Homelessness and health in adolescents

Bounding systems: A qualitative study exploring healthcare coordination between the emergency youth shelter system and health system in Toronto, Canada

BACKGROUND

Several youth staying at emergency youth shelters (EYSs) in Toronto experience poorly coordinated care for their health needs, as both the EYS and health systems operate largely in silos when coordinating care for this population. Understanding how each system is structurally and functionally bound in their healthcare coordination roles for youth experiencing homelessness (YEH) is a preliminary step to identify how healthcare coordination can be strengthened using a system thinking lens, particularly through the framework for transformative system change.

METHODS

Forty-six documents, and twenty-four semi-structured interviews were analyzed to explore how the EYS and health systems are bound in their healthcare coordination roles. We continuously compared data collected from documents and interviews using constant comparative analysis to build a comprehensive understanding of each system's layers, and the niches (i.e., programs and activities), organizations and actors within these layers that contribute to the provision and coordination of healthcare for YEH, within and between these two systems.

RESULTS

The EYS and health systems are governed by different ministries, have separate mandates, and therefore have distinct layers, niches, and organizations respective to coordinating healthcare for YEH. While neither system takes sole responsibility for this task, several government, research, and community-based efforts exist to strengthen healthcare coordination for this population, with some overlap between systems. Several organizations and actors within each system are collaborating to develop relevant frameworks, policies, and programs to strengthen healthcare coordination for YEH. Findings indicate that EYS staff play a more active role in coordinating care for YEH than health system staff.

CONCLUSION

A vast network of organizations and actors within each system layer, work both in silos and collaboratively to coordinate health services for YEH. Efforts are being made to bridge the gap between systems to improve healthcare coordination, and thereby youths' health outcomes.

The homeless period: a qualitative evidence synthesis

Women experiencing homelessness are marginalized not only through their housing status but also through their access and ability to manage their menstrual health. Currently, there are no existing published reviews exploring this topic. This study aimed to begin closing that gap, by systematically reviewing the literature examining women's experiences of menstruation whilst being homeless. In June 2020 (and updated in December 2022), we conducted comprehensive and systematic searches of four electronic databases: Medline, Web of Science, CINAHL, and PsychINFO, from which nine studies were found. The findings were thematically analyzed, using the enhancing transparency in reporting the synthesis of qualitative research tools (ENTREQ) guidelines. Three themes related to menstrual experiences were found: (1) challenges in the logistics of managing menstruation while homeless, (2) feelings of embarrassment, shame, and dignity linked to maintaining menstrual health, and (3) making do: how people experiencing homelessness manage challenges related to menstruation. We discuss barriers women face in getting necessary products and in accessing private, safe, and clean facilities to manage menstrual health. The study found that women living with homelessness often abandon other basic needs in favor of managing menstruation (i.e. using unsuitable materials, stealing, etc.), which furthers their risk. The findings highlight the need for future research to investigate the experiences of women who are menstruating while being homeless and what support they would find helpful. Results show that it is high time for commissioners and policy-makers to address the provision of menstrual resources as a basic human right.

Health Care Needs of Young Adults Who Have Experienced Homelessness

INTRODUCTION

Young adults experiencing homelessness have poorer overall health compared with the general population. However, not much is known about how health care needs may change in the transition from homelessness to supportive housing. This study utilizes the Gelberg-Andersen Behavioral Model for Vulnerable Populations to examine unmet health care needs among young adults currently experiencing homelessness and formerly homeless young adults living in supportive housing.

METHODS

This study includes data from 192 young adults who were either residing in a supportive housing program (n=103) or were "unhoused" (eg, residing on the street, staying in emergency shelters; n=89) in Los Angeles, CA, between 2017 and 2019. Hierarchical modeling examined unmet health care needs and factors that may enable those needs to be met, controlling for predisposing and other need factors.

RESULTS

Controlling for predisposing and other need characteristics, this study identified increased enabling factors among those residing in supportive housing, the most widely applied intervention for homelessness. Participants who resided in supportive housing were more likely to report at least 1 type of unmet need than youth who did not have access to housing. Additional findings regarding the association of enabling factors and unmet need yield mixed results based on the type of unmet need.

DISCUSSION

The acknowledgment of unmet needs may, in fact, be a byproduct of shifting priorities, which often occurs in the transition from homelessness to housing. Understanding the unmet need and health implications of this transition has relevance for practice as we work to better support formerly homeless young adults in meeting the needs that they identify.

Implications of the COVID-19 Pandemic for Youth Housing and Homelessness Services

Youth homelessness is a growing crisis in the United States that is associated with a range of adverse outcomes. A variety of social service programs exist to address youth homelessness and its consequences, such as street outreach and diversion services, emergency shelters, transitional housing programs, and rapid rehousing services, among others. The coronavirus disease 2019 (COVID-19) pandemic reached the United States in early 2020, altering nearly every facet of daily life, including the way social service organizations structure and deliver their programming. To understand the implications of the pandemic on housing and homelessness services for youth, the current study examines data from interviews conducted with staff from a large non-profit in Austin, Texas, serving vulnerable transition-age youth. Through these interviews, programmatic changes that occurred as a result of COVID-19-as well as challenges and facilitators to service delivery-were identified. This article provides an overview of these key learnings, as well as recommendations derived from these key learnings, for other organizations adapting their housing and homelessness services in response to the COVID-19 pandemic.

Application of project management tools and techniques to support nursing intervention research

Nursing research involves much planning and attention to details, yet novice and seasoned nurse researchers often overlook the day-to-day operations required to conduct research studies. Project management is a set of iterative steps that can facilitate the process of conducting nursing research. In this paper we aim to provide an overview of project management and identify ways in which its specific principles and strategies may be applied to facilitate nursing research. Here we give an overview of our current longitudinal study using a Solomon four-group design and illustrate how we applied strategies and tools from the project management literature. In addition, we offer descriptions and illustrations of several other project management tools that could have been used in specific phases of this research project. We encourage nurse educators and researchers to familiarize themselves with the principles of project management and consider using them in future studies.

Assessing and treating complex mental health needs among homeless youth in a shelter-based clinic

BACKGROUND

Rates of homelessness have been increasing in recent years, thereby necessitating a more direct approach to treating this complex social problem. Homeless youth have disproportionately high rates of untreated mental health problems and are therefore particularly vulnerable to the effects of homelessness during the transition period from adolescence to adulthood.

METHODS

The study team developed a shelter-based clinic and collected clinical measures on youth who attended this clinic from October 2016 through June 2018.

RESULTS

Youth attended an average number of three sessions, but there was a significant drop in follow-up after the first (intake) appointment. Depression, anger, and adjustment disorder emerged as the most common presenting mental health concerns identified by clinicians in the intake appointment, and trauma was identified as a significant complaint for those youth who returned for a second session.

CONCLUSION

Mental health care is needed in this population, but future studies should explore alternative approaches to retaining homeless youth in treatment and in designing targeted trauma-informed interventions.

"Until You Hit Rock Bottom There's No Support": Contradictory Sources and Systems of Support for Mothers Experiencing Homelessness in Southwestern Ontario

Nurses are vital community advocates and uniquely situated to support mothers experiencing homelessness. The purpose of this study was to examine the multidimensional nature of social exclusion in the lives of mothers experiencing homelessness in Southwestern Ontario. This article reports findings from one segment of a larger study that critically examined the sociopolitical context, health needs, exclusionary and inclusionary forces, and strategies of resistance demonstrated by mothers experiencing homelessness. Central to the women’s experiences of mothering while homeless were their interactions with “the system.” The contradictory nature of these systems was categorized into four subthemes: (1) “Until you hit rock bottom there’s no support,” (2) “It’s just not enough”: Insufficient support, (3) “Help comes with a price”: Support with surveillance, and (4) “Every shelter is so different”: Organizational philosophies impacting support. The contradictory nature of the system created an illusion of support, but in mothers’ lived realities, it perpetuated experiences of exclusion in spaces ironically designed to enhance inclusion. Implications for nursing practice include action the macro-, meso-, and microlevels. Nurses can advocate for Housing-First initiatives and evidence-informed approaches to poverty reduction while recognizing the system-level barriers to health and providing respective, compassionate care.

Mothering Without a Home: Internalized Impacts of Social Exclusion

Mothering while homeless poses significant barriers in achieving health and unique challenges while parenting without a home. The contextual processes shaping mothers' experiences of social exclusion and homelessness, and the internalized impacts on homeless mothers' lives, are reported on in this article. Critical narrative methodology was employed with 41 participants comprised of 26 mothers experiencing homelessness, and 15 service providers who provided care to mothers experiencing homelessness participated in this study. Two overarching themes were constructed: (1) internalized expectations and regulation and (2) pushing back from the margins: sources of resilience and resistance. Women showed a great deal of agency within the existing structures of exclusion; they worked, and at times fought, tirelessly for safety, housing, their children, and their human rights. They actively demonstrated their agency and resistance within the webs of exclusion they faced. In promoting health, nurses can best support mothers in many ways, such as by employing strengths-based nursing, challenging their own stigma and notions of 'good mothering', and by recognizing and challenging the often insurmountable barriers posed within the system for this population.

Revisiting the Housing-Health Relationship for HIV-Positive Persons: Qualitative Evidence From the Lower Manya Krobo District, Ghana

The relationship between housing and HIV infection is complex. On one hand, poor housing arrangements may affect the health of persons living with HIV/AIDS (PLWHAs). On the other hand, PLWHAs may be more likely to live in substandard homes because of their health. We used qualitative in-depth individual interviews of 38 PLWHAs attending voluntary counseling services at two government hospitals in the Lower Manya Krobo District (LMKD) in the Eastern region of Ghana to examine their housing and health outcomes. Results show that the majority of PLWHAs lived in homes that lacked basic amenities, were overcrowded, had structural deficiencies, and were noisy and dirty. They suffered from poor housing conditions mainly because of their HIV serostatus, as this affected their ability to finance adequate homes, while HIV-related stigmatization led to eviction from either family homes or rented facilities.

How Marginalized Young People Access, Engage With, and Navigate Health-Care Systems in the Digital Age: Systematic Review

PURPOSE

This systematic review examines how marginalized young people access and engage with health services and navigate health-care systems in high-income countries.

METHODS

Medline, CINAHL, PsychInfo, The University of Sydney Library database, and Google Scholar were searched to identify qualitative and quantitative original research, published from 2006 to 2017, that focused on selected definitions of marginalized young people (12 to 24 years), their parents/carers, and/or health professionals working with these populations. A thematic synthesis was undertaken identifying themes across and between groups on barriers and/or facilitators to access, engagement, and/or navigation of health-care systems.

RESULTS

Of 1,796 articles identified, 68 studies in the final selection focused on marginalized young people who were homeless (n = 20), living in rural areas (n = 14), of refugee background (n = 11), gender and/or sexuality diverse (n = 11), indigenous (n = 4), low income (n = 4), young offenders (n = 2), or living with a disability (n = 2). Studies were from the United States, Australia, Canada, United Kingdom, New Zealand, and Portugal, including 44 qualitative, 16 quantitative, and 8 mixed-method study types. Sample sizes ranged from 3 to 1,388. Eight themes were identified relating to ability to recognize and understand health issues; service knowledge and attitudes toward help seeking; structural barriers; professionals' knowledge, skills, attitudes; service environments and structures; ability to navigate the health system; youth participation; and technology opportunities.

CONCLUSIONS

Marginalized young people experience barriers in addition to those common to all young people. Future studies should consider the role of technology in access, engagement, and health system navigation, and the impact of intersectionality between marginalized groups.

Housing Instability and Concurrent Substance use and Mental Health Concerns: An Examination of Canadian Youth

OBJECTIVE

Though previous research has identified the high burden of mental health and addiction (MHA) concerns among precariously housed youth, earlier studies have not examined differences in MHA concerns among housing insecure Canadian youth across sectors. This study examines this issue using the Global Appraisal of Individual Needs Short Screener (GAIN-SS) in a cross-sectoral sample of Canadian youth.

METHOD

A total of 2605 youth ages 12 to 24 seeking services across sectors completed the GAIN-SS and a sociodemographic form. The analyses described demographic variables and sector of presentation, then evaluated internalizing, externalizing, substance use, and crime/violence concerns based on housing status.

RESULTS

While many precariously housed youth presented through the housing/outreach/support sector, 33.6% presented to other sectors. Housing groups endorsed comparably high levels of internalizing and externalizing problems. However, precariously housed youth reported higher rates of problematic substance use (OR = 1.54; 95% CI 1.25, 1.88; p < 0.01) and crime/violence issues (OR = 1.95; 95% CI 1.54, 2.46; p < 0.01). Precariously housed youth were 48% more likely to endorse concurrent disorders (OR = 1.48; 95% CI 1.21, 1.82; p < 0.01), which was largely driven by the high rate of concurrent disorders among precariously housed females.

CONCLUSIONS

Since precariously housed youth with multiple clinical needs presented across sectors, attention must be given to screening for both housing stability and MHA and building stronger cross-sectoral partnerships. The findings should encourage systematic screening, MHA training and capacity building within housing sectors as well as integrated services across all youth-serving organizations.

An Intervention to Enhance Psychological Capital and Health Outcomes in Homeless Female Youths

Female homeless youths are vulnerable to risky sex and substance use behaviors, yet they have strengths known as psychological capital. A quasi-experimental pre-post research design with repeated measures was used to examine the feasibility and preliminary efficacy of a brief intervention to enhance psychological capital, reduce health-risk behaviors, and achieve short-term behavioral goals. Study participants were 80 ethnically diverse homeless women between the ages of 18 and 23 years. Intervention participants had significant improvements in psychological capital, hope, resilience, and self-efficacy to refuse alcohol, social connectedness, and substance use ( p < .05). There was a significant group by time interaction for safe sex self-efficacy; intervention participants had greater self-confidence in negotiating safer sex practices than comparison participants. At the follow-up post-test, 82% of intervention participants who remained in the study had met or exceeded their short-term goals. This brief, street-based intervention was feasible and showed preliminary efficacy.

Improving Youth Mental Health through Family-Based Prevention In Family Homeless Shelters

This exploratory study examines changes in suicidal ideation among a sample (N = 28) of homeless youth, ages 11-14, residing within family shelters in a large metropolitan area. Changes in suicidal ideation from pretest to posttest are compared across two group approaches to delivering HIV prevention. Youth and their families participating in the HOPE Family Program, incorporating a family strengthening approach, are compared to those receiving a traditional health education-only approach. Multivariate analyses reveal that youth in the HOPE Family Program were 13 times more likely to report a decrease of suicidal ideation. These findings indicate that health education programs integrating a family strengthening approach hold promise for positively impacting mental health outcomes for vulnerable youth.

Meeting the challenge: responding to health care needs of homeless youth

PURPOSE

This article presents a worldview of youth who are victims of homelessness. A view of family dynamics and how they affect the emotional, psychological, social, and physical health of homeless youth is presented.

RESULTS

Homeless youth and their families are at high risk for poor health outcomes. Those who present for health care services are least likely to return to the same site for follow-up care.

CONCLUSION

Understanding the dynamics of homelessness and its effect on youth and family will facilitate efforts to engage the family and increase the likelihood for follow-up with the same provider. A patient-centered cognitive approach when managing these youth and their family will improve communication, potentiate engagement, whet creative decision making, and facilitate continuity of care.

Investigating community-based health and health promotion for homeless people: a mixed methods review

Homeless people are susceptible to a range of health problems, yet in terms of health promotion, tend to be a hard-to-reach, marginalized group. Robust evidence regarding the ability to engage with this population via effective health promotion programmes is essential if policy and practice are to be informed to improve the health of homeless people. A structured review was conducted with the aim of examining what is known about community-based health promotion for homeless people. Six databases were searched and 8435 records screened. Thirteen studies met the inclusion criteria. A mixed-methods 'combined separate synthesis' approach was used to accommodate both quantitative and qualitative evidence within one review. Three themes emerged: (i) incorporating homelessness, (ii) health improving and (iii) health engaging. The review has implications for health promotion design, with evidence suggesting that as part of a tailored approach, homeless people must be actively involved in intervention development, ensuring that appropriate, acceptable and potentially effective individual elements are incorporated into community-based interventions.

The mental and physical health of homeless youth: a literature review

Youth homelessness is a growing concern in the United States. Despite difficulties studying this population due to inconsistent definitions of what it means to be a youth and homeless, the current body of research indicates that abuse, family breakdown, and disruptive family relationships are common contributing factors to youth homelessness. Moreover, the experience of homelessness appears to have numerous adverse implications and to affect neurocognitive development and academics, as well as mental and physical health. Substance use, sexually transmitted infections, and psychiatric disorders are particularly prevalent in this population. Whereas some of these problems may be short-lived, the chronic stress and deprivation associated with homelessness may have long-term effects on development and functioning. Further, difficulties accessing adequate and developmentally-appropriate health care contribute to more serious health concerns. Suggestions for future research and interventions are discussed.

Online communities of practice as a communication resource for community health nurses working with homeless persons

AIMS

This study explored community health nurses' viewpoints about a Canadian online community of practice to support their practice with homeless or under-housed populations.

BACKGROUND

Community health nurses who specifically work with homeless and marginally housed populations often report feelings of isolation and stress in managing complex problems in resource constraints. To strengthen intra-professional ties and enhance information access, an online community of practice was designed, implemented and evaluated by and for them.

METHODS

Q-methodology was used. Sixty-six statements about the community of practice were collected from an online survey and focus groups, refined and reduced to 44 statements. In 2009, sixteen participants completed the Q-sort activity, rating each statement relative to the others. Scores for each participant were subjected to by-person factor analysis.

RESULTS

Respondents fell into two groups -tacit knowledge warriors and tacit knowledge communicators. Warriors strongly believed that the community of practice could combat stigma associated with homelessness and promote awareness of homelessness issues, and valued its potential to validate and improve practice. Communicators would have used the community of practice more with increased discussion, facilitation and prompt responses. Generally, nurses viewed the community of practice as a place to share stories, validate practice and adapt best practices to their work context.

CONCLUSIONS

Online communities of practice can be valuable to nurses in specialized fields with limited peer support and access to information resources. Tacit knowledge development is important to nurses working with homeless populations: this needs to be valued in conjunction with scientifically based knowledge.

Health-seeking challenges among homeless youth

BACKGROUND

Approximately 1.5 to 2 million homeless young persons live on the streets in the United States. With the current economic situation, research is needed on quality of services geared toward homeless young adults.

OBJECTIVES

The objective of this study was to explore homeless young adults' perspectives on barriers and facilitators of health-care-seeking behavior and their perspectives on improving existing programs for homeless persons.

METHODS

This article is a descriptive qualitative study using focus groups, with a purposeful sample of 24 homeless drug-using young adults.

RESULTS

Identified themes were failing access to care based on perceived structural barriers (limited clinic sites, limited hours of operation, priority health conditions, and long wait times) and social barriers (perception of discrimination by uncaring professionals, law enforcement, and society in general).

DISCUSSION

Results provide insight into programmatic and agency resources that facilitate health-seeking behaviors among homeless young adults and include implications for more research with providers of homeless health and social services.

Social and structural barriers to housing among street-involved youth who use illicit drugs

In Canada, approximately 150,000 youth live on the street. Street-involvement and homelessness have been associated with various health risks, including increased substance use, blood-borne infections and sexually transmitted diseases. We undertook a qualitative study to better understand the social and structural barriers street-involved youth who use illicit drugs encounter when seeking housing. We conducted 38 semi-structured interviews with street-involved youth in Vancouver, Canada from May to October 2008. Interviewees were recruited from the At-risk Youth Study (ARYS) cohort, which follows youth aged 14 to 26 who have experience with illicit drug use. All interviews were thematically analyzed, with particular emphasis on participants' perspectives regarding their housing situation and their experiences seeking housing. Many street-involved youth reported feeling unsupported in their efforts to find housing. For the majority of youth, existing abstinence-focused shelters did not constitute a viable option and, as a result, many felt excluded from these facilities. Many youth identified inflexible shelter rules and a lack of privacy as outweighing the benefits of sleeping indoors. Single-room occupancy hotels (SROs) were reported to be the only affordable housing options, as many landlords would not rent to youth on welfare. Many youth reported resisting moving to SROs as they viewed them as unsafe and as giving up hope for a return to mainstream society. The findings of the present study shed light on the social and structural barriers street-involved youth face in attaining housing and challenge the popular view of youth homelessness constituting a lifestyle choice. Our findings point to the need for housing strategies that include safe, low threshold, harm reduction focused housing options for youth who engage in illicit substance use.

Uprooted and displaced: a critical narrative study of homeless, Aboriginal, and newcomer girls in Canada

Uprooting and displacement are a common part of everyday life for millions of girls and young women throughout the world. While much of the discourse has centered on movement from one country to another, uprooting and displacement are also a reality for many within Canada. Notably, a growing population of homeless girls and Aboriginal girls also have experienced uprooting and dislocation from home, community, and in some cases, family. For many of these girls, multiple forms of individual and systemic violence are central features of their lives. The primary purpose of this critical narrative study is to examine how uprooting and displacement have shaped mental health among three groups: (1) newcomers to Canada (immigrant and refugee girls); (2) homeless girls; and (3) Aboriginal girls. In-depth narrative interviews were conducted with 19 girls in Southwestern Ontario. Narrative themes revealed that although there is much diversity within and between these groups, uprooting and displacement create social boundaries and profound experiences of disconnections in relationships. Barriers to re/establishing connections generate dangerous spaces within interlocking systems of oppression. However, in negotiating new spaces, there is the potential for the forming and re-forming of alliances where sources of support hold the promise of hope. It is within these spaces of hope and pathways of engagement where connections offer a renewed sense of belonging and well-being. The findings highlight the relevance of the construct of uprootedness in girls' lives, provide beginning directions for the design of gender-specific and culturally meaningful interventions, and comprise a substantial contribution to the growing body of research related to girls and young women.