Homeless adolescent parents: HIV risk, family structure and individual problem behaviors

'I told him I'm gonna get it': intimate partner birth control communication among homeless young women

Homeless youth have disproportionately high rates of unintended pregnancy and STIs. Enhancing communication between sexual partners can improve sexual health outcomes, yet little is known about this topic among homeless youth; therefore, this study aimed to examine how homeless youth communicate with their partners about birth control. In-depth semi-structured interviews regarding intimate partner birth control communication were conducted with 10 homeless young women aged 14-22 years following their completion of a comprehensive sexual health program (Wahine Talk). We transcribed the interviews verbatim and used a structured, inductive analytic approach to identify themes. Analysis identified three themes: Getting the Conversation Started, Conversation Content, and Impact of Conversation. Birth control conversations were prompted by programme participation, birth control side effects, and family members' interest in homeless youth becoming pregnant. Barriers to communication included fear and mistimed conversations (e.g. during the initiation of sex). Homeless young people shared simultaneous desires to delay pregnancy and concerns about side effects of birth control use. Discussions about birth control with their partners may demonstrably improve homeless youth's intimate relationships and family planning efforts. Providers can support homeless young women by helping them plan conversation timing and addressing fear, including the risk of violence.

Housing, opportunities, motivation and engagement (HOME) for homeless youth at-risk for opioid use disorder: study protocol for a randomized controlled trial

Background

Homeless youth experience high rates of substance use disorders, exposures to violence, mental and physical health conditions, and mortality. They have been particularly affected by the opioid crisis. However, no study to date has used a randomized controlled design to test preventive interventions of opioid and other drug use among this vulnerable population. Resolution of youth homelessness through housing and supportive services including prevention services, often referred to as “Housing First,” has great potential to reduce the likelihood for the development of an opioid use disorder as well as other problem behaviors associated with living on the streets. Housing First has been tested through randomized trials among homeless adults with mental health and substance use disorders, but has not been empirically tested for opioid prevention among homeless youth.

Methods

Homeless youth will be recruited from a drop-in shelter site frequented by disconnected youth; they will be screened for eligibility, including current homelessness, age 18–24 years, and not currently meeting criteria for opioid use disorder (OUD). In a controlled trial, 240 youth will then be randomized to one of two conditions, (1) housing + opioid and related risk prevention services, or (2) opioid and related risk prevention services alone. This project utilizes existing efficacious models of prevention to address opioid-related risks, including motivational interviewing, strengths-based outreach and advocacy, and an HIV risk preventive intervention. Follow-up will be conducted at 3, 6, 9 and 12-months post-baseline. The economic cost of each intervention will be determined to support implementation decisions with other providers and their funders.

Discussion

This study will provide essential information for researchers and providers on the efficacy of housing + opioid and related risk prevention services in an RCT for effects on opioid use and mechanisms underlying change. Because youth experiencing homelessness are at increased risk for a variety of adverse outcomes, the proposed intervention may produce substantial health care benefits to the youths and society at large.

Trial registration ClinicalTrials.gov, NCT04135703, Registered October 13, 2019, https://clinicaltrials.gov/ct2/show/NCT04135703?term=NCT04135703&draw=2&rank=1#contacts

"It seems kinda like a different language to us": Homeless youths' attitudes and experiences pertaining to condoms and contraceptives

Homeless youth become pregnant or involved in pregnancies at high rates. There are many ways by which unintended pregnancies may be prevented, including the use of condoms and other contraceptives. However, there is a dearth of research regarding contraceptive use among this vulnerable youth population, and especially through lenses that consider homeless youths' diverse gender identities, expressions, and sexualities. This study qualitatively explores homeless youths' attitudes and experiences regarding condom and other contraceptive use. Data were obtained from interviews with 30 youth experiencing homelessness, ages 18-21. Youth reported inconsistent use of condoms and other contraceptives, which youth often attributed to their perceptions of contraceptive inaccessibility and exorbitant cost. Most youth also did not know where to obtain contraceptive information and services, and reported transportation barriers and fear of being stigmatized in health care settings, particularly in relation to their gender identities and sexualities. Findings suggest that reproductive and sexual health information and services are urgently needed by all homeless young people, and from low-barrier, non-judgmental, and empathetic sources.

Interventions for promoting reintegration and reducing harmful behaviour and lifestyles in street-connected children and young people

BACKGROUND

Millions of street-connected children and young people worldwide live or work in street environments. They are vulnerable to many risks, whether or not they remain connected to families of origin, and despite many strengths and resiliencies, they are excluded from mainstream social structures and opportunities.

OBJECTIVES

Primary research objectivesTo evaluate and summarise the effectiveness of interventions for street-connected children and young people that aim to:• promote inclusion and reintegration;• increase literacy and numeracy;• facilitate access to education and employment;• promote mental health, including self esteem;• reduce harms associated with early sexual activity and substance misuse. Secondary research objectives• To explore whether effects of interventions differ within and between populations, and whether an equity gradient influences these effects, by extrapolating from all findings relevance for low- and middle-income countries (LMICs) (Peters 2004).• To describe other health, educational, psychosocial and behavioural effects, when appropriate outcomes are reported.• To explore the influence of context in design, delivery and outcomes of interventions.• To explore the relationship between numbers of components and duration and effects of interventions.• To highlight implications of these findings for further research and research methods to improve evidence in relation to the primary research objective.• To consider adverse or unintended outcomes.

SEARCH METHODS

We searched the following bibliographic databases, searched for the original review, from inception to 2012, and various relevant non-governmental and organisational websites: Cochrane Central Register of Controlled Trials (CENTRAL); MEDLINE and Pre-MEDLINE; EMBASE and EMBASE Classic; Cumulative Index to Nursing and Allied Health Literature (CINAHL); PsycINFO; Education Resource Information Center (ERIC); Sociological Abstracts; Social Services Abstracts; Social Work Abstracts; Healthstar; Latin American Caribbean Health Sciences Literature (LILACS); System for Grey literature in Europe (OpenGrey); ProQuest Dissertations and Theses; EconLit; IDEAS Economics and Finance Research; JOLIS Library Catalog of the holdings of the World Bank Group and International Monetary Fund (IMF) Libraries; British Library for Development Studies (BLDS); Google and Google Scholar. We updated the search in April 2015 for the review update, using the same methods.

SELECTION CRITERIA

This review includes data from harm reduction or reintegration intervention studies that used a comparison group study design; all were randomised or quasi-randomised studies. Studies were included if they evaluated interventions provided for street-connected children and young people, from birth to 24 years, in all contexts.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed risk of bias and other factors presented in the Discussion and Summary quality assessment (Grades of Recommendation, Assessment, Development and Evaluation (GRADE)). We extracted data on intervention delivery, context, process factors, equity and outcomes, and grouped outcomes into psychosocial outcomes, risky sexual behaviours or substance use. We conducted meta-analyses for outcomes where the outcome measures were sufficiently similar. We evaluated other outcomes narratively.

MAIN RESULTS

We included 13 studies evaluating 19 interventions from high-income countries (HICs). We found no sufficiently robust evaluations conducted in low- and middle-income countries (LMICs). Study quality overall was low and measurements used by studies variable. Participants were classified as drop-in and shelter-based. No studies measured the primary outcome of reintegration and none reported on adverse effects.We found no consistent results on a range of relevant outcomes within domains of psychosocial health, substance misuse and sexually risky behaviours . Interventions evaluated consisted of time-limited therapeutically based programmes that proved no more effective than standard shelter or drop-in services and other control interventions used for most outcomes in most studies. Favourable changes from baseline were reported for outcomes for most participants following therapy interventions and standard services. We noted considerable heterogeneity between studies and inconsistent reporting of equity data. No studies measured the primary outcome of reintegration or reported on adverse effects.

AUTHORS' CONCLUSIONS

Analysis revealed no consistently significant benefit for focused therapeutic interventions compared with standard services such as drop-in centres, case management and other comparable interventions for street-connected children and young people. Commonly available services, however, were not rigorously evaluated. Robust evaluation of interventions, including comparison with no intervention, would establish a more reliable evidence base to inform service implementation. More robust research is needed in LMICs to examine interventions for street-connected children and young people with different backgrounds and service needs.

The paradox of homeless youth pregnancy: a review of challenges and opportunities

Compared to their housed counterparts, homeless youth become pregnant at exceptionally high rates. Causes of such pregnancies are multifaceted, while a paradoxically high proportion of these pregnancies are intended. This review discusses causes and risk factors associated with homeless youth pregnancies, and notes experiences of pregnancy decision-making discord, challenges encountered during and following pregnancy, and difficulties faced by homeless youth when or if they become parents. Because homeless youth face a wide array of unique risks, future research would benefit from exploring alternative approaches to prevention to reduce pregnancies and improve sexual and reproductive health outcomes among this population.

Reducing High Risk Behaviors among Street Living Youth: Outcomes of an Integrated Prevention Intervention

Research efforts to reduce Human Immunodeficiency Virus (HIV) risk behavior among street living youth have shown disappointing outcomes, with few studies reporting reduced risk behaviors. The current study tested the impact of an integrated HIV prevention intervention, and predictors of change, for youth (N=270) between the ages of 14 to 20 years receiving substance use treatment through a drop-in center. Condom use, HIV knowledge, number of sexual partners and behaviors associated with an overall HIV risk index were assessed at baseline, 3, 6 and 12 months post-baseline. Findings suggest that HIV prevention integrated with substance use treatment is associated with increased condom use and reduced sex partners. However, the effects on condom use were short lived and dissipated by 12 months post-baseline. Higher treatment attendance and baseline substance use predicted increased condom use. Although no significant change was observed in the overall HIV risk index, increases in depressive symptoms were associated with increases in the index score, as well as more sexual partners. Future research should determine whether successful intervention requires reinforcement of risk reduction behaviors while youth remain homeless.

Interventions for promoting reintegration and reducing harmful behaviour and lifestyles in street-connected children and young people

BACKGROUND

Numbers of street-connected children and young people run into many millions worldwide and include children and young people who live or work in street environments. Whether or not they remain connected to their families of origin, and despite many strengths and resiliencies, they are vulnerable to a range of risks and are excluded from mainstream social structures and opportunities.

OBJECTIVES

To summarise the effectiveness of interventions for street-connected children and young people that promote inclusion and reintegration and reduce harms. To explore the processes of successful intervention and models of change in this area, and to understand how intervention effectiveness may vary in different contexts.

SEARCH METHODS

We searched the following bibliographic databases, from inception to 2012, and various relevant non-governmental and organisational websites: Cochrane Central Register of Controlled Trials (CENTRAL); MEDLINE and PreMEDLINE; EMBASE and EMBASE Classic; CINAHL; PsycINFO; ERIC; Sociological Abstracts; Social Services Abstracts; Social Work Abstracts; Healthstar; LILACS; System for Grey literature in Europe (OpenGrey); ProQuest Dissertations and Theses; EconLit; IDEAS Economics and Finance Research; JOLIS Library Catalog of the holdings of the World Bank Group and IMF Libraries; BLDS (British Library for Development Studies); Google, Google Scholar.

SELECTION CRITERIA

The review included data from harm reduction or reintegration promotion intervention studies that used a comparison group study design and were all randomised or quasi-randomised studies. Studies were included if they evaluated interventions aimed to benefit street-connected children and young people, aged 0 to 24 years, in all contexts.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed the risk of bias of included studies. Data were extracted on intervention delivery, context, process factors, equity and outcomes. Outcome measures were grouped according to whether they measured psychosocial outcomes, risky sexual behaviours or substance use. A meta-analysis was conducted for some outcomes though it was not possible for all due to differences in measurements between studies. Other outcomes were evaluated narratively.

MAIN RESULTS

We included 11 studies evaluating 12 interventions from high income countries. We did not find any sufficiently robust evaluations conducted in low and middle income countries (LMICs) despite the existence of many relevant programmes. Study quality overall was low to moderate and there was great variation in the measurement used by studies, making comparison difficult. Participants were drop-in and shelter based. We found no consistent results on a range of relevant outcomes within domains of psychosocial health, substance misuse and sexual risky behaviours despite the many measurements collected in the studies. The interventions being evaluated consisted of time limited therapeutically based programmes which did not prove more effective than standard shelter or drop-in services for most outcomes and in most studies. There were favourable changes from baseline in outcomes for most particpants in therapy interventions and also in standard services. There was considerable heterogeneity between studies and equity data were inconsistently reported. No study measured the primary outcome of reintegration or reported on adverse effects. The review discussion section included consideration of the relevance of the findings for LMIC settings.

AUTHORS' CONCLUSIONS

Analysis across the included studies found no consistently significant benefit for the 'new' interventions compared to standard services for street-connected children and young people. These latter interventions, however, have not been rigorously evaluated, especially in the context of LMICs. Robustly evaluating the interventions would enable better recommendations to be made for service delivery. There is a need for future research in LMICs that includes children who are on the streets due to urbanisation, war or migration and who may be vulnerable to risks such as trafficking.

Pregnancy attitudes, contraceptive service utilization, and other factors associated with Los Angeles homeless youths' use of effective contraception and withdrawal

STUDY OBJECTIVE

This study aims to understand the associations of contraceptive service utilization (ie, accessing condoms or birth control), pregnancy attitudes, and lifetime pregnancy history among male and female homeless youth in relation to use of effective contraception and withdrawal.

DESIGN, SETTING, AND PARTICIPANTS

Between October 2011 and February 2012, homeless youth (14-27 years old) from 2 drop-in centers in Los Angeles (N = 380) were recruited and completed a questionnaire. The data in this paper are restricted to those who reported vaginal sex at last sex (N = 283).

MAIN OUTCOME MEASURES

Analyses examined history of foster care, sexual abuse, exchange sex, pregnancy, lifetime homelessness duration, current living situation, contraceptive service utilization, and pregnancy attitudes in predicting use of effective contraception and withdrawal at last sex.

RESULTS

Over 62% of females and 43% of males report having ever been pregnant or impregnating someone. There are no gender-based differences in pregnancy attitudes; 21% agree they would like to become pregnant within the year. Additionally, there are no gender-based differences in reported contraceptive use at last vaginal sex. In the multivariable model, high school education, contraceptive service utilization (Relative Risk Ratio [RRR]: 4.0), and anti-pregnancy attitudes (RRR: 1.3) are significant positive predictors of using effective contraception; anti-pregnancy attitudes (RRR: 1.2) and gender (RRR: 0.3) are significantly associated with using withdrawal.

CONCLUSIONS

Health professionals should acknowledge that some homeless youth desire pregnancy; for those that do not, access to effective contraception is important. Programs must continue to promote pregnancy prevention, and include discussions of healthy pregnancy habits for pregnancy-desiring youth.

Interventions for promoting reintegration and reducing harmful behaviour and lifestyles in street-connected children and young people

BACKGROUND

Numbers of street-connected children and young people run into many millions worldwide and include children and young people who live or work in street environments. Whether or not they remain connected to their families of origin, and despite many strengths and resiliencies, they are vulnerable to a range of risks and are excluded from mainstream social structures and opportunities.

OBJECTIVES

To summarise the effectiveness of interventions for street-connected children and young people that promote inclusion and reintegration and reduce harms. To explore the processes of successful intervention and models of change in this area, and to understand how intervention effectiveness may vary in different contexts..

SEARCH METHODS

We searched the following bibliographic databases, from inception to 2012, and various relevant non-governmental and organisational websites: Cochrane Central Register of Controlled Trials (CENTRAL); MEDLINE and PreMEDLINE; EMBASE and EMBASE Classic; CINAHL; PsycINFO; ERIC; Sociological Abstracts; Social Services Abstracts; Social Work Abstracts; Healthstar; LILACS; System for Grey literature in Europe (OpenGrey); ProQuest Dissertations and Theses; EconLit; IDEAS Economics and Finance Research; JOLIS Library Catalog of the holdings of the World Bank Group and IMF Libraries; BLDS (British Library for Development Studies); Google, Google Scholar.

SELECTION CRITERIA

The review included data from harm reduction or reintegration promotion intervention studies that used a comparison group study design and were all randomised or quasi-randomised studies. Studies were included if they evaluated interventions aimed to benefit street-connected children and young people, aged 0 to 24 years, in all contexts.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed the risk of bias of included studies. Data were extracted on intervention delivery, context, process factors, equity and outcomes. Outcome measures were grouped according to whether they measured psychosocial outcomes, risky sexual behaviours or substance use. A meta-analysis was conducted for some outcomes though it was not possible for all due to differences in measurements between studies. Other outcomes were evaluated narratively.

MAIN RESULTS

We included 11 studies evaluating 12 interventions from high income countries. We did not find any sufficiently robust evaluations conducted in low and middle income countries (LMICs) despite the existence of many relevant programmes. Study quality overall was low to moderate and there was great variation in the measurement used by studies, making comparison difficult. Participants were drop-in and shelter based. We found no consistent results on a range of relevant outcomes within domains of psychosocial health, substance misuse and sexual risky behaviours despite the many measurements collected in the studies. The interventions being evaluated consisted of time limited therapeutically based programmes which did not prove more effective than standard shelter or drop-in services for most outcomes and in most studies. There were favourable changes from baseline in outcomes for most particpants in therapy interventions and also in standard services. There was considerable heterogeneity between studies and equity data were inconsistently reported. No study measured the primary outcome of reintegration or reported on adverse effects. The review discussion section included consideration of the relevance of the findings for LMIC settings.

AUTHORS' CONCLUSIONS

Analysis across the included studies found no consistently significant benefit for the 'new' interventions compared to standard services for street-connected children and young people. These latter interventions, however, have not been rigorously evaluated, especially in the context of LMICs. Robustly evaluating the interventions would enable better recommendations to be made for service delivery. There is a need for future research in LMICs that includes children who are on the streets due to urbanisation, war or migration and who may be vulnerable to risks such as trafficking.

Interaction of duration of homelessness and gender on adolescent sexual health indicators

PURPOSE

The purpose of this analysis was to determine the effects of duration of homelessness and gender on personal and social resources, cognitive-perceptual factors, and sexual health behaviors among homeless youth.

DESIGN

Cross-sectional analysis of data collected at baseline from 461 homeless adolescents who participated in a sexual health intervention study was done.

METHOD

Data were collected via laptop computers from homeless adolescents (mean age=19.52+1.91 years) in both comparison and intervention groups before the initiation of the intervention.

FINDINGS

Significant interaction effects were found for personal and social resources F (4, 426)=2.83, p<.05. Male participants who had been homeless<6 months had significantly higher scores on social connectedness than did male participants who were homeless>1 year. Univariate analysis of variance (ANOVA) indicated that both boys and girls who had been homeless>1 year had greater AIDS knowledge, F (1, 441)=7.91, p<.01, reported significantly more sexual risk-taking behaviors, F (1, 396)=9.93, p<.05, and engaged in fewer safe-sex behaviors, F (1, 396)=12.05, p<.05, than did those who had been homeless<6 months. Univariate ANOVA indicated that female participants had significantly lower levels of perceived health status, F (1, 429)=12.08, p<.01, significantly greater sexual self-care behaviors, F (1, 396)=16.29, p<.01, and significantly higher levels of assertive communication F (1, 396)=4.03, p<.05 than did male participants, regardless of duration of homelessness.

CONCLUSIONS

The duration of homelessness and gender has both direct and interaction effects on cognitive-perceptual and behavioral outcomes associated with sexual health.

CLINICAL RELEVANCE

Nurses and other healthcare providers working with homeless youth recognize the need to develop brief interventions that address health-risk behaviors. Findings from this study indicate that gender-specific interventions should be provided to youth soon after they become homeless.

Caring for and connecting with homeless adolescents

Adolescents from a variety of backgrounds are among the growing number of homeless Americans. Although they lack maturity and various skills, they manage to survive in dangerous and stressful environments. This article asserts that social policy that leads to services such as housing, education, and healthcare should be based on a philosophy, ethic, and theory of caring and connectedness, which have been shown to protect adolescents as they mature. The article includes brief descriptions of theories of caring, pathways to homelessness for adolescents, survival needs of homeless youth, and characteristics of service programs that incorporate caring and connectedness.

The impact of an integrated treatment on HIV risk behavior among homeless youth: a randomized controlled trial

While many studies provide useful information on the risk behaviors in which homeless youth engage, few prior studies evaluate Human Immunodeficiency Virus (HIV) risk related reduction strategies. In this study, homeless youth (n = 180) were recruited from a drop-in center and randomly assigned to one of two conditions, either an integrated individual cognitive-behavioral treatment and HIV prevention intervention that focused on skills building and education or to treatment as usual. All youth were assessed at entry into the program and at 3 and 6 month follow-up points. Findings showed an interaction between treatment condition, age and time. In the interaction, youth assigned to the integrated treatment reported greater condom usage than youth assigned to treatment as usual, with younger youth assigned to treatment as usual showing no change in condom use. The number of sexual partners reported by youth in both treatment conditions was also reduced over time. However, youth in both conditions continued to engage in other high-risk behaviors. The integrated treatment findings are promising and suggest that interventions which target both HIV risk behavior in addition to other life areas (substance use, mental health and housing) among homeless youth may be necessary in order to significantly impact high-risk behaviors among this unique group.