Pregnancy and mental health of young homeless women

The global prevalence of mental health disorders among runaway and homeless youth: A meta-analysis

A meta-analysis was performed to identify the pooled prevalence of mental health disorders (MHDs) among runaway and homeless youth (RHY). Relevant studies published between December 1, 1985, and October 1, 2023, were identified in the PubMed, Scopus, Web of Science, and Cochrane Library databases. A preliminary screening of 11,266 papers resulted in the inclusion of 101 studies. The pooled-prevalence estimates were obtained using a random-effects model. The findings showed varying lifetime prevalence rates of MHDs: 47% (conduct disorders and psychological distress), 43% (depression), 34% (major depressive disorders), 33% (post-traumatic stress disorder), 27% (personality disorders), 25% (attention-deficit/hyperactivity disorder), 23% (bipolar disorders), 22% (anxiety), 21% (oppositional defiant disorders), 15% (anorexia), 15% (adjustment disorders), 14% (dysthymia), 11% (schizophrenia), 9% (obsessive-compulsive disorders), and 8% (gambling disorder). The current prevalence rates were: 31% (depression), 23% (major depressive disorder), 23% (anxiety), 21% (post-traumatic stress disorder), 16% (attention-deficit/hyperactivity disorder), 15% (bipolar disorder), 13% (personality disorders), 13% (oppositional defiant disorders), 8% (schizophrenia), and 6% (obsessive-compulsive disorders). Regular screening and the implementation of evidence-based treatments and the promotion of integration and coordination between mental health services for adolescent minors and young adults with other service systems are recommended.

Short Interpregnancy Intervals Among Women Experiencing Homelessness in Colorado

Importance

Short interpregnancy intervals (SIPIs) are associated with increased risk of adverse maternal and neonatal outcomes. Disparities exist across socioeconomic status, but there is little information on SIPIs among women experiencing homelessness.

Objective

To investigate (1) differences in rates and characteristics of SIPIs between women experiencing homelessness and domiciled women, (2) whether the association of homelessness with SIPIs differs across races and ethnicities, and (3) whether the association between SIPIs of less than 6 months (very short interpregnancy interval [VSIPIs]) and maternal and neonatal outcomes differs between participant groups.

Design, Setting, and Participants

This cohort study used a Colorado statewide database linking the Colorado All Payer Claims Database, Homeless Management Information System, death records, and infant birth records. Participants included all women who gave birth between January 1, 2016, and December 31, 2021. Data were analyzed from September 1, 2022, to May 10, 2023.

Exposures

Homelessness and race and ethnicity.

Main Outcomes and Measures

The primary outcome consisted of SIPI, a binary variable indicating whether the interval between delivery and conception of the subsequent pregnancy was shorter than 18 months. The association of VSIPI with maternal and neonatal outcomes was also tested.

Results

A total of 77 494 women (mean [SD] age, 30.7 [5.3] years) were included in the analyses, of whom 636 (0.8%) were women experiencing homelessness. The mean (SD) age was 29.5 (5.4) years for women experiencing homelessness and 30.7 (5.3) years for domiciled women. In terms of race and ethnicity, 39.3% were Hispanic, 7.3% were non-Hispanic Black, and 48.4% were non-Hispanic White. Associations between homelessness and higher odds of SIPI (adjusted odds ratio [AOR], 1.23 [95% CI, 1.04-1.46]) were found. Smaller associations between homelessness and SIPI were found among non-Hispanic Black (AOR, 0.59 [95% CI, 0.37-0.96]) and non-Hispanic White (AOR, 0.57 [95% CI, 0.39-0.84]) women compared with Hispanic women. A greater association of VSIPI with emergency department visits and low birth weight was found among women experiencing homelessness compared with domiciled women, although no significant differences were detected.

Conclusions and Relevance

In this cohort study of women who gave birth from 2016 to 2021, an association between homelessness and higher odds of SIPIs was found. These findings highlight the importance of conception management among women experiencing homelessness. Racial and ethnic disparities should be considered when designing interventions.

Correlates of Past Childhood Homelessness in a Nationally Representative Sample of US Adults

ABSTRACT

Limited empirical data have been available on the adult sequelae of childhood homelessness. Using nationally representative data from the National Epidemiologic Survey of Alcohol and Related Conditions-III, we compared a hierarchy of adults who were never homeless, those who were only homeless as children, and those who were homeless both as children and adults, hypothesizing greater adversity as one moved up the three-level hierarchy on sociodemographic, behavioral, and lifetime mental health diagnostic characteristics. As a further evaluation of the status of adults who were homeless as both children and adults, we compared this highest risk group to those who had been homeless only as adults. Individuals who experienced childhood homelessness were 46.9 times more likely than others to also experience adult homelessness. Testing the hierarchical hypothesis, compared with those who were never homeless, individuals who experienced homelessness only as children reported numerous associated disadvantages, including childhood sexual abuse/neglect, parental adversities, adult incarceration, psychiatric disorders, and low academic achievement/employment. Those reporting both child and adult homelessness, in contrast to childhood homelessness alone, additionally met the criteria for multiple substance use disorders, confirming our hierarchical hypothesis. Those reporting both child and adult homelessness also showed more numerous social and psychiatric problems when compared with those experiencing homelessness for the first time as adults. This study demonstrates how homelessness in childhood is associated with extensive social and psychiatric adversities in both childhood and adulthood.

"I Need to Get My Culture Back": Youth and Provider Perspectives on Integrating Culturally Based Approaches into Sexual and Reproductive Health Programs for Native Hawaiian and Pacific Islander Youth Experiencing Homelessness

There is growing interest in decolonizing sexual and reproductive health (SRH) and embedding cultural practices into social and medical services in Hawai'i. Wahine ("woman") Talk is a multilevel, comprehensive SRH program for female youth experiencing homelessness (YEH) led by community health, social work, and medical providers. This study examines youth and program provider perspectives of culturally based approaches that may strengthen SRH programs. The study team conducted three focus groups and ten in-depth interviews with participating youth and program providers after the program's conclusion. Youth participants were aged 14 to 22 years (M = 18.1) and of Native Hawaiian or Pacific Islander ancestry. Interview transcripts were analyzed using structured thematic analysis. The youth described feeling estranged from their ancestral cultures and suggested incorporating multiple cultural practices to enhance their connection to community, body, and land into SRH programming for YEH. They identified several 'āina ("land")-based approaches, hands-on learning, hula, and language as possible practices to weave into the program. While youth felt estranged from their ancestral cultures, they discussed Native Hawaiian and Pacific Islander health perspectives where 'āina and relationships are considered life-sustaining. Youth and program staff stressed incorporating culture respectfully, caring for the whole person, and providing trauma-informed care. Future policy, practice, and research should consider protecting and integrating Native Hawaiian conceptions of health into SRH policy and practice and include youths' cultural identities in SRH intervention development.

"It's Not a Top Priority": A Qualitative Analysis of Provider Views on Barriers to Reproductive Healthcare Provision for Homeless Women in the United States

Women experiencing housing insecurity are at an elevated risk for adverse reproductive health outcomes due to the prevalence of chronic health conditions and higher risk behaviors. Social service and healthcare providers are front line in addressing women's needs when they seek support. Thus, we sought to explore reproductive healthcare barriers using in-depth interviews with 17 providers at 11 facilities serving housing-insecure women in Salt Lake County, Utah, USA from April to July 2018. Providers noted a number of system-, provider-, and individual-level barriers. Dominant themes include reliance on unstable funding, lack of provider training on reproductive health, and perceived logistical challenges to care. Due to the prevalence of immediate needs among housing-insecure women, providers attest that reproductive health needs often do not emerge as their urgent concern. Our findings suggest that addressing policy and funding challenges to prioritizing reproductive needs among housing-insecure women can help mitigate the potential for long-term adverse reproductive outcomes.

Adapting an evidence-based mindfulness-based intervention for sheltered youth experiencing homelessness

OBJECTIVES

Youth experiencing homelessness (YEH) face challenges that impact their physical, mental, and social wellbeing, emotion regulation, and coping. Mindfulness reduces stress and improves resilience, emotion regulation, and executive functioning. Mindfulness-based interventions (MBI) teach the practice of mindfulness to foster present-moment attention without judgement and enhance self-observation and self-regulation, resulting in greater awareness of thoughts and emotions and improved interpersonal relationships. One such intervention, .b, has been shown to lower stress among youth. While a pilot study of .b among sheltered youth found the intervention to be feasible, the need for modifications was identified to improve its relevance, accessibility, and incorporate a trauma-informed approach.

METHODS

We used the ADAPT-ITT (Assessment, Decisions, Administration, Production, Topical experts, Integration, Training staff, and Testing) framework to adapt the .b mindfulness intervention to YEH living in an emergency shelter. Nine focus group discussions (n = 56), key informant interviews (n = 8), and beta testing with five youth working group sessions (n = 10) identified needed modifications.

RESULTS

Adaptations to the curriculum and delivery modality were made to approximate the average length of stay in the shelter; integrate trauma-informed care approaches; increase diversity of images by race, ethnicity, age, sexual orientation, and gender identity; and increase the relevance of the audio-visual components.

CONCLUSIONS

Youth and the health and social services providers who care for youth generally liked the core concepts and presentation of the curriculum. Using the ADAPT-ITT framework, minor, yet important, changes were made to increase the relevance, acceptability, and feasibility of the intervention. Next steps are to conduct a randomized attention control pilot study to assess feasibility and acceptability.

Personality and attachment in the homeless: A systematic review

BACKGROUND

Homeless people present high rates of psychopathology, including personality disorders. Given the link between personality disorders and attachment, and the potential importance of these two traits for understanding homeless populations.

AIMS

Our aim was to review all studies focusing on attachment and on the full assessment of personality disorders in the homeless.

METHOD

Overall, 213 studies were screened through title and abstract. Of these, 63 articles were chosen for full-text assessment.

RESULTS

A total of 14 articles met eligibility criteria and were included in the present review. Six studies evaluated personality disorders and eight studies assessed attachment in the homeless. In general, reports suggested that personality disorders are highly common in the homeless, with frequencies ranging between 64% and 79% for any personality disorder. The most common personality diagnoses were paranoid (14%-74%), borderline (6%-62%), avoidant (14%-63%), and antisocial (4%-57%) personality disorders. Attachment reports differed in the methods used and presented diverse results and correlates. Even so, insecure types of attachment dominated in the homeless, accounting for 62% to 100% of the samples.

CONCLUSIONS

The high prevalence of personality disorders and insecure types of attachment in the homeless may impact intervention strategies for these people. The available literature evaluating attachment and the full assessment of personality disorders in the homeless is scarce, which supports the need for more research on these two topics.

The perceived impact of homelessness on health during pregnancy and the postpartum period: A qualitative study carried out in the metropolitan area of Nantes, France

The number of homeless people has been constantly increasing in Europe over recent years, as well as the proportion of women among the homeless population. Pregnancy can increase the risk of becoming homeless and, on the other hand, homelessness has been widely connected to adverse perinatal outcomes. The objective of this study was to describe the overall perceived impact of homelessness on health during pregnancy and the postpartum period, using a qualitative research approach to prioritize women's perspective. One-time semi structured interviews were conducted with 10 pregnant women and 10 women in the postpartum period experiencing homelessness in the metropolitan area of Nantes, as well as with six people from their social surroundings. A thematic analysis was performed to identify major themes and sub-themes. Homelessness was perceived as having an overall negative impact on all aspects of health (physical health, mental health, and social well-being) during pregnancy and the postpartum period. Stress and anxiety, food insecurity, social isolation, physical suffering, deterioration of chronic diseases, and pregnancy complications, were the main perceived consequences of homelessness on health. On the other hand, social support, and the "welcomeness" of healthcare professionals during pregnancy and the postpartum period were identified as capable of palliating those consequences. Finally, basic needs, such as having access to suitable housing, being independent, and being in good health, were identified by participants in the study as their main priorities. The results of this study, as well as those found by previous research, allowed us to identify possible axes in tackling homelessness and its complex consequences on health during pregnancy and the postpartum period. Housing and income assistance interventions, promoting social support and employment, outreach services enhancing collaborative networks among healthcare service providers, and integrating coordinated multidisciplinary approaches in primary care have shown to provide promising solutions to this issue.

'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.

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.

Evaluation of General Health Status of Persons Living in Socio-Economically Disadvantaged Neighborhoods in a Large European Metropolitan City

Background: Living in socio-economically disadvantaged neighborhoods can predispose persons to numerous health conditions. The purpose of this study was to report the general health conditions of persons living in disadvantaged neighborhoods in Rome, Italy, a large European metropolitan city. Participants were reached through the mobile facilities of the primary care services of the Dicastery for the Charity Services, Vatican City. Methods: People living in disadvantaged neighborhoods were reached with mobile medical units by doctors, nurses, and paramedics. Demographic characteristics, degree of social integration, housing conditions, and history of smoking and/or alcohol use were investigated. Unstructured interviews and general health assessments were performed to investigate common acute and/or chronic diseases, and history of positivity to COVID-19. Basic health parameters were measured; data were collected and analyzed. Results: Over a 10-month period, 436 individuals aged 18–95 years were enrolled in the study. Most lived in dormitories, whereas a few lived in unsheltered settings. Most participants (76%) were unemployed. Smoking and drinking habits were comparable to the general population. The most common pathological conditions were cardiovascular diseases in 103 subjects (23.39%), diabetes in 65 (14.9%), followed by musculoskeletal system disorders (11.7%), eye diseases (10.5%), psychiatric conditions such as anxiety and depression (9.2%), and chronic respiratory conditions (8.7%). Conclusions: Subjects in our sample showed several pathologic conditions that may be related to their living conditions, thus encouraging the development of more efficient and effective strategies for a population-tailored diagnosis and treatment.

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.

Profile of homeless people in emergency departments

OBJECTIVES

For homeless people, emergency departments (ED) are the place of medical care and satisfying physiological, safety and social needs. The treatment of the homeless in EDs is a common issue in many countries. The aim of study was to analyze selected parameters of health care to homeless people in EDs. The authors examined the frequency and the seasonality of admissions, their causes, stay duration, insurance status, and the type of radiological diagnostics performed.

MATERIAL AND METHODS

A retrospective analysis of stays of homeless patients in 3 EDs in one of the largest cities in Poland in 2013-2015 was carried out. Patients were qualified to the population of homeless people based of their registering in ED. Data was obtained on the total number of homeless patients' stays in all 3 EDs, which amounted to 3133.

RESULTS

During the 3 years of analysis: 1042 homeless individuals were identified staying 3133 times in EDs; 46.3% of the stays concerned uninsured homeless people; 31% were under influence of alcohol. On average, men used ED services 3 times, while women only twice. No significant seasonality of admissions was observed. Homeless people were admitted mainly for mental disorders and head injuries. Radiological tests were performed 1577 times, including 83% being CT scans. On average, women and those >30 stayed in EDs for the shortest time. The hospital wards admitted 9.3% of the patients.

CONCLUSIONS

Almost half of homeless patients repeatedly use ED services, regardless of the season. A patient's stay typically lasts 6 h. Half of them were uninsured. The main reasons for admission include mental and behavioral disorders, mostly due to alcohol use and head injuries. The primary radiological diagnostics used were CT scans. Int J Occup Med Environ Health. 2022;35(2):157-67.

Homelessness in pregnancy: perinatal outcomes

OBJECTIVE

Investigate the association between maternal homelessness at the time of delivery and perinatal outcomes, with a focus on neonatal health outcomes.

STUDY DESIGN

Population-based cohort using California's statewide database included 1,520,253 women with linked birth and maternal discharge data, 2008-2012. Multivariable analysis assessed homelessness at time of delivery on perinatal outcomes, preterm delivery, and neonatal intensive care unit admission.

RESULT

A total of 672 women (0.05%) were homeless at the time of delivery. Homelessness was associated with premature delivery at multiple gestational age cutoffs (34w0d-36w6d; 32w0d-33w6d; 28w0d-31w6d; <28w0d) (range of aORs:1.62-2.19), and neonatal intensive care unit admission (aOR = 1.66, 95% CI:1.31-2.09). Among term infants, homelessness remained associated with increased odds of neonatal intensive care unit admission (aOR = 1.84, 95% CI:1.34-2.53), low birthweight (aOR = 1.99, 95% CI:1.36-2.90), neonatal abstinence syndrome (aOR = 2.13, 95% CI:1.35-2.53), hypoxic-ischemic encephalopathy (aOR = 14.38, 95% CI:3.90-53.01), and necrotizing enterocolitis (aOR = 14.94, 95% CI:2.68-83.20).

CONCLUSION

Homelessness in pregnancy was associated with adverse perinatal outcomes including increased odds of preterm delivery across all gestational ages, and increased risk of neonatal intensive care unit admission and low birth weight independent of preterm delivery.

Access experiences and attitudes toward abortion among youth experiencing homelessness in the United States: A systematic review

Objectives

We sought to review the literature on the access experiences and attitudes toward abortion among youth experiencing homelessness in the United States.

Methods

We conducted a systematic review of peer‐reviewed literature published from 2001 to 2019. We included qualitative studies involving US participants that focused on access experiences, views, or accounts of unintended pregnancy and/or abortion among youth experiencing homelessness. We excluded studies published before 2001 as that was the year mifepristone medication abortion was made available in the US and we aimed to investigate experiences of access to both medical and surgical abortion options.

Results

Our thematic analysis of the data resulted in five key themes that characterize the abortion attitudes and access experiences of youth experiencing homelessness: (1) engaging in survival sex and forced sex, (2) balancing relationships and autonomy, (3) availability does not equal access, (4) attempting self-induced abortions using harmful methods, and (5) feeling resilient despite traumatic unplanned pregnancy experiences.

Conclusions

Youth experiencing homelessness experience barriers to abortion access across the US, including in states with a supportive policy context and publicly funded abortion services. In the absence of accessible services, youth may consider harmful methods of self-induced abortion. Improved services should be designed to offer low-barrier abortion care with the qualities that youth identified as important to them, including privacy and autonomy.

Gênero, pobreza e saúde

As mulheres em situação de rua, parte de um fenômeno que se constitui como uma problemática global e inerente ao modo de produção capitalista (MPC), estão submetidas a uma série de opressões e desigualdades, especialmente alarmantes no que se refere a sua saúde. O objetivo do presente trabalho foi realizar uma revisão sistemática de literatura a fim de conhecer o que tem sido pesquisado sobre a saúde desse grupo de mulheres no contexto nacional e internacional, considerando-se as especificidades relacionadas à condição de gênero. Foram realizadas buscas nas bases de dados Lilacs, Redalyc, Psychinfo, SciELO, ERIC e no Portal de Periódicos da Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES/Brasil). A partir dos descritores homeless women, health, health care, health care policy e therapeutic itineraries, chegou-se a uma amostra final composta por 21 artigos, cuja análise foi expressa em três categorias: violência, pobreza e viver nas ruas: implicações para a saúde das mulheres; maternidade, trabalho e saúde: ambivalência sentida nos corpos; e acesso aos serviços de saúde e assistência social. Os achados evidenciam a interseção entre condição de gênero, situação de rua e saúde, apontando o caráter transcultural do fenômeno, e a necessidade de se investir em mais investigações na área.

Engaging Expectant and Parenting Adolescents: Lessons from the Massachusetts Pregnant and Parenting Teen Initiative

INTRODUCTION

Programs supporting adolescent parents have been shown to increase socio-economic opportunities and promote healthy child development for young families, but retaining young parents is challenging. The Massachusetts Pregnant and Parenting Teen Initiative (MPPTI) offers case management and linkages to community and clinical services to young families. We examine engagement strategies identified by MPPTI participants and staff members in relation to participant retention by program site to identify potential strategies for increasing program engagement.

METHODS

We employed a mixed-methods approach incorporating quantitative data on program participant characteristics and program retention by site with qualitative data from staff and participant interviews and focus groups.

RESULTS

Key program engagement strategies identified by both MPPTI staff and youth participants were social-emotional supports, staffing model, and concrete supports. We found significant differences in program retention by site; the two sites with the highest levels of program retention offered all engagement strategies identified.

DISCUSSION

Quantitative data on program retention coupled with qualitative data from staff and youth interviews suggests that in our program, there may be an association between the engagement strategies identified and levels of program retention.

Addressing the Urgent Housing Needs of Vulnerable Women in the Era of COVID-19: The Los Angeles County Experience

For people experiencing homelessness, COVID-19 underscores existing health and social inequities, introduces additional threats to health and safety, and calls for rapid and creative solutions to reduce risk. This column focuses on the particular challenges of two frequently intersecting subpopulations of individuals experiencing homelessness: pregnant women and survivors of domestic violence. The authors describe rapid efforts and cross-agency collaboration in Los Angeles-home to the nation's largest number of unsheltered individuals-to provide these groups with safe interim housing in the context of COVID-19. The authors discuss gaps in care and recommendations for the future, calling attention to the unique mental health and social needs of these highly vulnerable women.

Systematic review and meta-analysis of the prevalence of depressive symptoms, dysthymia and major depressive disorders among homeless people

OBJECTIVES

To assess the global prevalence estimates of depressive symptoms, dysthymia and major depressive disorders (MDDs) among homeless people.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

Databases including PubMed, Scopus and Web of Science were systematically searched up to February 2020 to identify relevant studies that have reported data on the prevalence of depressive symptoms, dysthymia and MDDs among homeless people.

ELIGIBILITY CRITERIA

Original epidemiological studies written in English that addressed the prevalence of depressive problems among homeless people.

DATA EXTRACTION AND SYNTHESIS

A random-effect meta-analysis was performed to pool the prevalence estimated from individual studies. Subgroup and sensitivity analyses were employed to compare the prevalence across the groups as well as to identify the source of heterogeneities. The Joanna Briggs Institute's quality assessment checklist was used to measure the study quality. Cochran's Q and the I² test were used to assess heterogeneity between the studies.

RESULTS

Forty publications, including 17 215 participants, were included in the final analysis. This meta-analysis demonstrated considerably higher prevalence rates of depressive symptoms 46.72% (95% CI 37.77% to 55.90%), dysthymia 8.25% (95% CI 4.79% to 11.86%), as well as MDDs 26.24% (95% CI 21.02% to 32.22%) among homeless people. Our subgroup analysis showed that the prevalence of depressive symptoms was high among younger homeless people (<25 years of age), whereas the prevalence of MDD was high among older homeless people (>50 years of age) when compared with adults (25-50 years).

CONCLUSION

This review showed that nearly half, one-fourth and one-tenth of homeless people are suffering from depressive symptoms, dysthymia and MDDs, respectively, which are notably higher than the reported prevalence rates in the general population. The findings suggest the need for appropriate mental health prevention and treatment strategies for this population group.

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.

Desire for and barriers to obtaining effective contraception among women experiencing homelessness

Background

Homelessness is a significant and growing problem in the United States. Women experiencing homelessness face unique challenges as they have high rates of unintended pregnancy. They often face significant barriers to obtaining effective contraception. This study aimed to explore the contraceptive preferences, desire for, and barriers to obtaining effective contraception among women experiencing homelessness.

Study design

In this cross-sectional study, 54 women experiencing homelessness in Chicago who were at risk for unintended pregnancy were surveyed.

Results

While 94% of the women experiencing homelessness surveyed desired avoiding pregnancy, most were using the least effective contraceptive methods. Among participants, 80% had health insurance, 75% had a high school diploma, and 90% knew where to obtain birth control. Despite these factors, participants faced barriers to obtaining contraception. One significant barrier was lack of comprehensive contraceptive counseling as 62% report a physician had never counseled them on LARC methods. Approximately half of participants desired or would consider using a LARC in the future.

Conclusions

Women experiencing homelessness in our study demonstrate significant unmet needs for effective contraception. Women experiencing homelessness would benefit from comprehensive contraceptive counseling and improved access to effective forms of contraception.

"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.

Homelessness in Pediatric Populations: Strategies for Prevention, Assistance, and Advocacy

Recent data indicate that homelessness among pediatric and adolescent populations is significantly higher than previous studies and point-in-time counts indicate. Pediatricians and other health care providers often see children and youth who are at risk of or are currently experiencing homelessness, but may not be aware of their status. This article summarizes current definitions of homelessness and data on common health issues for pediatric patients. Information on how to recognize and help those experiencing homelessness as well as areas for continued advocacy is shared.

No straight lines - young women's perceptions of their mental health and wellbeing during and after pregnancy: a systematic review and meta-ethnography

Background

Young mothers face mental health challenges during and after pregnancy including increased rates of depression compared to older mothers. While the prevention of teenage pregnancy in countries such as the United States and the United Kingdom has been a focus for policy and research in recent decades, the need to understand young women’s own experiences has been highlighted. The aim of this meta-ethnography was to examine young women’s perceptions of their mental health and wellbeing during and after pregnancy to provide new understandings of those experiences.

Methods

A systematic review and meta-ethnographic synthesis of qualitative research was conducted. Seven databases were systematically searched and forward and backward searching conducted. Papers were included if they were from Organisation for Economic Co-operation and Development countries and explored mental health and wellbeing experiences of young mothers (age under 20 in pregnancy; under 25 at time of research) as a primary research question – or where evidence about mental health and wellbeing from participants was foregrounded. Nineteen papers were identified and the Critical Appraisal Skills Programme checklist for qualitative research used to appraise the evidence. Following the seven-step process of meta-ethnography, key constructs were examined within each study and then translated into one another.

Results

Seven translated themes were identified forming a new line of argument wherein mental health and wellbeing was analysed as relating to individual bodily experiences; tied into past and present relationships; underpinned by economic insecurity and entangled with feelings of societal surveillance. There were ‘no straight lines’ in young women’s experiences, which were more complex than dominant narratives around overcoming adversity suggest.

Conclusions

The synthesis concludes that health and social care professionals need to reflect on the operation of power and stigma in young women’s lives and its impact on wellbeing. It adds to understanding of young women’s mental health and wellbeing during and after pregnancy as located in physical and structural factors rather than individual capacities alone.

Efficacy-based Contraceptive Counseling for Women Experiencing Homelessness in Iowa City, Iowa

This study evaluated homeless women's contraception knowledge and demonstrated improved knowledge following efficacy-based contraceptive counseling. Women were surveyed using a pre-test then post-test following standardized efficacy-based contraceptive counseling. 47 women participated. 13/19 (68.4%) of reproductive-aged women were not using contraception. After education there was significant increase in good-excellent self-rated knowledge (35, 75.5% vs 44, 93.6%; p < .001) and correct identification of most effective contraception OR 5.90 (95% CI = 2.31-15.02; p < .001). In conclusion, homeless women overestimated their understanding of contraception. Following education, there was significantly increased understanding of efficacy. While most did not desire pregnancy, few were using effective contraception and may benefit from education. Abbreviations: SH: Shelter House; LARC: Long-Acting Reversible Contraception; IUD: Intra-Uterine Device; ACOG: American College of Obstetricians and Gynecologists.

Health Risks and Outcomes of Homelessness in School-Age Children and Youth: A Scoping Review of the Literature

Despite reports that over 1.3 million school-age children (ages 5-18) were homeless in 2019, little is known about the effects of homelessness on their overall health and well-being. To better understand where gaps exist, a scoping review of the literature was conducted to identify studies of the physical, mental, and behavioral health risks and outcomes of school-age children experiencing homelessness or housing instability. Following the Joanna Briggs Institute framework and Preferred Reporting Items (PRISMA) guidelines, seven electronic databases were searched using key words: homelessness, children, health, and well-being. Of the 4,372 records, 23 articles met inclusion criteria. Most examined mental health and high-risk activities or behavioral risks related to school achievement. Few studies tracked the long-term health outcomes of homeless school-age children. Findings have implications for school nurses who have contact with children experiencing homelessness and are in position to intervene to prevent negative health sequelae in this vulnerable population.

"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.

Young pregnant women and risk for mental disorders: findings from an early pregnancy cohort

BACKGROUND

Young women aged 16-24 are at high risk of common mental disorders (CMDs), but the risk during pregnancy is unclear.AimsTo compare the population prevalence of CMDs in pregnant women aged 16-24 with pregnant women ≥25 years in a representative cohort, hypothesising that younger women are at higher risk of CMDs (depression, anxiety disorders, post-traumatic stress disorder, obsessive-compulsive disorder), and that this is associated with low social support, higher rates of lifetime abuse and unemployment.

METHOD

Analysis of cross-sectional baseline data from a cohort of 545 women (of whom 57 were aged 16-24 years), attending a South London maternity service, with recruitment stratified by endorsement of questions on low mood, interviewed with the Structured Clinical Interview DSM-IV-TR.

RESULTS

Population prevalence estimates of CMDs were 45.1% (95% CI 23.5-68.7) in young women and 15.5% (95% CI 12.0-19.8) in women ≥25, and for 'any mental disorder' 67.2% (95% CI 41.7-85.4) and 21.2% (95% CI 17.0-26.1), respectively. Young women had greater odds of having a CMD (adjusted odds ratio (aOR) = 5.8, 95% CI 1.8-18.6) and CMDs were associated with living alone (aOR = 3.0, 95% CI 1.1-8.0) and abuse (aOR = 1.5, 95% CI 0.8-2.8).

CONCLUSIONS

Pregnant women between 16 and 24 years are at very high risk of mental disorders; services need to target resources for pregnant women under 25, including those in their early 20s. Interventions enhancing social networks, addressing abuse and providing adequate mental health treatment may minimise adverse outcomes for young women and their children.Declaration of interestNone.

Nursing Practice Strategies for Prenatal Care of Homeless Pregnant Women

Women who are homeless are less likely to receive preconception care or prenatal care in the first trimester, and they tend to have fewer prenatal visits overall than their housed counterparts. Homelessness during pregnancy can increase the risk for many maternal, fetal, and neonatal complications. Barriers to proper prenatal care can be categorized as logistical, psychosocial, intellectual, and attitudinal. Although all women face potential barriers to optimal care, women who are homeless are particularly vulnerable and experience these barriers to a greater degree. Nursing strategies for prenatal care of homeless pregnant women include therapeutic communication, focused assessment, and upstream interdisciplinary approaches.

UNDERSTANDING PARENTING STRESS AND CHILDREN'S BEHAVIOR PROBLEMS AMONG HOMELESS, SUBSTANCE-ABUSING MOTHERS

This article tested a model of parenting stress as a mediator between maternal depressive symptoms, emotion regulation, and child behavior problems using a sample of homeless, substance-abusing mothers. Participants were 119 homeless mothers (ages 18-24 years) and their young children (ages 0-6 years). Mothers responded to questions about their depressive symptoms, emotion regulation, parenting stress, and child behavior problems. A path analysis showed that maternal depressive symptoms were positively associated with child behavior problems through increased parenting stress whereas maternal cognitive reappraisal was negatively associated with child behavior problems through decreased parenting stress. Moreover, maternal expressive suppression was negatively related to child externalizing problems. Findings support the parenting stress theory and highlight maternal parenting stress as a mechanism associated with homeless children's mental health risk. This study has significant implications for understanding the parenting processes underlying child's resilience in the context of homelessness and maternal substance use.

Health Care Utilization and Expenditures of Homeless Family Members Before and After Emergency Housing

OBJECTIVES

To describe longitudinal health service utilization and expenditures for homeless family members before and after entering an emergency shelter.

METHODS

We linked Massachusetts emergency housing assistance data with Medicaid claims between July 2008 and June 2015, constructing episodes of health care 12 months before and 12 months after families entered a shelter. We modeled emergency department visits, hospital admissions, and expenditures over the 24-month period separately for children and adults.

RESULTS

Emergency department visits, hospital admissions, and expenditures rose steadily before shelter entry and declined gradually afterward, ending, in most cases, near the starting point. Infants, pregnant women, and individuals with depression, anxiety, or substance use disorder had significantly higher rates of all outcomes. Many children's emergency department visits were potentially preventable.

CONCLUSIONS

Increased service utilization and expenditures begin months before families become homeless and are potentially preventable with early intervention. Infants are at greater risk. Public Health Implications. Early identification and intervention to prevent homeless episodes, focusing on family members with behavioral health disorders, who are pregnant, or who have young children, may save money and improve family health.

Co-Occurring Trajectory of Mothers' Substance Use and Psychological Control and Children's Behavior Problems: The Effects of a Family Systems Intervention

This study examined the effects of a family systems therapy (Ecologically-Based Family Therapy [EBFT]) on the co-occurring trajectory of mothers' substance use and psychological control, and its association with children's problem behaviors. Participants included 183 mothers with a substance use disorder who had at least one biological child in their care. Mothers were randomly assigned to one of the three intervention conditions: EBFT-home, n = 62; EBFT-office, n = 61; or Women's Health Education, n = 60. Participants were assessed at baseline, 3, 6, 12, and 18 months post-baseline. A dual-trajectory class growth analysis identified three groups of mothers in regard to their change trajectories. The majority of the mothers exhibited a synchronous decrease in substance use and psychological control (n = 107). In all, 46 mothers exhibited a synchronous increase in substance use and psychological control. For the remaining 30 mothers, substance use and psychological control remained stable. Mothers in the family therapy condition were more likely to show reduced substance use and psychological control compared to mothers in the control condition. Moreover, children with mothers who showed decreased substance use and psychological control exhibited lower levels of problem behaviors compared to children with mothers showing increased substance use and psychological control. The findings provide evidence for the effectiveness of family systems therapy, EBFT, in treating mothers' substance use, improving parenting behaviors, and subsequently improving child behavioral outcomes.

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.

In Their Own Words: Exploring Family Pathways to Housing Instability

Housing instability threatens the health and well-being of millions of families across the United States, yet little is known about the characteristics or housing trajectories of at-risk families. To address this gap in our understanding of family risk for housing instability and homelessness, we undertook a qualitative descriptive study utilizing a convenience sample of 16 mothers recruited from a housing service agency living in Detroit and receiving emergency services to avoid homelessness. Participants completed the Brief Patient Health Questionnaire (PHQ), then narrated their life events and reasons for housing instability and disclosed desired interventions for homelessness prevention. Data analysis reveals that women experienced high rates of previously undisclosed trauma, broken family relationships, early parenting responsibilities, social isolation, and system failures that contributed to recurrent episodes of housing instability. We argue that housing instability is a symptom of multiple chronic underlying issues that need more than a temporary financial patch.

Discrepancies in Autonomy and Relatedness Promoting Behaviors of Substance Using Mothers and Their Children: The Effects of a Family Systems Intervention

Parents' and children's autonomy and relatedness behaviors are associated with a wide range of child outcomes. Yet, little is known about how parents and children's autonomy and relatedness behaviors jointly influence child outcomes. The current study captured this joint influence by exploring the longitudinal trajectory of mother-child discrepancies in autonomy and relatedness behaviors and its association with child problem behaviors. The effects of a family systems intervention on the trajectory of mother-child discrepancies were also examined. The sample included 183 substance using mothers and their children (M age = 11.54 years, SD = 2.55, range 8-16; 48 % females). Both the mother and child completed an assessment at baseline, 6- and 18-month post-baseline. A person-centered analysis identified subgroups varying in mother-child discrepancy patterns in their autonomy and relatedness behaviors. The results also showed that participation in the family systems therapy was associated with decreased mother-child discrepancies, and also a synchronous increase in mother's and child's autonomy and relatedness. Additionally, increased mother-child discrepancies and mother-child dyads showing no change in autonomy and relatedness was associated with higher levels of children's problem behaviors. The findings reveal a dynamic process of mother-child discrepancies in autonomy and relatedness behaviors related to child outcomes. The findings also support the effectiveness of the family systems therapy, and highlight the importance of understanding the complexities in family interactions when explaining children's problem behaviors.

Predictors of Emergency Department Visits and Inpatient Admissions Among Homeless and Unstably Housed Adolescents and Young Adults

BACKGROUND

Individuals under age 25 years are estimated to comprise one third of the homeless population nationally. Understanding the reasons for utilization of hospitals by homeless youth is important for optimizing disposition planning.

OBJECTIVES

Objectives of the present study were to: (1) report prevalence of emergency department (ED) and inpatient admissions among homeless and unstably housed youth; (2) describe demographic characteristics of those youth who seek hospital care; (3) describe their patterns of injury, illness, psychiatric, and substance use conditions; and (4) identify demographic and diagnostic predictors of ED visit or hospital readmission.

METHODS

Retrospective cohort study of 15-25-year-olds (N=402) who were admitted to the ED or inpatient floors of 2 urban teaching hospitals in King County, WA between July 1, 2009 and June 30, 2012 and whose address was "homeless" or "none" or a homeless shelter or service agency (ie, homeless or unstably housed), during any recorded encounter between July 1, 2009 and June 30, 2012.

RESULTS

A total of 1151 ED visits and 227 inpatient admissions were documented. Fifty percent of patients had an ED visit or hospital readmission within 1 year, with 43.1% receiving care within 30 days of discharge. Cox regression showed that female individuals with an injury diagnosis (hazard ratio=1.74, 95% confidence interval=1.06, 2.85) and male individuals with an acute medical condition (hazard ratio=1.59, 95% confidence interval=1.09, 2.32) at index visit were more likely to have an ED visit or hospital readmission during the following year, as were patients who provided a private address at their index visit.

CONCLUSIONS

Homeless young people who seek hospital care demonstrate a high rate of ED visits and hospital readmissions, with unique predictors of utilization associated with sex and housing status. Additional research is necessary to determine how best to transition these young people from hospital-based to community-based care.

Characteristics of Mothers Caring for Children During Episodes of Homelessness

This study provides a description of the physical, psychological, and substance use problems of adult homeless women who are and are not caring for children. We also examined differences in the characteristics of these two groups of women. Interviews were conducted with 148 homeless women from three mid-sized U.S. cities, 24.3 % of whom were caring for at least one child. Our results showed that women caring for children were more likely to be sheltered and have health insurance. Homeless women caring for children and solitary homeless women were generally similar in terms of substance abuse problems. However, rates of Borderline Personality Disorder were higher among women caring for children than among solitary homeless women. Our results are somewhat consistent with previous research, with the exception of substance abuse problems and mental health problems, which were shown to be equally problematic for all women, regardless of current caregiving status.

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.

Weaving dreamcatchers: mothering among American Indian women who were teen mothers

AIMS

The aim of this study was to explore the mothering experience and practice among reservation-based adult American Indian women who had been adolescent mothers.

BACKGROUND

Adolescent American Indian women are at an elevated risk for teen pregnancy and poor maternal/child outcomes. Identifying mothering practices among this population may help guide intervention development that will improve health outcomes.

DESIGN

A collaborative orientation to community-based participatory research approach.

METHODS

Employing interpretive phenomenology, 30 adult American Indian women who resided on a Northwestern reservation were recruited. In-depth, face-to-face and telephone interviews were conducted between 2007-2008.

FINDINGS

Women shared their mothering experience and practice, which encompassed a lifespan perspective grounded in their American Indian cultural tradition. Four themes were identified as follows: mother hen, interrupted mothering and second chances, breaking cycles and mothering a community. Mothering originated in childhood, extended across their lifespan and moved beyond mothering their biological offspring.

CONCLUSION

These findings challenge the Western construct of mothering and charge nurses to seek culturally sensitive interventions that reinforce positive mothering practices and identify when additional mothering support is needed across a woman's lifespan.

Committee opinion No. 576: health care for homeless women

: Homelessness continues to be a significant problem in the United States. Women and families represent the fastest growing segment of the homeless population. Health care for these women is a challenge but an important issue that needs to be addressed. Homeless women are at higher risk of injury and illness and are less likely to obtain needed health care than women who are not homeless. It is essential to undertake efforts to prevent homelessness, to expand community-based services for the homeless, and to provide adequate health care for this underserved population. Health care providers can help address the needs of homeless individuals by identifying their own patients who may be homeless or at risk of becoming homeless, educating these patients about available resources in the community, treating their health problems, and offering preventive care.

Psychopathology in young people experiencing homelessness: a systematic review

Understanding mental health issues faced by young homeless persons is instrumental to the development of successful targeted interventions. No systematic review of recent published literature on psychopathology in this group has been completed. We conducted a systematic review of published research examining the prevalence of psychiatric problems among young homeless people. We examined the temporal relationship between homelessness and psychopathology. We collated 46 articles according to the PRISMA Statement. All studies that used a full psychiatric assessment consistently reported a prevalence of any psychiatric disorder from 48% to 98%. Although there was a lack of longitudinal studies of the temporal relationship between psychiatric disorders and homelessness, findings suggested a reciprocal link. Supporting young people at risk for homelessness could reduce homelessness incidence and improve mental health.

Embodied meanings of early childbearing among American Indian women: a turning point

INTRODUCTION

American Indian women often have poor perinatal outcomes and are at risk for early childbearing. The purpose of this qualitative study was to understand the experience and meaning of early childbearing among American Indian women.

METHODS

Employing interpretive phenomenology and a semistructured interview guide, we interviewed 30 adult American Indian women residing in a northwestern American Indian reservation about their experiences and meaning of early childbearing.

RESULTS

Three overarching themes were tied to their eventual positive evaluation of the experience: 1) mourning a lost childhood, 2) seeking fulfillment, and 3) embodying responsibility.

DISCUSSION

Women indicated that despite their tumultuous childhoods, early childbearing presented an opportunity to effect positive change in their lives. Women's health care providers are positioned to help women change their lives, thereby, improving health outcomes.