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

Improving Reproductive Health Communication Between Providers and Women Affected by Homelessness and Substance Use in San Francisco: Results from a Community-Informed Workshop

OBJECTIVES

Many cisgender women affected by homelessness and substance use desire pregnancy and parenthood. Provider discomfort with patient-centered counseling about reproductive choices and supporting reproductive decisions of these women poses barriers to reproductive healthcare access.

METHODS

We used participatory research methods to develop a half-day workshop for San Francisco-based medical and social service providers to improve reproductive counseling of women experiencing homelessness and/or who use substances. Guided by a stakeholder group comprising cisgender women with lived experience and providers, goals of the workshop included increasing provider empathy, advancing patient-centered reproductive health communication, and eliminating extraneous questions in care settings that perpetuate stigma. We used pre/post surveys to evaluate acceptability and effects of the workshop on participants' attitudes and confidence in providing reproductive health counseling. We repeated surveys one month post-event to investigate lasting effects.

RESULTS

Forty-two San Francisco-based medical and social service providers participated in the workshop. Compared to pre-test, post-test scores indicated reduced biases about: childbearing among unhoused women (p < 0.01), parenting intentions of pregnant women using substances (p = 0.03), and women not using contraception while using substances (p < 0.01). Participants also expressed increased confidence in how and when to discuss reproductive aspirations (p < 0.01) with clients. At one month, 90% of respondents reported the workshop was somewhat or very beneficial to their work, and 65% reported increased awareness of personal biases when working with this patient population.

CONCLUSIONS FOR PRACTICE

A half-day workshop increased provider empathy and improved provider confidence in reproductive health counseling of women affected by homelessness and substance use.

Alcohol consumption and risky sexual behaviors among fishers in Elmina in Ghana

BACKGROUND

Alcohol consumption is part of human social behavior and constitutes a routine part of social life in many countries. Prior studies have found over-indulgence of fishers in alcohol in fishing communities. The study uses the Alcohol Myopia Theory (AMT) to analyze and explain the phenomena of fishers engaging in sex after alcohol consumption, and condom use with sexual partner(s) after alcohol consumption. The study investigated alcohol consumption, predictors of alcohol consumption, and the reasons for drinking alcohol among fishers. It also examined fishers' engagement in sex after alcohol consumption, the use of condoms with sexual partners after drinking alcohol, and predictors of the use of condoms with sexual partners after drinking alcohol.

METHODS

A cross-sectional convergent parallel mixed-method design was used to study 385 fishers in Elmina. Also, two focus group discussions were conducted among male and female fishers. Descriptive statistics were used to analyze the quantitative data, while the qualitative data was analyzed thematically.

RESULTS

Generally, 59.2% of participants indulged in alcohol consumption. Most male participants (70.6%) indulged in alcohol consumption than female participants (48.5%). Also, 48.5% of participants indulged in binge alcohol consumption, while 38.1% indulged in moderate alcohol consumption. The predictors of alcohol consumption were sex, religion, and type of fishing occupation. Participants identified consuming alcohol to kill loneliness and boredom, to forget family and work-related issues, and to have fun as reasons why fishers consume alcohol. Sixty-four percent of participants have ever engaged in sexual intercourse after consuming alcohol in the past 12 months. However, 70% of participants did not use a condom the last time they had sex after drinking alcohol. Only ethnicity of participants predicted their use of a condom the last time they had sex after drinking alcohol. The primary reasons for the non-use of condoms were do not like using condoms (37.9%), forgetting to use a condom (33.0%), and had sex with a trusted regular partner (15.5%).

CONCLUSIONS

This study demonstrated that alcohol consumption was prevalent among fishers, especially among male fishers, which contributes to risky sexual behaviors among them as espoused by the AMT. It is recommended that fishers are targeted for alcohol use and risky sexual behavior programs and interventions since alcohol use is prevalent among them and most of them also engage in unprotected sexual intercourse after consuming alcohol.

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 socioecological perspective to contraceptive access for women experiencing homelessness in the United States

OBJECTIVE

Although persons who are pregnancy-capable and experiencing homelessness may have a strong desire to avoid pregnancy, they face unique barriers to contraception. This multimethod qualitative study aimed to identify preferences for, barriers to, and facilitators of contraceptive access and use among women experiencing homelessness in the United States using a systems perspective.

STUDY DESIGN

We conducted semistructured interviews with women experiencing homelessness (n = 19), healthcare providers (n = 6), and social service providers (n = 6). We recruited participants from community-based, housing, and medical organizations in North Texas in the United States. Two coders conducted thematic analysis and reached consensus for codes.

RESULTS

Women participants were in emergency shelter, unsheltered, or transitional/rapid rehousing. We stratified themes using the Socioecological Framework to illustrate factors affecting contraception access at individual, interpersonal, organizational and community, and societal levels. Notable results include women's preferences for long-acting reversible contraception, difficulties healthcare providers face in initiating contraceptive counseling, and the underutilized role of social service providers in reproductive healthcare. Insurance policies, connections between health clinics and community organizations, and organizational priorities both facilitated and hindered women experiencing homelessness's access to women's healthcare services.

CONCLUSION

This study identified opportunities throughout the healthcare and social service systems to support contraceptive access for women experiencing homelessness. Future interventions should strengthen and leverage these connections to promote access among this vulnerable population with the goal of supporting reproductive autonomy.

IMPLICATIONS

This study explored the reproductive health needs of women experiencing homelessness. Multilevel interventions, such as interdisciplinary care, patient-centered approaches, and an emphasis on health literacy, are needed to adequately provide the preferred methods of contraception for women experiencing homelessness, thus enabling reproductive autonomy for this population.

Counter-Narratives of Structural Oppressions, Stigma and Resistance, and Reproductive and Sexual Health Among Youth Experiencing Homelessness

Youth experiencing homelessness (YEH) face myriad injustices regarding their reproductive and sexual health and rights. Reproductive and sexual health research with YEH often explores condom-use and sexually transmitted infections, potentially contributing to narrow conceptualizations of YEH as "unclean" or in need of disease-screening. A narrative theory perspective was applied to this study, which allowed for the emergence of alternative storylines, or counter-narratives, which attend to manifestations of power and oppression within the lives of marginalized individuals. Qualitative interviews engaged 30 young people (ages 18-21) accessing shelter services. Narrative analyses identified YEHs' documentations of dominant narratives related to structural oppressions, stigma, and numerous dimensions of reproductive and sexual health including how they create, through their resistance, counter-narratives that include their preferred futures. YEH emphasized systemic sources of stigma and outlined their criticisms of the state. Within-group stigma emerged as a noteworthy theme, with YEH showing both empathy and ambivalence towards other YEH, along with internalization of stigmatizing narratives about pregnancy and homelessness. Approaches to service provision that further amplify youths' voices in naming and challenging the many oppressions and stigmas they face should be prioritized. Moreover, policies should be implemented to dismantle the actual root causes of challenges faced by YEH, rather than perpetuating them through measures rooted in interlocking oppressions of discrimination, inequity, and judgment.

Examining sources of Social Support and Depression Prevention Among Pregnant Youth Experiencing Homelessness: Outcomes of a Seven-City Study

Young adults experiencing homelessness (YAEH) with pregnancy history are at higher depression risk. Receiving social support is protective for depression in pregnancy. This study differentiates social support sources associated with depression by pregnancy history among YAEH.Using a subsample of data collected from YAEH in seven US cities that were collected through REALYST, we conducted stratified logistic regression models (by pregnancy history) to identify support sources associated with depression. Logistic regression analysis including the interaction term (i.e., pregnancy history x support sources) using the full sample was then conducted.A higher proportion with pregnancy history reported depression compared to those without. Support from home-based peers was significantly associated with reduced depression risks among YAEH with pregnancy history, but not among youth without. Home-based supports were less frequently indicated by homeless female youth with pregnancy experience.Home-based social support is protective against major depression for YAEH with pregnancy experience. Findings of this study suggest that interventions addressing depression among YAEH should take their pregnancy history and social support sources into consideration. Specifically, for YAEH with pregnancy history, facilitating supportive social ties with home-based peers may be promising in reducing their depression risks.

Sexual and Reproductive Health and Reproductive Coercion in Women Victim/Survivors Receiving Housing Support

Housing instability and intimate partner violence (IPV) compromise women's sexual and reproductive health (SRH) through reduced contraceptive access and increased risk of unintended pregnancy. This study describes the reproductive health status and needs of IPV survivors receiving housing support and explores factors influencing their experience of reproductive coercion (RC), specifically. Cross-sectional baseline data from a quasi-experimental study of 70 IPV survivors enrolled in housing programs in the Baltimore, MD, metropolitan area from June 2019 through December 2020 were analyzed. Of the 70 women enrolled in the study, 70.3 percent (n = 45) desired to avoid pregnancy, but 57.4 percent were either using no contraceptive method (31.2%) or methods with low effectiveness (26.2%). Approximately, 1 in 6 women (16.4%, n = 11) experienced RC in the past 3 months, which was associated with frequency and severity of IPV (p = 0.001 to 0.005) and PTSD (p = 0.001), as well as not sharing children with the abusive partner (p = 0.002). This study highlights reproductive health risks in an important and under-studied population of women seeking housing due to IPV. Leaving an abusive relationship is a uniquely vulnerable time, and also a time of opportunity, as women are accessing services that can be tailored to their SRH needs. Significant results highlight vulnerability to and consequences of RC in this population. This study has implications for IPV support programs and housing programs that serve women.

Pregnancy and parenting support for youth experiencing homelessness

This study explored the perceptions and experiences related to pregnancy and parenting support among youth while homeless. This study employed a qualitative descriptive design using data collected from focus group discussions. We assessed the experiences and perceptions of youth related to pregnancy and parenting support. Eighty-one youth participated in eight focus group discussions and were recruited from shelters, drop-in centers, and organizations that serve youth in a large metropolitan areas in the southern United States. Thematic content analyses were used to generate results from the qualitative data. Four main themes emerged: youth encountered barriers to accessing healthcare services at the individual and system levels; pregnancy and parenting are stressful, especially during homelessness; support can help overcome the stresses of parenting; and embracing responsibility or "stepping up" is a positive influence of pregnancy and parenting during homelessness. Youth experiencing homelessness (YEH) face significant challenges to accessing healthcare services and adjusting to the parental role. Interventions for pregnant and parenting youth should be co-designed with and tailored for youth and address the existing health inequities within the healthcare and social service systems.

Relationship Between Sexual Activity, Contraceptive Utilization and Biopsychosocial Characteristics Among Homeless Shelter Adolescents

Objective: To determine whether biopsychosocial factors are associated with sexual activity and contraceptive utilization among homeless shelter adolescents.

Methods: A retrospective study of 440 adolescents at a shelter in Pennsylvania between February 2015 and September 2019 was conducted. The cohort was evaluated to determine what relationship age, gender identity, substance use, and trauma history have with sexual activity and contraceptive utilization.

Results: Sexual activity was significantly related to age (mean 15.8+1.4 years in sexually active vs. 14.7+1.6 years in abstinent youth, p<0.001); remote history of self-harm behavior (relative risk ratio (RR) 1.23 [95% CI 1.03-1.46]; p=0.02), history of aggressive behavior (RR 1.21 [95% CI 1.01-1.46]; p=0.04), history of trauma (RR 1.24 [95% CI 1.04-1.48]; p=0.03), and substance use (RR 2.27 [95%CI 1.86-2.77]; p<0.001). There were 55.7% sexually active females vs. 42.50% males reporting contraception use (p=0.01). After adjustment, older age and substance use remained significantly associated with sexual activity (adjusted odds ratio (AOR) 1.58 [95% CI 1.36-1.83]; p<0.001 and AOR 5.18 [95% CI 3.28-8.18]; p<0.001, respectively).

Conclusions: Females self-reported sexual activity using contraception more than males. After adjustment, older age and substance use were associated with sexual activity. By better understanding the impact these factors can have on contraceptive utilization, informed policy and practice interventions can be developed and implemented to help increase safe sex practices in spaces where homeless adolescents access healthcare.

The body cannot be cheated: sexual practices and modern contraceptive use among street-involved young people in two South West States in Nigeria

Background: Young people aged 10-24 years constitute about one-third of the total population of Nigeria. Street-involved young people (SIYP) face a double burden of living condition instability and lack of adequate parental monitoring. This leaves them vulnerable to poor sexual and reproductive health (SRH) choices and behaviour. Risky sexual behaviour with poor access to SRH information and interventions increases their vulnerability to adverse SRH outcomes. This study explored the use of modern contraceptives and sexual practices among male and female SIYP (10-24 years) in Nigeria. Methods: This qualitative study used an exploratory research design to guide the development of the focus group discussion (FGD) and in-depth interview (IDI) guides. Participants were asked questions on background information, lived experiences and SRH practices. The FGDs were stratified by sex and age. Both FGD discussions and IDI interviews were recoded; transcripts were transcribed and translated from local dialect into English language. Content analysis was conducted thematically with the aid of NVivo. Results: In total, 17 IDIs and 11 FGDs were conducted among SIYP aged 10-24 years. The total number of respondents interviewed was 109. There is high awareness of modern contraceptives among SIYP; the commonly known method was condom with a few also aware of emergency contraceptives pills. However, participants reported low use of modern contraceptives. The common reasons alluded for not using condoms were reduced sexual pleasure, cost and associated myths. The five themes that emerged under sexual practices of SIYP included early age at first sexual encounter, multiple sex partners, transactional sex, same-sex relationships, and transactional sex. Conclusions: There is low utilization of contraceptives by SIYP against the background of their high-risk sexual practices. SIYP would benefit from free contraceptive education, social safety nets and interventions to dissuade them from transactional sex and other unhealthy sexual practices.

Perceived barriers and facilitators to accessing and utilising sexual and reproductive healthcare for people who experience homelessness: a systematic review

INTRODUCTION

People who experience homelessness face disproportionately poor reproductive health and adverse pregnancy outcomes, including but not limited to unintended pregnancy, abortion, low birth weight and preterm birth, as well as a higher risk of sexually transmitted infections (STIs). Precarious living conditions are known to contribute to poor uptake and engagement with sexual and reproductive healthcare (SRH) for this population.

AIM

To identify and understand the perceived barriers and facilitators for accessing and utilising SRH for people who experience homelessness from their perspective, and the perspective of support staff/volunteers and healthcare professionals.

METHODS

Electronic databases and online sources were searched. Two reviewers independently carried out the screening, data extraction, critical appraisal, data synthesis and thematic analysis of findings.

RESULTS

Following deduplication and screening, 23 papers/reports were considered eligible for the review. Barriers for people experiencing homelessness to accessing and utilising SRH were identified within the themes of complexity, feelings and knowledge (ie, individual-level factors), as well as patient/provider interaction and healthcare system (ie, organisational factors). Facilitators were identified within all of the above themes except for complexity.

CONCLUSIONS

Both population characteristics and attributes of the healthcare system influence access and utilisation of SRH by people experiencing homelessness. Given the complexity of living conditions associated with homelessness, greater efforts to improve access should be placed on healthcare systems and aspects of care delivery. This systematic review highlights current gaps in the literature and provides recommendations for enhancing future research and practice to meet the needs of this vulnerable group more effectively.

A Literature Review of Health Literacy of Adolescents During Pregnancy

Adolescents who are pregnant are a vulnerable population at risk for poor health literacy. Health literacy is an important determinant of health, and poor health literacy among adolescents is correlated with high-risk health behaviors and adverse health outcomes into adulthood. A review of the literature showed a significant gap in research related to health literacy in pregnant adolescents. The limited findings indicate the need for additional research attention on health literacy in pregnant adolescents and upstream approaches to improve adolescent health literacy, such as incorporating health literacy education into secondary schools. To strengthen approaches that build health literacy capacity, it is imperative that future research focuses on pregnant adolescents' health literacy related to health behaviors, health outcomes, measurement instruments, health literacy frameworks, and targeted interventions.

"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.

The effect of a no-cost contraceptive initiative on method selection by women with housing insecurity

OBJECTIVES

To compare the sociodemographic characteristics of participants in a contraceptive initiative by housing security and determine the association between housing insecurity on contraceptive method selection before and after the removal of cost.

STUDY DESIGN

This cross-sectional assessment includes 4,327 reproductive-aged participants in the HER Salt Lake Contraceptive Initiative who sought new contraceptive services and reported housing status at enrollment. HER Salt Lake prospectively explored the impact of improved contraceptive access on socioeconomic outcomes in Salt Lake County (USA). For six months (September 2015-March 2016) we collected control data, which included clinic standard-of-care cost-sharing. The intervention started March 2016, and provided no-cost contraception services and unlimited opportunities for method switching over the subsequent three years.

RESULTS

There were 964 (22%) housing-insecure participants. Compared to those with stable housing, housing-insecure individuals more commonly identified as a sexual minority, received public assistance and lacked health insurance. Housing-insecure women preferentially selected long-acting reversible contraception during the control period (aOR 1.60; 95%CI 1.01-2.56), but method selection equalized across housing status during the intervention.

CONCLUSIONS

When cost is not a barrier, all women desire a comprehensive selection of contraceptive methods, regardless of housing security. Contraceptive clients in this vulnerable population need interventions which address access barriers to all methods to support reproductive planning.

IMPLICATIONS

Unintended pregnancy during housing insecurity may result in homelessness. This study found housing-insecure women desire access to all contraceptive methods, not just long acting reversible contraception. Integration of comprehensive family planning initiatives into efforts to address homelessness is essential to support this vulnerable population in their reproductive planning.