Associations between youth homelessness, sexual offenses, sexual victimization, and sexual risk behaviors: a systematic literature review

Prevalence of youth experiencing homelessness and its association with suicidal thoughts and behaviors: Findings from a population-based study

Although various studies have examined factors associated with suicidal behaviors among youth, few studies have investigated the association between youth experiencing homelessness (YEH) and suicidal thoughts and behaviors (STBs) using a large nationally representative sample. The objectives of this study were to investigate prevalence of YEH and its association with STBs. Data for this study came from the 2021 Youth Risk Behavior Survey. An analytic sample of 17,033 youth aged 14-18 (51.7 % male) was analyzed using binary logistic regression. Of the 17,033 youth examined, 3 % experienced homelessness during the past 30 days, 21.3 % experienced suicidal ideation, 17.3 % made a suicide plan, and 10.9 % attempted suicide during the past 12 months. Controlling for demographic characteristics and feeling sad or hopeless, YEH was associated with 2.48 times higher odds of experiencing suicidal ideation (AOR=2.48, p<.001), 2.46 times higher odds of making a suicide plan (AOR=2.46, p<.001), and 4.38 times higher odds of making a suicide attempt (AOR=4.38, p<.001). The findings of this study highlight the importance of identifying youth who are at risk of experiencing homelessness to ensure early interventions are put in place to prevent suicidal behaviors.

The influence of sexual violence on suicide risk among runaway youth in South Korea: The multiple additive moderating effect of peer attachment and parental attachment

BACKGROUND

Runaway youth without an adequate and safe place are vulnerable to sexual violence. Sexual violence is strongly associated with suicide risk, but peers and family are important factors in attenuating the negative outcomes of sexual violence; however, research on this relationship is insufficient because previous studies have focused only on runaway youth's problematic behavior.

OBJECTIVE

This study's specific aims were as follows: 1) to verify the association between sexual violence and suicide risk among runaway youth, and 2) to assess whether peer and parental attachment moderated the association between sexual violence and suicide risk among runaway youth.

PARTICIPANTS AND SETTING

The participants comprised 232 runaway youth (51.3 % girls); more than half were aged 17-19 years and approximately two-thirds of them had experienced child abuse.

METHODS

Self-administered questionnaires were provided to the participating runaway youth in youth shelters in South Korea. The data were analyzed using a multiple additive moderating model that simultaneously included moderating and control variables.

RESULTS

In total, 18.5 % of runaway youth were exposed to sexual violence (10.6 % boys, 26.1 % girls). Sexual violence victimization affected suicide risk among runaway youth. Peer attachment alleviated the negative relationship between sexual violence and suicide risk, and acted as a protective factor. Although the moderating effect of parental attachment was not significant, it significantly influenced suicide risk.

CONCLUSION

Our findings demonstrate that runaway youth are vulnerable to sexual violence victimization, especially severe types of sexual violence. Our study verified the role of peer and parental attachment in the association between sexual violence and suicide risk among runaway youth. These findings suggest the need to improve positive peer and parent relationships to mitigate suicide risk among runaway youth.

Prostitution in the shadow of life-long sexual abuse: Arab women's retrospective experiences

The present study uses the life-course and intersectionality perspectives to explore the meaning that aging Arab women attribute to their lived experiences of life-long sexual abuse in the shadow of engaging in prostitution. Interpretive phenomenological analysis was used to analyze the narratives of 10 older Arab women in Israel who were engaged in prostitution. Four themes emerged: experiencing childhood in the shadow of sexual abuse, becoming a prostitute, being entrapped in prostitution, and settling accounts with the native culture. Women aging in prostitution experience a harsh reality of abuse and loss. The present study points to multiple channels of abuse throughout the life course, from childhood until old age.

Adults and Family as Supportive of Adolescent Sexual Development in the Age of Smartphones? Exploring Cybersexual Violence Victimization, Pornography Use, and Risky Sexual Behaviors

Among adolescents, engagement in risky sexual behavior is an important public health concern. Research has begun to explore the impact of adolescents' online experiences with their social and behavioral health as approximately 95% of adolescents have access to a smartphone connected to the internet. However, little research has specifically examined how online experiences impact sexual risk behaviors among adolescence. To fill gaps in the existing research, the current study sought to investigate the association between two potential risk factors and three sexual risk behavior outcomes. We examined how experiencing cybersexual violence victimization (CVV) and using pornography during early adolescence was associated with condom use, birth control use, and use of alcohol and drugs before sex among U.S. high school students (n = 974). Additionally, we explored multiple forms of adult support as potential protective factors of sexual risk behaviors. Our findings suggest that CVV and porn use may be associated with risky sexual behaviors for some adolescents. In addition, parental monitoring and support from adults at school may be two ways to support healthy adolescent sexual development.

A population-based study of homelessness, antisocial behaviour and violence victimisation among young adults in Victoria, Australia

Homeless young adults are at increased risk for contact with the police and are overrepresented in the justice system. This study explored associations between homelessness, antisocial behaviour and violence victimisation using longitudinal panel data gathered through young adulthood. Data were drawn from a state representative population-based sample of young adults from Victoria, Australia participating in the International Youth Development Study (IYDS; n = 2884, 54% female). Participants were surveyed at age 21 years, with follow-up at ages 23 and 25 years. We examined changes in the prevalence of homelessness and tested hypothesised directional relationships between young adult homelessness, antisocial behaviour and violence victimisation using longitudinal cross-lagged panel models. Multiple-group modelling was used to test whether these relationships were moderated by gender. The prevalence of young adult homelessness was highest at age 21 (6.5%), declining at ages 23 (3.9%) and 25 years (2.5%). Results showed that young adult homelessness, antisocial behaviour and victimisation were related cross-sectionally, but not longitudinally. Gender did not significantly moderate these associations. Findings suggest that the state of homelessness is associated with temporary vulnerability to potentially harmful and problematic situations involving antisocial behaviour and victimisation. These situations are likely to heighten risk for contact with the police and direct physical and psychological harm.

Toward Precision Medicine in ADHD

Attention-Deficit Hyperactivity Disorder (ADHD) is a complex and heterogeneous neurodevelopmental condition for which curative treatments are lacking. Whilst pharmacological treatments are generally effective and safe, there is considerable inter-individual variability among patients regarding treatment response, required dose, and tolerability. Many of the non-pharmacological treatments, which are preferred to drug-treatment by some patients, either lack efficacy for core symptoms or are associated with small effect sizes. No evidence-based decision tools are currently available to allocate pharmacological or psychosocial treatments based on the patient's clinical, environmental, cognitive, genetic, or biological characteristics. We systematically reviewed potential biomarkers that may help in diagnosing ADHD and/or stratifying ADHD into more homogeneous subgroups and/or predict clinical course, treatment response, and long-term outcome across the lifespan. Most work involved exploratory studies with cognitive, actigraphic and EEG diagnostic markers to predict ADHD, along with relatively few studies exploring markers to subtype ADHD and predict response to treatment. There is a critical need for multisite prospective carefully designed experimentally controlled or observational studies to identify biomarkers that index inter-individual variability and/or predict treatment response.

Homelessness and health-related outcomes: an umbrella review of observational studies and randomized controlled trials

BACKGROUND

Homelessness has been associated with multiple detrimental health outcomes across observational studies. However, relatively few randomized controlled trials (RCTs) have been conducted on people who experience homelessness (PEH). Thus, this umbrella review ranked the credibility of evidence derived from systematic reviews (SRs) and meta-analyses (MAs) of observational studies investigating the associations between homelessness and any health outcome as well as RCTs targeting health needs in this population.

METHODS

Several databases were systematically searched from inception through April 28, 2021. Any SR and/or MA reporting quantitative data and providing a control group were eligible for inclusion. The credibility of the evidence derived from observational studies was appraised by considering the significance level of the association and the largest study, the degree of heterogeneity, the presence of small-study effects as well as excess significance bias. The credibility of evidence was then ranked in five classes. For SRs and/or MAs of RCTs, we considered the level of significance and whether the prediction interval crossed the null. The AMSTAR-2 and AMSTAR-plus instruments were adopted to further assess the methodological quality of SRs and/or MAs. The Newcastle-Ottawa Scale (NOS) was employed to further appraise the methodological quality of prospective cohort studies only; a sensitivity analysis limited to higher quality studies was conducted.

RESULTS

Out of 1549 references, 8 MAs and 2 SRs were included. Among those considering observational studies, 23 unique associations were appraised. Twelve of them were statistically significant at the p≤0.005 level. Included cases had worst health-related outcomes than controls, but only two associations reached a priori-defined criteria for convincing (class I) evidence namely hospitalization due to any cause among PEH diagnosed with HIV infection, and the occurrence of falls within the past year among PEH. According to the AMSTAR-2 instrument, the methodological quality of all included SRs and/or MAs was "critically low." Interventional studies were scant.

CONCLUSION

While homelessness has been repeatedly associated with detrimental health outcomes, only two associations met the criteria for convincing evidence. Furthermore, few RCTs were appraised by SRs and/or MAs. Our umbrella review also highlights the need to standardize definitions of homelessness to be incorporated by forthcoming studies to improve the external validity of the findings in this vulnerable population.

Multilevel Barriers to Sexual Health Behavior Among Vulnerable Adolescent Girls in the USA

Introduction

Most sexual health interventions focus on individual-level predictors of sexual behavior. Given the considerable influence of environmental factors on adolescent girls' sexual health, current interventions may be insufficient to promote safer sex. In this study, we aimed to understand adolescent girls' anticipated barriers to engaging in safer sex behavior after completing a brief, web-based sexual health intervention called HEART.

Methods

This study used qualitative interviews with 50 adolescent girls who were recruited from community-based organizations that serve vulnerable youth. All participants were 12 to 19 years old (mean age=15.62, SD=1.83), and identified with a marginalized racial/ethnic group (58% Black; 18% Latinx; 24% Asian, biracial, or multiracial). Further, 24% identified as LGBTQ+, and 58% were sexually active.

Results

Guided by the social ecological model, we delineate six unique barriers to safer sex discussed by adolescents: partner manipulation, slut shaming, unclear sexual values, present time orientation, embarrassment, and access to sexual and reproductive health services.

Discussion

We conclude with recommendations for addressing these barriers to optimize adolescent girls' sexual health.

Prevalence and Correlates of Illicit Substance Use Among Young Adults Experiencing Homelessness in Seven Cities Across the United States

Background

Young adults experiencing homelessness (YAEH) engage in substantially higher substance use rates than housed young adults. This current study builds on previous research by investigating the prevalence of and salient correlates of illicit substance use across a seven-city sample.

Methods

This study used the Homeless Youth Risk and Resiliency Survey (HYRRS) dataset, n=1426 Young adults experiencing homelessness to study patterns and correlates of illicit substance use.

Results

Multivariate logistic regression analyses were used to assess correlates of substance use. Study site, age, gender identity, sexual orientation, history of suicidal ideation, use of specific substances, and trading sex for drugs were associated with five types of illicit substance use (ecstasy, cocaine, crack, methamphetamine, and injection drug use).

Conclusion

Findings indicate that substance use interventions for YAEH must be multifaceted, addressing illicit and multiple substance use, along with the myriad factors associated with substance use among this at-risk group.

Risk Behaviors and Experiences Among Youth Experiencing Homelessness-Youth Risk Behavior Survey, 23 U.S. States and 11 Local School Districts, 2019

Youth experiencing homelessness experience violence victimization, substance use, suicide risk, and sexual risk disproportionately, compared with their stably housed peers. Yet few large-scale assessments of these differences among high school students exist. The youth risk behavior survey (YRBS) is conducted biennially among local, state, and nationally representative samples of U.S. high school students in grades 9-12. In 2019, 23 states and 11 local school districts included a measure for housing status on their YRBS questionnaire. The prevalence of homelessness was assessed among states and local sites, and relationships between housing status and violence victimization, substance use, suicide risk, and sexual risk behaviors were evaluated using logistic regression. Compared with stably housed students, students experiencing homelessness were twice as likely to report misuse of prescription pain medicine, three times as likely to be threatened or injured with a weapon at school, and three times as likely to report attempting suicide. These findings indicate a need for intervention efforts to increase support, resources, and services for homeless youth.

Adolescent Antecedents of Young Adult Homelessness: a Cross-national Path Analysis

Adolescent and young adult health, development, and behavior lay a foundation for future population health. Increasing rates of young adult homelessness mean there is a need for research which generates evidence to support a stronger focus on population-level prevention. Using longitudinal data from a population-based sample of young adults participating in the cross-nationally matched International Youth Development Study, we examined adolescent antecedents of young adult homelessness in Washington State in the USA and in Victoria, Australia. Participants were surveyed using a modified version of the Communities That Care youth survey. Analyses of prospective, longitudinal data from 1945 participants, recruited as state-representative secondary school samples at grade 7 (average age 13, 2002) and longitudinally compared at young adulthood (average age 25, 2014), showed that young adults in Washington State reported higher rates of past year homelessness (5.24%) compared to those in Victoria (3.25%). Path modeling showed less positive family management strategies at age 13 uniquely increased risk for age 25 homelessness. This effect remained after accounting for age 15 antecedents in peer-group, school, and community environments. Friends' drug use, school suspension, academic failure, and low neighborhood attachment at age 15 mediated the association between less positive family management strategies at age 13 and age 25 homelessness. Despite observing some cross-national differences in levels of family, peer-group, school, and community antecedents, we found that these factors equally increased risk for age 25 homelessness in both states, suggesting similar cross-national influences for young adult homelessness. The findings indicate cross-nationally common adolescent antecedents for young adult homelessness that could be targeted by prevention strategies across international settings.

The Risks, Invisibility, and Health Issues Facing Women Veterans Who Are Homeless

Women veterans may experience a variety of traumatizing events and conditions before, during, and after their military service, such as intimate partner violence, military sexual trauma, moral injury, and posttraumatic stress disorder. These experiences put them at greater risk for significant behavioral and physical health sequelae, which can be associated with difficulty with civilian reintegration and complexities around homelessness. Homeless women military veterans are often uncounted, undergo different environmental situations than their male counterparts, and are vulnerable to sexual violence and unintended pregnancies. Identifying homeless women military veterans is an important first step; otherwise, they remain "invisible." Comprehensive, collaborative, interdisciplinary health care in which trust is established and care is holistic and individualized will produce the most optimal outcomes.

Sex Differences in the Pathways from Exposure to Parental Fighting to Risky Sexual Activities Among Adolescents in Urban Neighborhoods

OBJECTIVES

Adolescents' exposure to violence between parents acts as a precursor to risky behaviors; however, empirical studies that examined the potential pathways from exposure to violence between parents to risky behaviors are rare. Consequently, the prevention and intervention strategies for risky sexual activities are limited without the identification of malleable mediators.

METHODS

Mediators on the association between adolescent exposure to parental fighting and risky sexual activities are examined, which include internalizing behaviors, running away from home, and affiliation with risky peers. Relationships between these variables are examined for males and females separately. The sample consists of 673 adolescents in a neighborhood located in Chicago's Southside who completed a survey.

RESULTS

Exposure to parental fighting was not directly associated with risky sexual activities for either males or females. However, among females, exposure to parental fighting was significantly and positively related to internalizing behaviors and running away from home, and internalizing behaviors were also positively associated with running away from home. For males, however, only the association between internalizing behaviors and running away from home was found to be significant. Further, the relationship between exposure to parental fighting and risky sexual activities was mediated by running away from home.

CONCLUSIONS

Targeted strategies for prevention are critical for improving sexual health outcomes among adolescents in low-resourced urban neighborhoods.

Better off alone? Comparing the substance use, mental health and trauma risks of youth alcohol and other drug service users either living in out of home care, living with parents or experiencing homelessness

INTRODUCTION

All young people seeking assistance from youth alcohol and other drug services require support to help them minimise the harms from their substance use and continue to develop healthy and meaningful lives. A particular focus on young people in residential out of home care (OoHC) highlights the increased risks of substance use, mental health issues and continued vulnerabilities in this group. While in the past, research contrasted this group with young people living at home, this study contrasted young people in OoHC with homeless youths alongside those living with parents.

METHODS

The research contrasted these three groups of young people on substance use profiles, mental health and wellbeing and vulnerability to abuse (historic and current) in the Youth Needs Census conducted in Victoria and Queensland over 2013-2017.

RESULTS

The results demonstrate a clear risk of increased casual and daily methamphetamine use in the homeless youth group and occasional heroin use in the OoHC group. Mental health measures for both the OoHC and homeless youths were worse than the young people living at home. Trauma was similarly higher in these groups, with both historical and ongoing risks of violent crime for homeless youths.

DISCUSSION AND CONCLUSIONS

The results demonstrate the similar and serious health and wellbeing risks facing both youths in residential OoHC and homeless youths. These results are concerning as one of these groups is ostensibly in the care of the community and government, while the other group is experiencing unstable accommodation and associated physical risks.

Efficacy of a Just-in-Time Adaptive Intervention to Promote HIV Risk Reduction Behaviors Among Young Adults Experiencing Homelessness: Pilot Randomized Controlled Trial

BACKGROUND

People experiencing homelessness have higher rates of HIV than those who are stably housed. Mental health needs, substance use problems, and issues unique to homelessness such as lack of shelter and transiency need to be considered with regard to HIV prevention. To date, HIV prevention interventions for young adults experiencing homelessness have not specifically addressed modifiable real-time factors such as stress, sexual or drug use urge, or substance use, or been delivered at the time of heightened risk. Real-time, personalized HIV prevention messages may reduce HIV risk behaviors.

OBJECTIVE

This pilot study tested the initial efficacy of an innovative, smartphone-based, just-in-time adaptive intervention that assessed predictors of HIV risk behaviors in real time and automatically provided behavioral feedback and goal attainment information.

METHODS

A randomized attention control design was used among young adults experiencing homelessness, aged 18-25 years, recruited from shelters and drop-in centers in May 2019. Participants were randomized to either a control or an intervention group. The intervention (called MY-RID [Motivating Youth to Reduce Infection and Disconnection]) consisted of brief messages delivered via smartphone over 6 weeks in response to preidentified predictors that were assessed using ecological momentary assessments. Bayesian hierarchical regression models were used to assess intervention effects on sexual activity, drug use, alcohol use, and their corresponding urges.

RESULTS

Participants (N=97) were predominantly youth (mean age 21.2, SD 2.1 years) who identified as heterosexual (n=51, 52%), male (n=56, 57%), and African American (n=56, 57%). Reports of sexual activity, drug use, alcohol use, stress, and all urges (ie, sexual, drug, alcohol) reduced over time in both groups. Daily drug use reduced by a factor of 13.8 times over 6 weeks in the intervention group relative to the control group (Multimedia Appendix 4). Lower urges for sex were found in the intervention group relative to the control group over the duration of the study. Finally, there was a statistically significant reduction in reports of feeling stressed the day before between the intervention and control conditions (P=.03).

CONCLUSIONS

Findings indicate promising intervention effects on drug use, stress, and urges for sex in a hard-to-reach, high-risk population. The MY-RID intervention should be further tested in a larger randomized controlled trial to further investigate its efficacy and impact on sexual risk behaviors.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03911024; https://clinicaltrials.gov/ct2/show/NCT03911024.

Longitudinal Associations Between Early-Mid Adolescent Risk and Protective Factors and Young Adult Homelessness in Australia and the United States

Homelessness is associated with a range of negative health and behavioral outcomes, yet life-course pathways to homelessness from adolescence to early adulthood are not well-documented. This study asks to what extent do early-mid adolescent risk and protective factors predict young adult homelessness, and whether the predictive nature of these factors is similar in Victoria, Australia, and Washington State in the USA. As part of the International Youth Development Study, adolescents were recruited as state representative secondary school samples at grade 7 (age 13, 2002) and longitudinally compared at average age 25. Higher rates of past year homelessness were reported by Washington State (5.24%), compared to Victorian young adults (3.25%). Although some cross-state differences in levels of adolescent demographic, individual, family, peer group, school, and community predictors were found, cross-state comparisons showed these factors were equally predictive of young adult homelessness in both states. In univariate analyses, most adolescent risk and protective factors were significant predictors. Unique multivariate adolescent predictors associated with young adult homelessness included school suspension (adjusted odds ratio [AOR] = 2.76) and academic failure (AOR = 1.94). No significant unique protective effects were found. Prevention and intervention efforts that support adolescents' academic engagement may help in addressing young adult homelessness. The similar cross-state profile of adolescent predictors suggests that programs seeking to support academic engagement may influence risk for homelessness into young adulthood in both states. The similarity in life-course pathways to homelessness suggests that the USA and Australia can profitably translate prevention and intervention efforts to reduce homelessness while continuing to identify modifiable predictors.

Sexual victimization and intellectual disabilities among child welfare involved youth

BACKGROUND AND OBJECTIVE

Youth with intellectual disabilities involved in child welfare systems are at greater risk of sexual victimization than youth who have not been investigated for child maltreatment. This study addresses a gap in the literature regarding older youth with intellectual disabilities who are sexually victimized and pushed to engage in transactional sex while they are transitioning from child welfare systems involvement. It does so by examining risk and protective factors at the individual, micro, exo, and macro systems levels.

PARTICIPANTS AND SETTING

This study included 334 youth ages 18-19.5 from a nationally representative sample of 5,872 child welfare-involved youth.

METHODS

Multivariate logistic regression models were used to conduct a secondary analysis of the National Survey of Child and Adolescent Well-Being II to examine relationships between intellectual ability, social support, and community environment and sexual victimization and engaging in transactional sex.

RESULTS

Results indicate that 2.5 % of the youth experienced sexual victimization in the past 12 months, and 3.9 % had engaged in transactional sex in the past 6 months. The mean intelligence score for these youth was one standard deviation below average (M = 84.62, SD = 19.60). Being female was associated with experiencing sexual victimization (Odds Ratio = 17.29, p = .025). Higher intellectual ability scores were associated with lower odds of engaging in paid sexual activity (Odds Ratio = 0.92, p = .002).

CONCLUSIONS

This study highlights the need for early identification of intellectual disabilities among child welfare-involved youth, provision of informed social supports and services, and building community connections during transition to prevent sexual victimization.

Substance Use among Homeless Reproductive Age People in Southern Ethiopia

Introduction

Substance use by homeless reproductive age people may result to anxiety, involvement of risky sexual behaviors, and increasing the likelihood of unwanted pregnancy and sexually transmitted diseases (STDs). Therefore, this study assessed the magnitude of alcohol use, sexual intercourse after alcohol use, and its associated factors among homeless reproductive age people in southern Ethiopia.

Methods

Community-based cross-sectional study design was conducted among homeless reproductive age people. The snowball sampling technique was used to recruit 842 participants. Pretested and structured interviewer-administered questionnaire was used to collect the data. Data were entered into Epidata version 3.1 and exported to SPSS version 23 for analysis. Binary logistic regression was used to determine the association of independent variables with the outcome variables. Odds ratio with their 95% confidence interval and P value was used to identify the significant variables.

Results

More than half 423 (53.2%) of the respondents had taken a drink that contains alcohol in the last one year of the study period. Out of 324 khat chewers, 190 (58.64%) had sex after chewing khat. More than one-thirds, 323(38.4%) homeless people were smoking cigarette during the study period. Factors associated with alcohol use were age 19-25 years (AOR: 0.49; CI: 0.34, 0.72), ≥26 years (AOR: 0.40; CI: 0.25, 0.65), level of education (AOR: 0.61; CI: 0.39, 0.94), place of residence: major urban (AOR: 0.31; CI: 0.18, 0.51), small town (AOR: 0.38; CI: 0.23, 0.63), ever heard about STDs (AOR: 0.14; CI: 0.07, 027), and being a cigarette smoker (AOR: 2.67; CI: 1.94, 3.71).

Conclusions

In this study, significant percentage of respondents had taken a drink that contains alcohol. Age, level of education, place of residence, ever heard about STDs, and smoking cigarette were variables significantly associated with alcohol use. Awareness creation on the effect and outcome of substance use is recommended.

Exchange Sex Among High School Students-Washington, DC, 2017

PURPOSE

Exchange sex, the exchange of money or nonmonetary items for sex, is associated with sexually transmitted diseases and HIV. We sought to identify prevalence and characteristics associated with exchange sex among District of Columbia (DC) high school students.

METHODS

We used the 2017 DC Youth Risk Behavior Survey, a cross-sectional survey of students in grades 9-12 (n = 8,578). We performed multivariable logistic regression to examine associations between exchange sex and demographic, home environment, and substance use measures.

RESULTS

In 2017, a total of 7.4% (95% confidence interval [CI]: 6.6-8.2) of students reported ever having engaged in exchange sex. Odds of exchange sex were higher among males (adjusted odds ratio [AOR]: 2.5; 95% CI: 1.6-4.0) and students who had sexual contact with partners of both sexes (AOR: 2.4; 95% CI: 1.2-4.9), compared with students having sexual contact with partners of opposite sex only. Exchange sex was also associated with having been kicked out, run away, or abandoned during the past 30 days (AOR: 10.7; 95% CI: 7.0-16.3]); going hungry during the past 30 days (AOR: 2.2; 95% CI: 1.1-4.5); and ever using synthetic marijuana (AOR: 2.6; 95% CI: 1.3-5.0) or cocaine, heroin, methamphetamines, or ecstasy (AOR: 2.9; 95% CI: 1.6-5.3]), compared with those who had not.

CONCLUSIONS

Approximately one in 14 DC high school students engaged in exchange sex. Programs providing services to youth with unstable housing, food insecurity, or who use drugs should incorporate sexual health services to address exchange sex practices.

A Systematic Review and Meta-Analysis of the Prevalence of Post-Traumatic Stress Disorder among Homeless People

Post-traumatic stress disorder (PTSD) is common among homeless people and is associated with an increased risk of mortality from suicide, medical causes, and drug-related problems. However, there are no previous systematic review and meta-analysis studies that reported the consolidated magnitude of PTSD among homeless people. A literature search was conducted on PubMed, Embase, and Scopus to discover pertinent studies that determined the prevalence of PTSD among the homeless. Articles were evaluated by titles, abstracts, and full-text. Comprehensive meta-analysis software was used to conduct the meta-analysis. Subgroup and sensitivity analysis were performed and Cochran's Q- and the I² test were used to assess heterogeneity. The evidence of publication bias was evaluated by using Egger's test and visual inspection of the symmetry in funnel plots. From the total, 19 studies with 20,364 participants across seven countries were included in the final analysis. Our meta-analysis revealed that the pooled prevalence of PTSD among homeless people was 27.38% (95% CI; 21.95-33.57). In our subgroup analysis, we found that the prevalence of PTSD was considerably high as measured by the screening instrument (35.93%) than the diagnostic instrument (23.57% %). The prevalence of PTSD among homeless showed a significant variation by the location of the studies, the instruments used to measure PTSD as well as the quality of the included studies. This review showed that the pooled prevalence estimate of PTSD among homeless peoples was remarkably high (27.38%). Early screening and treatment of PTSD among homeless peoples are warranted to alleviate suffering.

A systematic review and meta-analysis of the prevalence of bipolar disorder among homeless people

Background

Bipolar disorder (BD) is a common severe mental disorder among homeless people and is associated with an increased risk of disability and mortality from suicide, medical causes (including HIV/AIDS, hepatitis infection, hypertension, and tuberculosis), as well as substance use disorders. However, a systematic synthesis of the existing evidence on the subject is lacking. To fill this gap in the literature, this study aimed to carry out systematic review and meta-analysis to determine the consolidated prevalence of BD among homeless people.

Methods

In this systematic review and meta-analysis, we searched Embase, PubMed, and Scopus to identify pertinent studies that reported the prevalence of BD among homeless people in March 2019. Random effect meta-analysis was employed to pool data from the eligible studies. Subgroup and sensitivity analysis was conducted and Cochran’s Q- and the I² test were utilized to quantify heterogeneity. Publication bias was assessed by using Egger’s test and visual inspection of the symmetry in funnel plots.

Results

Of 3236 studies identified, 10 studies with 4300 homeless individuals were included in the final analysis. Among the 10 studies, five studies used the Diagnostic Statistical Manual of Mental disorders (DSM), three studies used Mini-International Neuropsychiatric Interview (MINI), one study used Schedule for Clinical Assessment of Neuropsychiatry (SCAN), and one study used Composite International Neuropsychiatric Interview (CIDI) to assess BD among homeless individuals. Based on the results of the random effect model, the prevalence of BD among homeless people was 11.4% (95% CI; 7.5–16.9). The prevalence of BD was 10.0% (95% CI; 3.1–27.9) in Europe and it was 13.2% (95% CI; 8.9–19.3) in other countries. Moreover, the prevalence of BD was 11.5% (95% CI; 5.5–22.3) for studies that used DSM to assess BD and it was 11.0% (95% CI; 6.1–19.2) for studies that used other instruments (MINI, SCAN, and CIDI).

Conclusion

Our meta-analysis demonstrated that BD is highly prevalent among homeless individuals, underlying the importance of early screening and targeted interventions for BD among homeless individuals.

"This Research Is Cool": Engaging Youth Experiencing Homelessness in Research on Reproductive and Sexual Health

Youth experiencing homelessness face myriad barriers and inequities regarding their reproductive and sexual health and rights. Moreover, homeless youth are often characterized as "disaffiliated" and depicted as difficult to engage in research. This study qualitatively explored homeless youths' attitudes, beliefs, and needs regarding reproductive and sexual health, and sought their perspectives on being involved in research on such topics, which are often thought of as "taboo" or sensitive. Youth were enthusiastic about openly discussing such issues, which they deemed as highly relevant to their daily lives. Youth identified that how they were engaged in such research, and having opportunities for longer-term contributions to such efforts, were both important and exciting to them. Future social work and public health research efforts should seek to further disrupt narratives of homeless youth as "disaffiliated" and difficult to engage, and in doing so, develop more creative, participatory, and youth-led opportunities for including this group in reproductive and sexual health research.

Childhood Disadvantage, Social and Psychological Stress, and Substance Use Among Homeless Youth: A Life Stress Framework

We used a life stress framework to examine linkages between distal or primary stressors (e.g., child abuse) and proximal or secondary stressors (e.g., street victimization) and their association with substance use among 150 youth experiencing homelessness in the Midwestern United States. Results revealed that numerous primary stressors such as number of times youth ran from home and number of foster care placements were associated with secondary stressors, such as anxiety, total duration of homelessness, and street victimization. Only street physical victimization (e.g., been beaten up since leaving home) was associated with greater substance use. Our findings provide a more holistic picture of both distal and proximal life stressors that these young people experience and reveal the complexity of issues that service providers must acknowledge when working with this population.

Gaps in Sexual Assault Health Care Among Homeless Young Adults

INTRODUCTION

Young adults experiencing homelessness are at increased risk for sexual assault. Receiving a post-sexual assault examination has important implications for HIV and unintended pregnancy prevention; yet, utilization is not well understood. In a population at elevated risk for HIV, unintended pregnancy, and sexual violence, identifying barriers and facilitators to post-sexual assault examination is imperative.

METHODS

As part of a large, multisite study to assess youth experiencing homelessness across 7 cities in the U.S, a cross-sectional survey was conducted between June 2016 and July 2017. Data were analyzed in 2019 to determine the prevalence and correlates of sexual violence and examine the correlates of post-sexual assault examination utilization.

RESULTS

Respondents (n=1,405), aged 18-26 years, were mainly youth of color (38% black, 17% Latinx) and identified as cisgender male (59%) and lesbian, gay, bisexual, or queer (29%). HIV risks were high: 23% of participants had engaged in trade sex, 32% had experienced sexual assault as a minor, and 39% had experienced sexual exploitation. Young adults reported high rates of sexual assault (22%) and forced sex (24%). Yet, only 29% of participants who were forced to have sex received a post-sexual assault examination. Latinx young adults were more likely than other races/ethnicities to receive post-assault care. Participants frequently said they did not get a post-sexual assault exam because they did not want to involve the legal system and did not think it was important.

CONCLUSIONS

Interventions are needed to increase use of preventive care after experiencing sexual assault among young adults experiencing homelessness.

Prevalence of homelessness and co-occurring problems: A comparison of young adults in Victoria, Australia and Washington State, United States

Homelessness is associated with various co-occurring health and social problems yet; few contemporary international studies have examined these problems in young adulthood. This descriptive study presents cross-state comparison of the prevalence of young adult homelessness in Washington State, USA and Victoria, Australia using state representative samples from the International Youth Development Study (IYDS; n = 1,945, 53% female). Associations between young adult homelessness and a range of co-occurring problems were examined using a modified version of the Communities That Care youth survey. Results showed significantly higher rates of past year homelessness were reported by young adults in Washington State (5.24% vs. 3.25% in Victoria). Cross-state differences were evident in levels of friends' drug use, antisocial behavior, weekly income and support from peers. Unemployment (Adjusted Odds Ratio [AOR] = 2.67), antisocial behavior (AOR = 3.54) and victimization (AOR = 3.37) were more likely among young adults reporting homelessness in both states. Young adults with higher weekly income were less likely to report homelessness (AOR = .69) in both states. No significant association between mental health problem symptoms, substance use, family conflict or interaction with antisocial peers and homelessness were found in either state. Rates of violent behavior were more strongly related to young adult homelessness in Washington State than Victoria. The current findings suggest that programs that enable young adults to pursue income and employment, reduce antisocial behavior and include services for those who have been victimized, may help to mitigate harm among young adults experiencing homelessness.

Suicidal Ideation and Attempt among Homeless People: a Systematic Review and Meta-Analysis

Globally, suicide is a major public health problem among homeless people. Suicidal ideation and attempt are remarkably higher among homeless people as compared to the general population and they are linked with greater risk of complete suicide. However, no systematic review and meta-analysis has been conducted to report the consolidated magnitude of suicidal ideation and attempt among homeless people. We searched PubMed, Embase, and Scopus to identify pertinent studies on suicidal ideation and attempt among homeless people. A meta-analysis of the studies was conducted using a random effect model. We also conducted a sensitivity analysis and Cochran's Q- and the I² test was employed to evaluate heterogeneity. Publication bias was assessed by Egger's test and visual inspection of the symmetry in funnel plots. In total, 20 eligible studies with 27,497 homeless people matched the inclusion criteria. Nineteen studies assessed suicidal attempt and thirteen studies assessed suicidal ideation among homeless people. The pooled current and lifetime prevalence of suicidal ideation was 17.83% (95% CI;10.73-28.14) and 41.60% (95% CI; 28.55-55.95), respectively whereas the pooled current and lifetime prevalence of suicidal attempt was 9.16% (95% CI;4.10-19.20) and 28.80% (95% CI; 21.66-37.18), respectively. We found a considerable heterogeneity between the studies, but we found no significant publication bias. The current review revealed a remarkably higher magnitude of suicidal ideation and attempt among homeless people as compared to the estimated prevalence in the general population. The concerned stakeholders need to give attention to address this problem emphasizing more on prevention and treatment strategies as well as utilizing holistic approaches to address the potential predictors of suicide among homeless people including physical, mental, and substance use problems.

Knowledge and Attitudes About Pre-Exposure Prophylaxis Among Young Adults Experiencing Homelessness in Seven U.S. Cities

PURPOSE

Evidence suggests that young adults experiencing homelessness (YEH) are at elevated risk of HIV compared to housed youth. Given the limited research on pre-exposure prophylaxis (PrEP) awareness among YEH, this study examined their PrEP knowledge and attitudes.

METHODS

Data from a cross-sectional survey among YEH (ages 18-26) (n = 1,427) in seven U.S. cities were used to assess their knowledge and attitudes regarding PrEP to inform HIV prevention efforts.

RESULTS

Participants were primarily male youth of color. The mean age was 20.9years. While 66% felt at risk for HIV, only 14% strongly agreed that they try to protect themselves from getting infected with HIV. Most (84%) were eligible for PrEP based on risk, yet only 29% had knowledge of PrEP. Despite this, 59% reported they were likely/extremely likely to take PrEP. Access to free PrEP (55%), HIV testing (72%), healthcare (68%), and one-on-one (62%), and text messaging support (57%) were rated as very/extremely important for PrEP uptake and adherence.

CONCLUSIONS

The results of this study suggest missed opportunities to prevent new HIV infections among YEH. Efforts to increase PrEP uptake among this population should consider provider- and system-level interventions to increase PrEP awareness, decrease PrEP-associated healthcare costs, improve access to PrEP providers, and provide in-person and text messaging support.

Investigating Health Risk Environments in Housing Programs for Young Adults: Protocol for a Geographically Explicit Ecological Momentary Assessment Study

Background

Young adults who experience homelessness are exposed to environments that contribute to risk behavior. However, few studies have examined how access to housing may affect the health risk behaviors of young adults experiencing homelessness.

Objective

This paper describes the Log My Life study that uses an innovative, mixed-methods approach based on geographically explicit ecological momentary assessment (EMA) through cell phone technology to understand the risk environment of young adults who have either enrolled in housing programs or are currently homeless.

Methods

For the quantitative arm, study participants age 18-27 respond to momentary surveys via a smartphone app that collects geospatial information repeatedly during a 1-week period. Both EMAs (up to 8 per day) and daily diaries are prompted to explore within-day and daily variations in emotional affect, context, and health risk behavior, while also capturing infrequent risk behaviors such as sex in exchange for goods or services. For the qualitative arm, a purposive subsample of participants who indicated engaging in risky behaviors are asked to complete an in-depth qualitative interview using an interactive, personalized geospatial map rendering of EMA responses.

Results

Recruitment began in June of 2017. To date, 170 participants enrolled in the study. Compliance with EMA and daily diary surveys was generally high. In-depth qualitative follow-ups have been conducted with 15 participants. We expect to recruit 50 additional participants and complete analyses by September of 2019.

Conclusions

Mixing the quantitative and qualitative arms in this study will provide a more complete understanding of differences in risk environments between homeless and housed young adults. Furthermore, this approach can improve recall bias and enhance ecological validity.

International Registered Report Identifier (IRRID)

DERR1-10.2196/12112

Mental Health of Homeless Youth: Moderation by Peer Victimization and Teacher Support

The link between youth homelessness and mental health functioning was examined using state population-representative 2015 Youth Risk Behavior Survey (YRBS) data. The moderating role of victimization and perceived teacher support also was examined. Consistent with hypotheses, results indicated that homelessness was associated with greater mental health challenges, more victimization, and less teacher support. The association between homelessness and mental health was not moderated by perceived teacher support. However, victimization experiences served as a moderator such that more victimization exacerbated the effect of homelessness on mental health challenges. This study supports the utility of the YRBS for gaining understanding of the experiences and needs of youth experiencing homelessness and adds to the growing literature on predictors of individual differences in mental health functioning of these vulnerable youth.

Predicting Sexual Behaviors Among Homeless Young Adults: Ecological Momentary Assessment Study

BACKGROUND

Homeless youth continue to be disproportionately affected by HIV compared with their housed peers, with prevalence rates as high as 13%. Yet, HIV prevention in this high-risk population has been only marginally effective.

OBJECTIVE

The aim of this study was to use ecological momentary assessments to examine real-time factors to determine the predictors of sexual activity among homeless youth.

METHODS

Youth experiencing homelessness aged between 18 and 24 years were recruited from a drop-in center in Houston, Texas, between August 2015 and May 2016. All the participants received a study-issued mobile phone that prompted brief ecological momentary assessments (EMAs) 5 times a day for 21 days. EMA items assessed near real-time sexual behaviors, cognitions, stress, affect, environmental factors, and environmental circumstances.

RESULTS

Participants (N=66) were predominantly male (41/66, 64%) and black (43/66, 66%) with a median age of 20 years. The mean number of EMAs completed by each participant was 45 out of 105 possible observations. During the study, 70% (46/66) of participants were sexually active and reported condomless sex in 102 of the 137 cases of sexual intercourse (74.5%). In total, 82% (38/46) of the youth who reported having sex during the 3 weeks of data collection also reported engaging in high-risk sexual activities, including having condomless sex (24/46, 53%), having multiple sexual partners on the same day (12/46, 26%), trading sex (7/46, 16%), and sharing needles while injecting drugs (1/46, 3%). Of those, 71% (27/38) were engaged in multiple sexual risk behaviors. The predictive model was based on observations from 66 subjects who reported 137 cases of sexual intercourse over 811 days; sexual orientation, race, mental health, drug use, and sexual urge were included as predictors in the parsimonious generalized linear mixed model selected on the basis of the Akaike information criterion. The estimated odds ratios (ORs) were notable for same-day drug use (OR 2.17, 95% CI 4.48-17.31; P<.001) and sexual urge (OR 1.44, 95% CI 1.60-11.28; P=.004). The performance of the risk estimator was satisfactory, as indicated by the value of 0.834 for the area under the receiver operating characteristic curve.

CONCLUSIONS

Real-time EMA data can be used to predict sexual intercourse among a sample of high-risk, predominately unsheltered homeless youth. Sexual urge and drug use accounts for increased odds of engaging in sexual activity on any given day. Interventions targeting sexual urge and drug use may help predict sexual activity among a population at high risk of HIV.

My Own Best Friend: Homeless Youths' Hesitance to Seek Help and Strategies for Coping Independently after Distressing and Traumatic Experiences

Although homeless youth face extreme adversities, they are often hesitant to seek help from formal and informal supports. The current study qualitatively explored homeless youths' reasons for coping independently and their strategies for doing so. Youth accessing services (N = 145) in three U.S. cities were interviewed about their rationales for not seeking help from others regarding distressing experiences. Analyses illustrated specific barriers to help seeking that prompted homeless youth to cope on their own by utilizing soothing, avoidant, aggressive, and introspective coping strategies. Implications for outreaching to those least likely to seek help are discussed.

Exchange of Sex for Drugs or Money in Adolescents and Young Adults: An Examination of Sociodemographic Factors, HIV-Related Risk, and Community Context

The goal of this research was to examine associations among sociodemographic factors, HIV risk, and community context (e.g., economic insecurity, job training, housing instability, crime victimization, and perceived community norms) in adolescents and young adults who ever exchanged sex for drugs or money. Anonymous survey data were collected using ACASIs at community venues where adolescents and young adults congregate in resource-challenged, STI prevalent, urban, US neighborhoods. Conventional descriptive statistics, Fisher's exact tests, and generalized estimating equations approaches were used to examine associations. Participants (1818, 95.5 % of those screened eligible) were, on average, aged 21.0 years; 42.2 % were males, and 4.6 % were transgender. Almost one-third (32.1 %) identified as gay or lesbian, 18.1 % identified as bisexual; 66.2 % were Black and 21.0 % were Hispanic; 1.3 % was 'living on the street'. A sizeable proportion reported HIV-related risk: 16.3 % exchanged sex, 12.6 % had sex with someone they knew to be HIV-infected, 7.8 % had sex with someone who injected drugs, and 1.3 % injected drugs. Multivariate comparisons identified a number of variables (e.g., being male or transgender, homelessness, sex with a partner who has HIV, STI history, unemployment, job training access, housing instability, crime victimization, perceived community norms) that were significantly associated with exchange of sex (p < 0.05). This research contributes to the knowledge-base regarding exchange of sex among adolescents and young adults, particularly as it relates to community context. Longitudinal studies to describe the trajectory of social, health, and physical risks and consequences are needed for development of effective evidence-based prevention strategies.

The impact of transitional programmes on post-transition outcomes for youth leaving out-of-home care: a meta-analysis

Youth residing in out-of-home care settings have often been exposed to childhood trauma, and commonly report experiencing adverse outcomes after transitioning from care. This meta-analysis appraised internationally published literature investigating the impact of transitional programme participation (among youth with a baseline age of 15-24 years) on post-transition outcomes of housing, education, employment, mental health and substance use. A comprehensive search of sociology (e.g. ProQuest Sociology), psychology (e.g. PsycInfo) and health (e.g. ProQuest Family Health) electronic abstraction databases was conducted for the period 1990-2014. Search terms included 'out-of-home care', 'transition', 'housing', 'education', 'employment', 'mental health' and 'substance use'. Nineteen studies, all from the United States, met the inclusion criteria and were included in the meta-analysis. Living independently and homelessness were the most commonly described housing outcomes. Rates of post-transition employment varied, while rates of post-secondary education were low. Depression and alcohol use were commonly reported among transitioning youth. Findings of the meta-analysis showed that attention should be given to the potential benefit of transitional programme participation on outcomes such as housing, employment and education. Moderator analyses showed that these benefits may differ based on study design, sample size and sampling unit, but not for mean age or gender. Detailed and rigorous research is needed internationally to examine the characteristics of transitional programmes resulting in more successful outcomes for youth, and whether these outcomes are sustained longitudinally.

Reproductive health rights and survival: The voices of mothers experiencing homelessness

Women experiencing homelessness report higher rates of reproductive health-related traumas, including unplanned pregnancy, miscarriage, and abortion than their non-homeless peers. Using phenomenological hermeneutic methods, we sought to understand the reproductive health histories of women currently experiencing homelessness (N = 20, 25-61 years old, Mage = 38.33, SDage = 9.33) analyzing data collected between June 2014 and July 2015 in north central Texas. Three key themes highlight the essence of the women's experiences: (1) unexpected pregnancy-pregnancy just happened, (2) loss of reproductive health rights-I was broken, and (3) resilience-giving back and looking forward to good things. Many of the women became mothers through unexpected pregnancies, and overnight found that their lives were transformed irrevocably. Often unexpected pregnancy was the result or cause of a lack of ownership over their reproductive health and led to prolonged health-related traumas. Over time, though, many of the women whom we interviewed re-expressed resilience through social support, housing assistance, and a sense of giving back to society. Results indicate that reproductive health care providers require training to identify the relationship among unexpected pregnancy, reproductive health-related traumas, and housing insecurity. Providers can help preserve women's reproductive health rights through education and empowerment.

Causes of Child and Youth Homelessness in Developed and Developing Countries: A Systematic Review and Meta-analysis

IMPORTANCE

A systematic compilation of children and youth's reported reasons for street involvement is lacking. Without empirical data on these reasons, the policies developed or implemented to mitigate street involvement are not responsive to the needs of these children and youth.

OBJECTIVE

To systematically analyze the self-reported reasons why children and youth around the world become street-involved and to analyze the available data by level of human development, geographic region, and sex.

DATA SOURCES

Electronic searches of Scopus, PsychINFO, EMBASE, POPLINE, PubMed, ERIC, and the Social Sciences Citation Index were conducted from January 1, 1990, to the third week of July 2013. We searched the peer-reviewed literature for studies that reported quantitative reasons for street involvement. The following broad search strategy was used to search the databases: "street children" OR "street youth" OR "homeless youth" OR "homeless children" OR "runaway children" OR "runaway youth" or "homeless persons."

STUDY SELECTION

Studies were included if they met the following inclusion criteria: (1) participants were 24 years of age or younger, (2) participants met our definition of street-connected children and youth, and (3) the quantitative reasons for street involvement were reported. We reviewed 318 full texts and identified 49 eligible studies.

DATA EXTRACTION AND SYNTHESIS

Data were extracted by 2 independent reviewers. We fit logistic mixed-effects models to estimate the pooled prevalence of each reason and to estimate subgroup pooled prevalence by development level or geographic region. The meta-analysis was conducted from February to August 2015.

MAIN OUTCOMES AND MEASURES

We created the following categories based on the reported reasons in the literature: poverty, abuse, family conflict, delinquency, psychosocial health, and other.

RESULTS

In total, there were 13 559 participants from 24 countries, of which 21 represented developing countries. The most commonly reported reason for street involvement was poverty, with a pooled-prevalence estimate of 39% (95% CI, 29%-51%). Forty-seven studies included in this review reported family conflict as the reason for street involvement, with a pooled prevalence of 32% (95% CI, 26%-39%). Abuse was equally reported in developing and developed countries as the reason for street involvement, with a pooled prevalence of 26% (95% CI, 18%-35%). Delinquency was the least frequently cited reason overall, with a pooled prevalence of 10% (95% CI, 5%-20%).

CONCLUSIONS AND RELEVANCE

The street-connected children and youth who provided reasons for their street involvement infrequently identified delinquent behaviors for their circumstances and highlighted the role of poverty as a driving factor. They require support and protection, and governments globally are called on to reduce the socioeconomic inequities that cause children and youth to turn to the streets in the first place, in all regions of the world.

Exploring Contextual Factors of Youth Homelessness And Sexual Risk Behaviors: A Qualitative Study

CONTEXT

HIV disproportionately affects homeless youth, and interventions to date have had minimal success in reducing sexual risk behaviors in this population. Few qualitative studies have been conducted to provide insight into the influence of homelessness-related factors on sexual risk behaviors.

METHODS

A qualitative study with a quantitative component was conducted with a nonprobability sample of 64 homeless youth aged 14-24; participants were recruited from a variety of venues in Houston between October 2013 and March 2014. Thirteen focus group discussions were conducted; thematic analysis was used to identify themes related to HIV risk.

RESULTS

Participants were predominantly black (75%), sheltered (67%) and aged 18 or older (77%). Youth discussed how the circumstances of their homelessness and the struggle to meet their immediate needs led to behaviors and experiences that put them at risk for HIV. Three themes emerged: Homeless youth frequently engage in risky sexual behavior, sometimes as a way to cope with stress; they often trade sex, either voluntarily or involuntarily, for such necessities as money or a place to sleep; and many experienced childhood sexual victimization or have been victimized since becoming homeless. Youth also described how stress, stigma and self-reliance contributed to their involvement in HIV risk behaviors.

CONCLUSIONS

HIV prevention methods that target stress and stigma while respecting youths' self-reliance may help reduce sexual risk behaviors. Further research is needed to determine suitable behavioral change techniques to address these potentially modifiable factors.