no studies have examined and measured whether longitudinal changes in social networks are associated with reductions in impaired driving.

OBJECTIVE

The current study first examines longitudinal changes in social networks among participants receiving services following a first-time DUI, and then examines the association between network change and drinking outcomes at 4- and 10-month follow-up.

METHODS

The study surveyed a subsample of participants (N = 94) enrolled in a clinical trial of individuals randomized to cognitive behavioral therapy (CBT) or usual care (UC) on an iPad using EgoWeb 2.0-an egocentric social network data collection software-about pre-DUI and post-DUI networks and their short- and long-term drinking behaviors.

RESULTS

Participants were 65% male, 48% Hispanic, and an average of 32.5 years old. Overall, participants significantly reduced the proportion of network members with whom they drank from 0.41 to 0.30 (p = .001) and with whom they drank more alcohol than they wanted to from 0.15 to 0.07 (p = .0001) from two weeks prior to the DUI (measured at baseline) to 4-month follow-up. Furthermore, decreases in proportion of drinking partners over time were associated with reduced drinks per week, self-reported driving after drinking, and intentions to drive after drinking at 4-month follow-up. Participants who reported decreases in proportion of drinking partners also reported significantly less binge drinking at 10-month follow-up. Finally, increases in emotional support were associated with decreases in binge drinking at 4-month follow-up. The study found no differences in the changes in composition of networks between CBT and UC groups.

CONCLUSIONS

These results suggest that individuals receiving services in DUI programs significantly reduced risky network members over time and that these social network changes were associated with reduced drinking and other indicators of risk for DUI recidivism. Clinical interventions that target reductions in risky network members may improve outcomes for those enrolled in a DUI program.

Exploring Reproductive Coercion in Relationship Contexts Among Young Adult, Primarily African American Women at Three Women's Health Clinics

Understanding reproductive coercion experiences in marginalized populations is important to assist in tailoring care and services. Reproductive coercion is consistently associated with intimate partner violence (IPV), engaging in sexual risk-taking, and is more commonly reported among non-White women. We conducted a secondary analysis of data from a mixed methods study to examine reproductive coercion in relationship contexts among a sample (N = 130) of young adult, primarily African American women recruited from three women's health clinics; 12 also participated in an in-depth interview. Thirty-six women (27.7%) reported reproductive coercion in the past year. Past-year reproductive coercion was associated with relationship trust, (t(128) = -3.01, p = .003), and past-year IPV (Fisher's exact test, p = .005). In the best-fit model, odds of past-year reproductive coercion increased by 4% with each one-point increase in relationship trust score (indicating reproductive coercion increased with lower trust; adjusted odds ratio [AOR] = 1.04; 95% confidence interval [CI] = [1.00, 1.08]), and by more than 4 times with past experience of IPV (AOR = 4.74; 95% CI = [1.07, 20.86]). Qualitative analysis revealed women's awareness of reproductive coercion whether or not they personally experienced it. Those who experienced reproductive coercion identified it as a form of abuse and additionally described experiences of pressure to conceive from the partner's family. Our results support routine screening for IPV and reproductive coercion. Furthermore, the intersection of partner reproductive coercion with family pressure related to reproductive decision making should be explored to better inform clinical interventions.

Social Networks of Clients in First-Time DUI Programs

OBJECTIVE

Social networks play an important role in the development of and recovery from problem drinking behaviors; however, few studies have measured the social networks of individuals convicted of driving under the influence (DUI) or assessed the relationship between social network characteristics and risk for DUI relapse and recidivism. The goal of this study is to describe the social network characteristics of a first-time DUI population in the 2 weeks before the DUI incident; examine demographic differences in social network characteristics by age, ethnicity, and gender; and assess the relationship between social network characteristics and risk factors for DUI.

METHOD

We collected personal (egocentric) social network survey data from 94 participants (65% male) enrolled in a randomized clinical trial comparing the effects of cognitive behavioral therapy with usual care for individuals convicted of a first-time DUI. Multivariate models were used to assess the relationship between pre-DUI personal network characteristics and risk factors for DUI measured at baseline interview.

RESULTS

Results indicate that the proportion of drinking partners in one's personal network was positively associated with drinks per week, binge drinking, alcohol use, marijuana use, and alcohol-related consequences. Several dimensions of personal network support were inversely associated with risk factors for DUI.

CONCLUSIONS

The pre-DUI composition of personal networks has a strong relationship to baseline risk factors for DUI; networks composed of more risky individuals (e.g., drinking partners) were associated with greater substance use and drinking and driving behaviors. Networks with greater levels of social support were associated with lower likelihood of self-reported driving after drinking and intentions to drive after drinking. Interventions that target positive and negative aspects of personal networks may enhance clinical treatments.

Social Networks of Clients in First-Time DUI Programs

OBJECTIVE

Social networks play an important role in the development of and recovery from problem drinking behaviors; however, few studies have measured the social networks of individuals convicted of driving under the influence (DUI) or assessed the relationship between social network characteristics and risk for DUI relapse and recidivism. The goal of this study is to describe the social network characteristics of a first-time DUI population in the 2 weeks before the DUI incident; examine demographic differences in social network characteristics by age, ethnicity, and gender; and assess the relationship between social network characteristics and risk factors for DUI.

METHOD

We collected personal (egocentric) social network survey data from 94 participants (65% male) enrolled in a randomized clinical trial comparing the effects of cognitive behavioral therapy with usual care for individuals convicted of a first-time DUI. Multivariate models were used to assess the relationship between pre-DUI personal network characteristics and risk factors for DUI measured at baseline interview.

RESULTS

Results indicate that the proportion of drinking partners in one's personal network was positively associated with drinks per week, binge drinking, alcohol use, marijuana use, and alcohol-related consequences. Several dimensions of personal network support were inversely associated with risk factors for DUI.

CONCLUSIONS

The pre-DUI composition of personal networks has a strong relationship to baseline risk factors for DUI; networks composed of more risky individuals (e.g., drinking partners) were associated with greater substance use and drinking and driving behaviors. Networks with greater levels of social support were associated with lower likelihood of self-reported driving after drinking and intentions to drive after drinking. Interventions that target positive and negative aspects of personal networks may enhance clinical treatments.

Current Age, Age at First Sex, Age at First Homelessness, and HIV Risk Perceptions Predict Sexual Risk Behaviors among Sexually Active Homeless Adults

While HIV disproportionately impacts homeless individuals, little is known about the prevalence of HIV risk behaviors in the southwest and how age factors and HIV risk perceptions influence sexual risk behaviors. We conducted a secondary data analysis (n = 460) on sexually active homeless adults from a cross-sectional study of participants (n = 610) recruited from homeless service locations, such as shelters and drop-in centers, in an understudied region of the southwest. Covariate-adjusted logistic regressions were used to assess the impact of age at homelessness onset, current age, age at first sex, and HIV risk perceptions on having condomless sex, new sexual partner(s), and multiple sexual partners (≥4 sexual partners) in the past 12 months. Individuals who first experienced homelessness by age 24 were significantly more likely to report condomless sex and multiple sexual partners in the past year than those who had a later onset of their first episode of homelessness. Individuals who were currently 24 years or younger were more likely to have had condomless sex, new sexual partners, and multiple sexual partners in the past 12 months than those who were 25 years or older. Those who had low perceived HIV risk had lower odds of all three sexual risk behaviors. Social service and healthcare providers should consider a younger age at homelessness onset when targeting HIV prevention services to youth experiencing homelessness.

A pilot test of a motivational interviewing social network intervention to reduce substance use among housing first residents

This article presents findings of a pilot test of a Motivational Interviewing social network intervention (MI-SNI) to enhance motivation to reduce high risk alcohol and other drug (AOD) use among formerly homeless individuals transitioning to housing. Delivered in-person by a facilitator trained in MI, this four-session computer-assisted intervention provides personalized social network visualization feedback to help participants understand the people in their network who trigger their alcohol and other drug (AOD) use and those who support abstinence. If ready, participants are encouraged to make changes to their social network to help reduce their own high-risk behavior. Participants were 41 individuals (33 male, 7 female, 1 other; 23 African-American, 5 non-Latino White, 6 Latino, 7 other, mean age 48) who were transitioning from homelessness to permanent supportive housing. They were randomly assigned to either the MI-SNI condition or usual care. Readiness to change AOD use, AOD abstinence self-efficacy, and AOD use were assessed at baseline and shortly after the final intervention session for the MI-SNI arm and around 3-months after baseline for the control arm. Acceptability of the intervention was also evaluated. MI-SNI participants reported increased readiness to change AOD use compared to control participants. We also conducted a subsample analysis for participants at one housing program and found a significant intervention effect on readiness to change AOD use, AOD abstinence self-efficacy, and alcohol use compared to control participants. Participants rated the intervention as highly acceptable. We conclude that a brief computer-assisted Motivational Interviewing social network intervention has potential to efficaciously impact readiness to change AOD use, AOD abstinence self-efficacy, and AOD use among formerly homeless individuals transitioning to permanent supportive housing, and warrants future study in larger clinical trials.

Woman to Woman (W2W): Adapting an HIV risk reduction intervention for older women

Woman to Woman (W2W) is a novel adaptation of the Sisters Informing Sisters about Topics on AIDS (SISTA) HIV prevention program. This article describes the process of adapting and piloting W2W based on recommendations from existing HIV prevention research. Six older women, all of whom had histories of homelessness and the majority of whom identified as African American, enrolled in the study, which piloted the adapted intervention and materials, evaluated the acceptability of the program, and assessed the measures related to the intervention. Participants described satisfaction with the program and had high rates of attendance; observations regarding the measures suggest the need to further develop assessments of HIV knowledge, condom use self-efficacy, and risk behaviors in this context.

Pilot Test of an Adapted, Evidence-Based HIV Sexual Risk Reduction Intervention for Homeless Women

Women experiencing homelessness are at heightened risk for HIV, yet risk reduction interventions specifically designed for this population are lacking. This study reports on a pilot efficacy trial of a brief evidence-based intervention, Sister To Sister (STS), that we specifically adapted for homeless women in the temporary/emergency settings where they typically seek services. Seventy-nine women, recruited from three service sites in Los Angeles County, were assigned to the 40-min adapted STS intervention or an information-only control group. At 30-day follow-up, intervention participants reported significantly greater condom use, intentions to use condoms, and sexual impulse control (as well as marginally higher positive condom beliefs and condom self-efficacy) compared to control participants. Results provide preliminary evidence that HIV risk reduction can be achieved for homeless women through a brief skill-based intervention. A randomized controlled trial employing a longer follow-up period to monitor outcomes will be necessary to determine efficacy of the adapted intervention.

A computer-assisted motivational social network intervention to reduce alcohol, drug and HIV risk behaviors among Housing First residents

BACKGROUND

Individuals transitioning from homelessness to housing face challenges to reducing alcohol, drug and HIV risk behaviors. To aid in this transition, this study developed and will test a computer-assisted intervention that delivers personalized social network feedback by an intervention facilitator trained in motivational interviewing (MI). The intervention goal is to enhance motivation to reduce high risk alcohol and other drug (AOD) use and reduce HIV risk behaviors.

METHODS/DESIGN

In this Stage 1b pilot trial, 60 individuals that are transitioning from homelessness to housing will be randomly assigned to the intervention or control condition. The intervention condition consists of four biweekly social network sessions conducted using MI. AOD use and HIV risk behaviors will be monitored prior to and immediately following the intervention and compared to control participants' behaviors to explore whether the intervention was associated with any systematic changes in AOD use or HIV risk behaviors.

DISCUSSION

Social network health interventions are an innovative approach for reducing future AOD use and HIV risk problems, but little is known about their feasibility, acceptability, and efficacy. The current study develops and pilot-tests a computer-assisted intervention that incorporates social network visualizations and MI techniques to reduce high risk AOD use and HIV behaviors among the formerly homeless. CLINICALTRIALS.

GOV IDENTIFIER

NCT02140359.

Understanding Consistent Condom Use Among Homeless Men Who Have Sex with Women and Engage in Multiple Sexual Partnerships: A Path Analysis

Consistent condom use is the main strategy aimed at preventing individuals from acquiring HIV through sexual intercourse. The mechanism of consistent condom use among a high-risk homeless subpopulation-homeless men who have sex with women and also engage in multiple sexual partnerships-remains unclear. This study identified 182 homeless men who engaged in multiple sexual partnerships from a representative sample of homeless men, who self-identified as heterosexual, using meal line services in Downtown Los Angeles' Skid Row area. Information such as participants' condom use psychosocial correlates, sexual risk behaviors, and social network characteristics were collected. Results suggested that condom efficacy is a potential intervening mechanism through which condom attitudes (β = -0.199; p = 0.005) and depression (β = -0.156; p = 0.029) are associated with an individual's consistent condom use. Having more network members with whom participants talked about HIV prevention (β = 0.051; p = 0.006) was also found to be associated with an individual's consistent condom use. HIV prevention programs should focus on increasing their condom efficacy to help reduce HIV risks among this vulnerable homeless subpopulation.

Differences in housing, health, and well-being among HIV-positive women living in poverty

The social context of living in poverty has a direct and indirect impact on a woman's health and well-being. This cross-sectional study investigates the relationship between housing and adherence to treatment, emotional wellness, environmental safety, physical health status, and risk behaviors among HIV-positive women receiving services from an AIDS service organization in the mid-South. Significant differences were found between stably housed and unstably housed women on the dependent outcome variables. Results suggest that housing services for HIV-positive women may be an effective way to increase their health and well-being as well as prevent transmission to others.

Risk and Protective Factors for HIV Self-disclosure among Poor African-American Women Living with HIV/AIDS

African-American women with HIV are among the fastest growing populations with HIV. The psychosocial factors and beliefs/attitudes associated with disclosure and other un-safe sex practices are not fully understood in this population. A total of 158 HIV-positive women receiving primary care in an HIV clinic in Philadelphia who enrolled in a safe-sex intervention, completed a baseline questionnaire on their sexual activities with male partners and psychosocial factors that were potential protective/risk factors for unsafe sex. Women who were emotionally close and monogamous with their partner were most likely to disclose their HIV status and least likely to worry they had infected their partner. Women who were non-monogamous and who did not have an emotional connection to any of their partners were least likely to self-disclose. Partners were more likely to know each other's status when the woman felt she had a responsibility to talk about the importance of staying HIV-negative.

Risk evaluations and condom use decisions of homeless youth: a multi-level qualitative investigation

Background

Homeless youth are at higher risk for sexually transmitted infections and unwanted pregnancy than non-homeless youth. However, little is known about how they evaluate risk within the context of their sexual relationships. It is important to understand homeless youths' condom use decisions in light of their sexual relationships because condom use decisions are influenced by relationship dynamics in addition to individual attitudes and event circumstances. It is also important to understand how relationship level factors, sexual event circumstances, and individual characteristics compare and intersect.

Methods

To explore these issues, we conducted semi-structured interviews with 37 homeless youth in Los Angeles County in 2011 concerning their recent sexual relationships and analyzed the data using systematic methods of team-based qualitative data analysis.

Results

We identified themes of risk-related evaluations and decisions at the relationship/partner, event, and individual level. We also identified three different risk profiles that emerged from analyzing how different levels of risk intersected across individual respondents. The three profiles included 1) Risk Takers, who consistently engage in risk and have low concern about consequences of risk behavior, 2) Risk Avoiders, who consistently show high concern about protection and consistently avoid risk, and 3) Risk Reactors, those who are inconsistent in their concerns about risk and protection and mainly take risks in reaction to relationship and event circumstances.

Conclusions

Interventions targeting homeless youth should reflect multiple levels of risk behavior and evaluation in order to address the diversity of risk profiles. Relationship/partner-, event-, and individual-level factors are all important but have different levels of importance for different homeless youth. Interventions should be tailored to address the most important factor contributing to homeless youth reproductive needs.

Electronic supplementary material

The online version of this article (doi:10.1186/s12889-015-1419-9) contains supplementary material, which is available to authorized users.

Adapting an evidence-based intervention for homeless women: engaging the community in shared decision-making

As interest grows in the diffusion of evidence-based interventions (EBIs), there is increasing concern about how to mitigate implementation challenges; this paper concerns adapting an EBI for homeless women. Complementing earlier focus groups with homeless women, homeless service providers (n = 32) were engaged in focus groups to assess capacity, needs, and barriers with implementation of EBIs. Deductive analyses of data led to the selection of four EBIs. Six consensus groups were then undertaken; three each with homeless women (n = 24) and homeless service providers (n = 21). The selected EBI was adapted and pretested with homeless women (n = 9) and service providers (n = 6). The structured consensus group process provided great utility and affirmed the expertise of homeless women and service providers as experts in their domain. Engaging providers in the selection process reduced the structural barriers within agencies as obstacles to diffusion.

Monogamy on the Street: A Mixed-Methods Study of Homeless Men

In this study, we used a mixed methods approach to explore the determinants of relationship patterns and risky sex among homeless men living in downtown Los Angeles. This involved analysis of qualitative interviews focused on gender ideology and sexual events ( n = 30) as well as structured interviews ( n = 305) focused on homeless men’s sexual partners, sexual behaviors, and social networks. We found that men valued committed relationships but were frustrated by their lack of access to female partners (accentuated by the stigma attached to homeless males) and also by structural and logistical barriers to relationships. Some men reported monogamous relationships; such relationships were less likely with homeless or substance-using partners and more likely with partners central to men’s social networks.

Shared risk: who engages in substance use with American homeless youth?

AIMS

To identify characteristics of social network members with whom homeless youth engage in drinking and drug use.

DESIGN

A multi-stage probability sample of homeless youth completed a social network survey.

SETTING

Forty-one shelters, drop-in centers and known street hangouts in Los Angeles County.

PARTICIPANTS

A total of 419 homeless youth, aged 13-24 years (mean age = 20.09, standard deviation = 2.80).

MEASUREMENTS

Respondents described 20 individuals in their networks, including their substance use and demographics, and the characteristics of the relationships they shared, including with whom they drank and used drugs. Dyadic, multi-level regressions identified predictors of shared substance use.

FINDINGS

Shared drinking was more likely to occur with recent sex partners [odds ratio (OR) = 2.64, confidence interval (CI): 1.67, 4.18], drug users (OR = 4.57, CI: 3.21, 6.49), sexual risk takers (OR = 1.71, CI: 1.25, 2.33), opinion leaders (OR = 1.69, CI: 1.42, 2.00), support providers (OR = 1.41, CI: 1.03, 1.93) and popular people (those with high degree scores in the network) (OR = 1.07, CI: 1.01, 1.14). Shared drug use was more likely to occur with recent sex partners (OR = 2.44, CI: 1.57, 3.80), drinkers (OR = 4.53, CI: 3.05, 6.74), sexual risk takers (OR = 1.51, CI: 1.06, 2.17), opinion leaders (OR = 1.24, CI: 1.03, 1.50), support providers (OR = 1.83, CI: 1.29, 2.60) and popular people (OR = 1.16, CI: 1.08, 1.24).

CONCLUSIONS

Homeless youth in the United States are more likely to drink or use drugs with those who engage in multiple risk behaviors and who occupy influential social roles (popular, opinion leaders, support providers, sex partners). Understanding these social networks may be helpful in designing interventions to combat substance misuse.

Understanding heterosexual condom use among homeless men

This study uses an event-based approach to examine individual, relationship, and contextual correlates of heterosexual condom use among homeless men. Structured interviews were conducted with a predominantly African American sample of 305 men recruited from meal lines in the Skid Row area of Los Angeles. Men reported on their most recent heterosexual event involving vaginal or anal intercourse. Adjusting for demographic characteristics only, condom use was more likely when men had higher condom use self-efficacy, greater HIV knowledge, or talked to their partner about condoms prior to sex. Condom use was less likely when men held more negative attitudes towards condoms, the partner was considered to be a primary/serious partner, hard drug use preceded sex, or sex occurred in a public setting. Condom attitudes, self-efficacy, partner type, and communication were the strongest predictors of condom use in a multivariate model that included all of the above-mentioned factors. Associations of unprotected sex with hard drug use prior to sex and having sex in public settings could be accounted for by lower condom self-efficacy and/or less positive condom attitudes among men having sex under these conditions. Results suggest that it may be promising to adapt existing, evidence-based IMB interventions for delivery in non-traditional settings that are frequented by men experiencing homelessness to achieve HIV risk reduction and thus reduce a significant point of disparity for the largely African American population of homeless men.

Unprotected sex among heterosexually active homeless men: results from a multi-level dyadic analysis

HIV is a serious public health problem for homeless populations. Homeless men who have sex with women have received less attention in the HIV risk literature than other homeless populations. This research uses multi-level modeling to investigate the context of unprotected sex among heterosexually active homeless men in the Skid Row area of Los Angeles. Based on interviews with 305 randomly selected men who discussed 665 of their recent female sexual relationships, this project investigates the correlates of unprotected sex during the past 6 months at the partnership, individual, and social network levels. Several different measures of relationship closeness and lack of communication about HIV/condoms were associated with unprotected sex. Controlling for relationship factors, men's negative attitudes towards condoms, mental health, and higher number of male sex partners also were associated with having unprotected sex with female partners. We discuss the implications of these findings for health interventions.

Masculinity and HIV Risk among Homeless Men in Los Angeles

HIV continues to be a serious public health problem for men who have sex with women (MSW), especially homeless MSW. Although consideration of gender has improved HIV prevention interventions, most of the research and intervention development has targeted how women's HIV risk is affected by gender roles. The effect of gender roles on MSW has received relatively little attention. Previous studies have shown mixed results when investigating the association between internalization of masculine gender roles and HIV risk. These studies use a variety of scales that measure individual internalization of different aspects of masculinity. However, this ignores the dynamic and culturally constructed nature of gender roles. The current study uses cultural consensus analysis (CCA) to test for the existence of culturally agreed upon masculinity and gender role beliefs among homeless MSW in Los Angeles, as well as the relationship between these beliefs and HIV-related behaviors and attitudes. Interviews included 30 qualitative and 305 structured interviews with homeless MSW in Los Angeles's Skid Row area. Analysis identified culturally relevant aspects of masculinity not represented by existing masculinity scales, primarily related to barriers to relationships with women. Behaviors, attitudes, and knowledge related to HIV were significantly associated with men's level of agreement with the group about masculinity. The findings are discussed in light of implications for MSW HIV intervention development.

The HIV risk reduction needs of homeless women in Los Angeles

BACKGROUND

Substance use, housing instability, and transactional sex all contribute to HIV risk engagement among homeless women. Because of the increased risk of HIV among homeless women, this study sought to understand the context of sexual behaviors and condom use among homeless women and elucidate modifiable factors that can be targeted by interventions.

METHODS

Homeless women (n = 45) participated in focus groups (n = 6) at shelters throughout Los Angeles County. Thematic analyses revealed that similar to other high-risk women, homeless women engage in sex with multiple types of partners (steady, casual, and transactional).

FINDINGS

Our findings indicate that, similar to use among other high-risk women, condom use by homeless women varied by type of partner. Substance use also contributed to condom non-use. In a departure from previous research, homeless women reported overarching feelings of hopelessness. Participants spoke of hopelessness contributing to risk engagement, specifically the number of ongoing stressors experienced because of homelessness contributing to despair. Without acknowledgement of this unique quality of homelessness, women felt their risk reduction needs would never truly be understood.

CONCLUSIONS

Interventions involving homeless women should include self-esteem building, acknowledgment and use of inherent resilience qualities gained during homelessness, respect for current knowledge and skills, and an exploration of when women choose to trust their partners and how they make safer sex choices.

Who is Supporting Homeless Youth? Predictors of Support in Personal Networks

Homeless youth lack the traditional support networks of their housed peers, which increases their risk for poor health outcomes. Using a multilevel dyadic analytic approach, this study identified characteristics of social contacts, relationships, and social networks associated with the provision of tangible and emotional support to homeless youth (N = 419, M age = 20.09, SD = 2.80). Support providers were likely to be family members, sex-partners, or non-street based contacts. The provision of support was also associated with contacts' employment and homelessness status, frequency of contact, shared risk behaviors, and the number of network members that were homeless and employed. The results provide insights into how homeless youth could be assisted to develop more supportive social networks.

Unprotected sex of homeless youth: results from a multilevel dyadic analysis of individual, social network, and relationship factors

Homeless youth have elevated risk of HIV through sexual behavior. This project investigates the multiple levels of influence on unprotected sex among homeless youth, including social network, individual, and partner level influences. Findings are based on analyses of an exploratory, semi-structured interview (n = 40) and a structured personal network interview (n = 240) with randomly selected homeless youth in Los Angeles. Previous social network studies of risky sex by homeless youth have collected limited social network data from non-random samples and have not distinguished sex partner influences from other network influences. The present analyses have identified significant associations with unprotected sex at multiple levels, including individual, partner, and, to a lesser extent, the social network. Analyses also distinguished between youth who did or did not want to use condoms when they had unprotected sex. Implications for social network based HIV risk interventions with homeless youth are discussed.

Substance use and other risk factors for unprotected sex: results from an event-based study of homeless youth

This study used an event-based approach to understand condom use in a probability sample of 309 homeless youth recruited from service and street sites in Los Angeles County. Condom use was significantly less likely when hard drug use preceded sex, the relationship was serious, the partners talked about "pulling out", or sex occurred in a non-private place (and marginally less likely when heavier drinking preceded sex, or the partnership was monogamous or abusive). Condom use was significantly more likely when the youth held positive condom attitudes or were concerned about pregnancy, the partners talked about condom use, and the partners met up by chance. This study extends previous work by simultaneously examining a broad range of individual, relationship, and contexual factors that may play a role in condom use. Results identify a number of actionable targets for programs aimed at reducing HIV/STI transmission and pregnancy risk among homeless youth.

HIV risk behavior and access to services: what predicts HIV testing among heterosexually active homeless men?

HIV is a serious epidemic among homeless persons, where rates of infection are estimated to be three times higher than in the general population. HIV testing is an effective tool for reducing HIV transmission and for combating poor HIV/AIDS health outcomes that disproportionately affect homeless persons, however, little is known about the HIV testing behavior of homeless men. This study examined the association between individual (HIV risk) and structural (service access) factors and past year HIV testing. Participants were a representative sample of 305 heterosexually active homeless men interviewed from meal programs in the Skid Row region of Los Angeles. Logistic regression examined the association between past year HIV testing and demographic characteristics, HIV risk behavior, and access to other services in the Skid Row area in the past 30 days. Despite high rates of past year HIV testing, study participants also reported high rates of HIV risk behavior, suggesting there is still significant unmet need for HIV prevention among homeless men. Having recently used medical/dental services in the Skid Row area (OR: 1.91; CI: 1.09, 3.35), and being a military veteran (OR: 2.10; CI: 1.01-4.37) were significantly associated with HIV testing service utilization. HIV testing was not associated with HIV risk behavior, but rather with access to services and veteran status, the latter of which prior research has linked to increased service access. We suggest that programs encouraging general medical service access may be important for disseminating HIV testing services to this high-risk, vulnerable population.

Bias and variance trade-offs when combining propensity score weighting and regression: with an application to HIV status and homeless men

The quality of propensity scores is traditionally measured by assessing how well they make the distributions of covariates in the treatment and control groups match, which we refer to as "good balance". Good balance guarantees less biased estimates of the treatment effect. However, the cost of achieving good balance is that the variance of the estimates increases due to a reduction in effective sample size, either through the introduction of propensity score weights or dropping cases when propensity score matching. In this paper, we investigate whether it is best to optimize the balance or to settle for a less than optimal balance and use double robust estimation to adjust for remaining differences. We compare treatment effect estimates from regression, propensity score weighting, and double robust estimation with varying levels of effort expended to achieve balance using data from a study about the differences in outcomes by HIV status in heterosexually active homeless men residing in Los Angeles. Because of how costly data collection efforts are for this population, it is important to find an alternative estimation method that does not reduce effective sample size as much as methods that aggressively aim to optimize balance. Results from a simulation study suggest that there are instances in which we can obtain more precise treatment effect estimates without increasing bias too much by using a combination of regression and propensity score weights that achieve a less than optimal balance. There is a bias-variance tradeoff at work in propensity score estimation; every step toward better balance usually means an increase in variance and at some point a marginal decrease in bias may not be worth the associated increase in variance.

A review of factors associated with unprotected sex among adult women in the United States

OBJECTIVE

To provide an updated review of research since 2005 on factors associated with unprotected sex among women in the United States.

DATA SOURCES

PubMed, CINAHL, and PsychINFO were searched from January 2006 through April 2011 using the terms unsafe sex, sexual risk taking, contraception, contraception behavior, birth control, condoms, and condom utilization.

STUDY SELECTION

Inclusion criteria included studies written in English on adult women in the United States age ≥ 18. Forty-five publications met inclusion criteria.

DATA EXTRACTION

All factors associated with engagement in unprotected sex are presented.

DATA SYNTHESIS

Unprotected sex has been associated with increasing age, being married, establishment of trust, recent experience of intimate partner violence, contraceptive side effects, infrequent sexual intercourse, and decreased arousal and pleasure due to contraceptive use. Religion, depression, history of abortion, number of children, having children, and number of pregnancies have not been associated with unprotected sex in recent studies. Several other variables have been studied with mixed results, possibly due to differences in research methods and sample characteristics.

CONCLUSIONS

More research is needed to elucidate the impact of cultural factors, relationship factors, attitude to pregnancy and motherhood, and reproductive coercion on prevention of pregnancy and sexually transmitted infections. Nurses can lead research on these topics and implement evidence-based practice based on study findings.