Initiation of services in the Boston HAPPENS Program: human immunodeficiency virus-positive, homeless, and at-risk youth can access services

Problem Behaviors of Homeless Youth: A Social Capital Perspective

Homeless youth are one of the most marginalized groups in our society. Many researchers identify much higher levels of various problem behaviors among these youth compared to their non-homeless peers. The current study examined the utility of social capital in predicting problem behaviors among homeless youth. Overall, the theoretically derived social capital variable significantly predicted substance use frequency, sexual risk behavior, depression, delinquent behavior as well as number of days homeless. Thus, social capital was useful in understanding and predicting the current life situation among these youth and may be worthy of further study. Findings suggest that meaningful change should utilize interventions that go beyond the individual and are geared towards modifying the social context of individuals' lives.

Research on Clinical Preventive Services for Adolescents and Young Adults: Where Are We and Where Do We Need to Go?

We reviewed research regarding system- and visit-level strategies to enhance clinical preventive service delivery and quality for adolescents and young adults. Despite professional consensus on recommended services for adolescents, a strong evidence base for services for young adults, and improved financial access to services with the Affordable Care Act's provisions, receipt of preventive services remains suboptimal. Further research that builds off successful models of linking traditional and community clinics is needed to improve access to care for all youth. To optimize the clinical encounter, promising clinician-focused strategies to improve delivery of preventive services include screening and decision support tools, particularly when integrated into electronic medical record systems and supported by training and feedback. Although results have been mixed, interventions have moved beyond increasing service delivery to demonstrating behavior change. Research on emerging technology-such as gaming platforms, mobile phone applications, and wearable devices-suggests opportunities to expand clinicians' reach; however, existing research is based on limited clinical settings and populations. Improved monitoring systems and further research are needed to examine preventive services facilitators and ensure that interventions are effective across the range of clinical settings where youth receive preventive care, across multiple populations, including young adults, and for more vulnerable populations with less access to quality care.

The experiences of emergency department use by street-involved youth: Perspectives of health care and community service providers

Street-involved (SI) youth represent a significant proportion of urban homeless populations. While previous research has identified SI youth as substantial users of emergency department (ED) services and has examined their experiences of ED care, little is known about the experiences and perceptions of the service providers who assist these youth with health care related issues. Using grounded theory, individual interviews and focus groups were conducted with 20 community agency staff serving SI youth, 17 health service providers, two hospital administrators, and two hospital security personnel regarding their experiences in providing or facilitating ED care for SI youth. Results identify differences in expectations between SI youth and hospital staff, along with service issues and gaps, including relational barriers and resource constraints. Implications for practice and policy development are offered.

The Experiences and Perceptions of Street-Involved Youth Regarding Emergency Department Services

Street-involved (SI) youth comprise a substantial component of the urban homeless population. Despite being significant users of hospital emergency department (ED) services for acute and ongoing health needs, little is known about their experiences of ED care and the factors affecting their ED use. This study used a grounded theory and community-based approach to examine these issues. Focus groups and individual interviews were facilitated with 48 SI youth between ages 15 and 26 years, recruited in hospital or through community agencies serving SI youth in a major Western Canadian city. Results demonstrate that SI youth often perceived suboptimal care and experienced long waiting periods that led to many avoiding or prematurely exiting the ED. Service gaps appeared to have a negative bearing on their care and health outcomes. Findings invite a critical review of ED care processes, structures, and staff interactions in the aim of enhancing ED services to SI youth.

HIV and Sexually Transmitted Infection Testing Among High-Risk Youths: Supporting Positive Opportunities With Teens (SPOT) Youth Center

OBJECTIVES

We investigated the development of and service utilization at Supporting Positive Opportunities with Teens (SPOT)-a community-based health and social service facility in St. Louis, Missouri, for youths that focuses on increasing HIV and sexually transmitted infection (STI) testing.

METHODS

We identified the US-based, co-located youth health and social service models that guided the establishment of the SPOT. We analyzed the first 5 years (2008-2013) of service delivery and utilization data.

RESULTS

During the study period, the SPOT provided services for 8233 youths in 37,480 visits. The 5 most utilized services included HIV and STI screening, food, transportation, contraception, and case management. A total of 9812 gonorrhea and chlamydia screenings revealed 1379 (14.1%) cases of chlamydia and 437 (4.5%) cases of gonorrhea, and 5703 HIV tests revealed 59 HIV infections (1.0%); 93.0% of patients found to have an STI were treated within a 5-day window.

CONCLUSIONS

Co-locating health and social services in informal community settings attracts high-risk youths to utilize services and can prove instrumental in reducing STI burden in this population.

Homeless youths' HIV risk behaviors with strangers: Investigating the importance of social networks

The purpose of this study was to examine the relationship between homeless youths' HIV risk behaviors with strangers and risk and protective characteristics of their social networks. Data were from the Social Network and Homeless Youth Project. A total of 249 youth aged 14-21 years were interviewed over 15 months in three Midwestern cities in the United States using a systematic sampling strategy. Multivariate results revealed that homeless youth with a greater average number of network members who engaged in more drug risk behaviors and who pressured them into precarious behaviors at least once were more likely to have participated in a greater number of HIV risk behaviors with strangers compared to homeless youth without such network characteristics. Additionally, 19-21 year olds, gay, lesbian, bisexual, and transgendered youth, and those who have run away from home more frequently, participated in more HIV risk behaviors with strangers than 14-18 year olds, heterosexual youth, and those who have run away less often. The final model explained 43 % of the variance in homeless youths' HIV risk behaviors with strangers. It is important to identify network characteristics that are harmful to homeless youth because continued exposure to such networks and participation in dangerous behaviors may result in detrimental outcomes, including contraction of sexually transmitted infections and potentially HIV.

A vacation for the homeless: evaluating a collaborative community respite programme in Canada through clients' perspectives

This study assesses the Urban Breakaway Project, a collaborative project offering a structured vacation in the countryside of the province of Quebec intended for homeless (or street) youths. The objective of this study was to document participants' perspectives regarding this project by examining their satisfaction, intention to change following their stay and perceived improvement with respect to their life situation. Another goal of this research was to investigate the relationship between satisfaction level and perceived improvement of participants. One hundred and seven individuals participated in the study, during Urban Breakaway's first year of operation. Satisfaction with the project, assessed with the global Client Satisfaction Questionnaire-3 score, revealed a positive relationship with global scores of perceived improvement, as measured by the Perceived Improvement Questionnaire [PIQ; r = 0.37 (67), 95% CI (0.15; 0.56)]. Regarding intention to change, the data indicated that 95% of participants had moderate-to-definite intentions to do something to change their lives. Participants reported an improvement for most items covered by the PIQ. They experienced the greatest changes in relation to mood, leisure, appetite, physical condition and self-esteem. Results indicate that the Urban Breakaway Project reaches not only street youths but also an older homeless population. Participants, regardless of their age, were found to be very satisfied with services obtained, and their satisfaction was significantly correlated with the perceived improvement in their situation. Qualitative data indicate that characteristics of the programme, such as the countryside setting, the focus on basic needs, the climate and the opportunity for socialisation, peer support (or belonging) and personal growth were appreciated.

Six- and twelve-month outcomes among homeless youth accessing therapy and case management services through an urban drop-in center

RESEARCH OBJECTIVE

To evaluate the impact of case management and individual therapy offered through a drop-in center for homeless youth on substance use, mental health, housing, education, employment, and medical care utilization.

STUDY POPULATION

All youth (n=172) between the ages of 14-24 who accessed treatment services through an urban, southwestern drop-in center were included.

DATA SOURCE

Semistructured and self-report questionnaires were administered to youth between October 2002 and April 2005.

STUDY DESIGN

A repeated measures design was utilized. Youth were assessed at baseline, 6 months, and 12 months postbaseline. Hierarchical linear modeling was used to test the hypotheses.

PRINCIPAL FINDINGS

Statistically significant improvements were found in substance abuse, mental health, and percent days housed up to 12 months postbaseline. Decreased alcohol and drug use was associated with an increase in housing. However, most youth did not acquire permanent housing, and education, employment, and medical service utilization did not significantly change over time.

CONCLUSIONS

While treatment offered through drop-in centers for homeless youth can positively impact homeless youth, policy, funding, and service provision need greater focus, collaboration, and support if youth homelessness is to be successfully addressed.

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.

Perceptions of Human Immunodeficiency Virus (HIV) Testing Services Among HIV-Positive Persons Not in Medical Care

BACKGROUND AND OBJECTIVES

Human immunodeficiency virus (HIV) counseling, testing, and referral (CTR) are provided in a wide variety of settings.

GOAL

To compare, by test setting, the perceptions of the testing experience among HIV-positive persons who were not receiving medical care.

DESIGN

A baseline questionnaire was administered at enrollment into the Antiretroviral Treatment Access Study by the use of audio computer-assisted self-interview.

RESULTS

Of 316 respondents, 27% reported that the counselor did not spend enough time with them and 22% that the counselor did not answer all questions. The odds were higher that persons in the following settings, compared with those at HIV test sites, would report that the counselor did not spend enough time with them: office of private physician or health maintenance organization (HMO) (adjusted odds ratio [AOR], 5.24; 95% confidence interval, 1.26-21.7), jail (AOR, 5.10; 95% CI, 1.06-24.6), and emergency room (ER) or hospital overnight visit (AOR, 2.93; 95% CI, 1.15-7.44). Similarly, the odds were higher that persons in the following settings compared with those at HIV test sites would report that the counselor did not answer all questions: office of private physician or HMO (AOR, 9.62; 95% CI, 2.22-41.7), jail (AOR, 7.87; 95% CI, 1.50-41.4), and ER or hospital overnight visit (AOR, 3.32; 95% CI, 1.11-9.90).

CONCLUSION

Further training and quality assurance in HIV CTR may be needed in some test settings.

Outreach, mental health, and case management services: can they help to retain HIV-positive and at-risk youth and young adults in care?

OBJECTIVES

To assess the impact of outreach, mental health, and case management services on retention in primary care of HIV+ and at-risk youth and young adult clients of the Boston HAPPENS program, a comprehensive adolescent HIV prevention and care network of agencies.

METHODS

Providers at 8 urban sites used standard data forms at each visit to collect background and service receipt information on at-risk clients aged 12-24 years. Data were aggregated across all visits for each client to create summary variables for the number of times each client received each type of service. The retention measure was the number of days between a client's first and last visits during the 4-year data collection period. Kaplan-Meier survival curve and Cox proportional hazards regression analyses were used to assess the association between receipt of the support services of interest and the retention measure.

RESULTS

The median retention times were 21 days for male clients (range, 0-1406, N = 512), and 26 days for female clients (range, 0-1577, N = 914). Among males, 45% were retained beyond a month, 24% beyond a year, and 10% beyond 2 years. Similar proportions of females were retained beyond a month and a year, but more females were retained beyond 2 years (15%). After adjusting for other covariates, both male and female clients had significantly longer retention times if they received > or = 2 outreach contacts, or case management at > or = 3 visits. Among males, receipt of mental health counseling at > or = 2 visits also increased retention times.

CONCLUSIONS

These findings suggest that provision of outreach, mental health, and case management services can improve retention in care of at-risk youth and young adults.

Boston HAPPENS Program: HIV-positive, homeless, and at-risk youth can access care through youth-oriented HIV services

The Boston HAPPENS Program is a collaborative network of care consisting of multiservice outreach agencies; community health centers; and hospitals for HIV-positive, homeless, and hard-to-reach youth. In four years of data collection, the program served more than 2,000 youth, including 54 HIV-positive youth. The youth were 19.9 +/- 2.9 years old; 64 percent female; 45 percent youth of color; 11 percent gay/lesbian, bisexual, or undecided; and 13 percent homeless or runaway. Homeless youth were much more likely to have been involved with a mental health system (47% vs. 12%, P < 0.001), the criminal justice system (20% vs. 2%, P < 0.001), high-risk sexual behaviors (21% vs. 3%, P < 0.001), and substance abuse (25% vs. 6%, P < 0.001) than were other youth served by the program. Comprehensive networks of care offering a continuum of services and a variety of entry routes and types of care sites are needed to connect under-served youth to health care. Outreach and human immunodeficiency virus (HIV) counseling and testing services can offer important portals of entry into health services for at-risk youth. Support services such as outreach, case management, and mental health services are needed to complement medical services by all youth at-risk for contracting HIV. Support services are necessary for the initiation and retention of youth in care so that early case identification and complex treatment regimens can be initiated and tailored to the individual.