The bidirectional association between psychiatric disorders and sheltered homelessness

BACKGROUND

Psychiatric disorders and homelessness are related, but temporal associations are unclear. We aimed to explore the overlap between hospital-based psychiatric disorders and sheltered homelessness.

METHODS

This population-based cohort study was conducted using the Danish registers e.g., the Danish Homeless Register and the Danish National Patient Register. The study cohort included all individuals aged 15 years or older, living in Denmark at least one day during 2002-2021 (born 1984-2006). First psychiatric diagnosis was used to define psychiatric disorder and first homeless shelter contact to define homelessness. Adjusted incidence rate ratios (IRRs) and cumulative incidences were estimated.

RESULTS

Among 1 530 325 individuals accounting for 16 787 562 person-years at risk aged 15-38 years, 11 433 (0.8%) had at least one homeless shelter contact. Among 1 406 410 individuals accounting for 14 131 060 person-years at risk, 210 730 had at least one psychiatric disorder. People with any psychiatric disorder had increased risk of sheltered homelessness relative to individuals with no psychiatric disorder [IRR 9.2, 95% confidence interval (CI) 8.8-9.6]. Ten years after first psychiatric disorder, 3.0% (95% CI 2.9-3.1) had at least one homeless shelter contact. Individuals experiencing homelessness had increased risk of any psychiatric disorder compared to individuals with no homeless shelter contact (IRR 7.0, 95% CI 6.7-7.4). Ten years after first homeless shelter contact, 47.1% (45.3-48.0) had received a hospital-based psychiatric diagnosis.

CONCLUSION

Strong bidirectional associations between psychiatric disorders and homelessness were identified. Health and social care professionals should be aware of and address these high risks of accumulated psychiatric and social problems.

Heterogeneous trajectories of suicidal ideation among homeless youth: predictors and suicide-related outcomes

The current study examined heterogeneous trajectories of suicidal ideation among homeless youth experiencing suicidal ideation over 9 months in a randomized controlled intervention study. Suicidal homeless youth (N = 150) were randomly assigned to Cognitive Therapy for Suicide Prevention (CTSP) + Treatment as Usual (TAU) or TAU alone. Youth reported their suicidal ideation four times during a 9-month period. We also assessed pretreatment mental health, demographic information and session attendance as predictors of the subgroups, as well as suicide-related factors as outcomes at the 9-month follow-up. Growth mixture models suggested three distinct trajectory groups among youth: Fast Declining (74.7%), Chronic (19.3%), and Steadily Declining (6.0%). Youth in the Chronic group used more substances at baseline than the Steadily Declining group, were more likely to be White, non-Hispanic than the Fast Declining group, and attended more CTSP sessions than other groups. Contrastingly, youth in the Steadily Declining group all experienced childhood abuse. Finally, youth in the Chronic group showed significant higher risk for future suicide compared to those in the Fast Declining group at 9 months. Findings support the heterogeneity of treatment responses in suicide intervention among homeless youth, with implications to improve treatment efforts in this very high-risk population.

Identifying Biopsychosocial Characteristics of Emergency Youth Shelter Residents With Psychiatric Diagnoses

Background In the United States, homelessness is an issue that may affect a significant portion of the adolescent population. There is no consensus on the extent to which this population has been impacted by poor mental health and lack of resources. This study aimed to characterize trends among those who struggle with housing insecurity and mental illness to provide a clearer picture of mental health needs among this population. Methods Data from 641 adolescents who presented to a local adolescent homeless shelter between 2015 and 2021 were utilized to determine if there were significant associations between specific mental illness diagnoses and biopsychosocial characteristics. A chi-square test of independence was performed on demographic and psychosocial variables for categories with a frequency greater than five. For continuous variables, an unpaired t-test was utilized to assess significance (p<0.05). Results Among the study population, 61.3% (369) had at least one psychiatric diagnosis, which is higher than even the most conservative estimates of mental illness among the general public. Having one or more psychiatric diagnoses was significantly associated with suicide attempts, documented aggressive behavior, and tobacco use. Contrary to our initial hypothesis, there were no significant correlations between psychiatric diagnoses and demographic characteristics or drug use other than tobacco. Conclusions Our findings indicate that though the particular reasons for homelessness among adolescents may vary, the prevalence of mental illness among these young individuals was roughly uniformly distributed and vastly above normal levels. Future research must focus on developing interventions to mitigate the effects of mental illness among homeless adolescents, as they are at a vulnerable point in their formative years.

Respiratory syncytial virus and other respiratory virus infections in residents of homeless shelters - King County, Washington, 2019-2021

Respiratory syncytial virus (RSV) causes disproportionate morbidity and mortality in vulnerable populations. We tested residents of homeless shelters in Seattle, Washington for RSV in a repeated cross-sectional study as part of community surveillance for respiratory viruses. Of 15 364 specimens tested, 35 had RSV detected, compared to 77 with influenza. The most common symptoms for both RSV and influenza were cough and rhinorrhea. Many individuals with RSV (39%) and influenza (58%) reported that their illness significantly impacted their ability to perform their regular activities. RSV and influenza demonstrated similar clinical presentations and burden of illness in vulnerable populations living in congregate settings.

Application of the ecobiodevelopmental model for research among youth experiencing homelessness

Youth experiencing homelessness (YEH) often face increased levels of adversity and higher rates of trauma, suicide, and mortality compared to their housed peers. A multi-level life course lens is proposed by applying the ecobiodevelopmental model to examine social support mechanisms as a buffer to psychopathologies following adversity within YEH. Further discussion contributes to the theoretical basis for future public health research and intervention work addressing youth homelessness and related adversities.

Lesbian, Gay, and Bisexual Students Experiencing Homelessness and Substance Use in the School Context: A Statewide Study

PURPOSE

This study explored differences between lesbian, gay, and bisexual (LGB)-housed and homeless students regarding substance use patterns on and off school grounds and the unique contribution of homelessness to substance use in school.

METHODS

Data were from the 2013-2015 California Healthy Kids Survey, a statewide survey of school protective factors and risk behaviors. A representative sample of 9th- and 11th-grade students (N = 20,337) was used. Comparisons between housed (n = 19,456) and homeless (doubled up: n = 715; acute homeless: n = 166) LGB students were conducted. We used chi-square tests to compare rates of lifetime, past-30-day, and in-school substance use and conducted multivariate logistic regression models for each substance use variables.

RESULTS

Chi-square test results indicated significant differences in rates of substance use among students experiencing homelessness (both categories) and housed LGB students. Lesbian, gay, and bisexual students experiencing homelessness were more likely to report substance use off and on school grounds. Results from logistic regression analyses indicated that LGB students who experience homelessness were significantly more likely to report recent and in-school substance use. For example, students experiencing acute homelessness were about 3 times as likely to report heavy episodic drinking (adjusted odds ratio [AOR] = 3.13; 95% confidence interval [CI] = 2.13, 4.26) and more than 5 times as likely to smoke marijuana in school (AOR = 5.38; 95% CI = 3.46, 8.36), compared to housed LGB students.

CONCLUSIONS

LGB students who experience homelessness are at higher risk than housed LGB students of substance use on and off school grounds. Findings highlight the need to provide support in the school context for this subpopulation.

Association between suicide attempt and previous healthcare utilization among homeless youth

INTRODUCTION

The purpose of this study was to examine the association between prior emergency department (ED) visit or hospitalization and subsequent suicide attempt among homeless youth aged 10-17 years old.

METHODS

With New York statewide databases, a case-control design was conducted. Cases and controls were homeless patients with an ED visit or hospitalization due to suicide attempt (cases) or appendicitis (controls) between April and December. We examined ED and inpatient records for 90 days prior to the visit for suicide attempt or appendicitis. The primary exposure variable was prior healthcare utilization for any reason other than the following four reasons: mental health disorder, substance use, self-harm, and other injuries. Multivariable logistic regression models, with year fixed effect and hospital random effect, were used.

RESULTS

A total of 335 cases and 742 controls were identified. Cases had lower odds of prior healthcare utilization for any reason other than the four reasons listed above. (adjusted Odds Ratio [aOR]: 0.53, p-value = 0.03).

CONCLUSIONS

The association between prior healthcare utilization and decreased risk of suicide attempt among homeless youth may be due to comprehensive care provided during healthcare utilization. It may also reflect the presence of a social network that provided a protective effect.

LGBTQ Youth Homelessness: Why We Need to Protect Our LGBTQ Youth

Lesbian, gay, bisexual, transgender, and queer/questioning (LGBTQ) youth are 120% more likely to be homeless than cisgender and heterosexual youth, yet current federal policies are insufficient and exclude LGBTQ youth. Youth homeless shelters are inadequately equipped to serve LGBTQ homeless youth due to poor funding, a focus on heterosexual or cisgender clients in their programs, and a lack of LGBTQ-friendly policies. Given the pervasiveness of this issue, public health and social policy interventions must be considered. In this perspective, the LGBTQ homeless youth epidemic is introduced and described, past policies are analyzed, and policy recommendations are made.

Illicit Drug Use, Cognitive Distortions, and Suicidal Ideation Among Homeless Youth: Results From a Randomized Controlled Trial

Illicit drug use and cognitive distortions confer significant risks to youth suicidal thoughts and behaviors. However, there has been limited evidence regarding the efficacy of suicide prevention interventions with homeless youth, especially studies testing whether such interventions can reduce the risk for suicidal ideation associated with illicit drug use. Suicidal homeless youth (N = 150) between the ages of 18 to 24 years were recruited from a drop-in center. Youth were randomly assigned to Cognitive Therapy for Suicide Prevention (CTSP) + Treatment as Usual (TAU) or TAU alone. Youth reported their illicit drug use, cognitive distortions, and suicidal ideation 4 times over 9 months. A multiple-group multilevel structural equation model showed that higher illicit drug use at baseline predicted a slower reduction in cognitive distortions and suicidal ideation in the TAU group. These associations were not found in the CTSP + TAU group, suggesting an interruption of such risk from illicit drug use. Findings suggest that CTSP can reduce the risk of illicit drug use as a treatment barrier towards cognitive distortions and suicidal ideation among homeless youth, with implications to improve treatment efforts and to reduce premature mortality in a vulnerable population.

Victimization and Resilience Among Sexual and Gender Minority Homeless Youth Engaging in Survival Sex

This study examined how a diverse group of sexual and gender minority (SGM) homeless youth described and understood their victimization experiences occurring before they were homeless and those occurring after they were homeless and engaging in survival sex. In addition, the study explored how these youths manifested resilience when living on the street. The sample consisted of 283 racially/ethnically diverse youth between the ages of 15 and 26 years (M = 19.6, SD = 1.28) living in a large U.S. city. Participants identified their gender as male (47%), female (36%), transgender (15%), or queer and other (3%) and their sexual orientation as bisexual (37%), gay (23%), lesbian (15%), heterosexual (13%), or queer and other (13%). Thirty-seven percent identified as Black, 30% as multiracial, 22% as Latino/a, 5% as White, and 5% as another race. Content and thematic analyses were used to conduct a secondary analysis of qualitative data. Four themes were identified: unsafe and unsupported at home; barriers to housing and employment stability; ongoing victimization and lack of protection; and unexpected opportunities for resilience. Findings demonstrated that participants experienced victimization related not only to their SGM identities but also to chaotic home environments. Once homeless and engaging in survival sex, youth experienced barriers to securing employment and housing as well as victimization by police and clients. These experiences frequently involved prejudice related to their intersecting identities. Despite encountering numerous challenges, participants described surviving on the streets by living openly and forming relationships with other youth. Implications for practice and policy are discussed.

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

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

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

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

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

Improving access of young adults with experience of homelessness to primary care dental services in the UK: A realist synthesis

OBJECTIVE

To understand why, how and under what circumstances interventions lead to improved access of young adults with experience of homelessness (YAEH) to primary care dental services in the UK.

METHODS

We followed a realist, theory-driven methodology. It involved locating existing theories, searching for evidence, document selection, data extraction/appraisal and evidence synthesis. We searched scientific databases and grey literature sources. We used these data and relevant substantive theories to develop explanations of how, why and under what circumstances interventions lead to desired outcomes. We presented these explanations in the form of context-mechanism-outcome configurations (CMOCs). The CMOCs were incorporated in an overarching programme theory, which was iteratively developed and refined throughout the realist synthesis.

RESULTS

We used 106 scientific and 18 grey literature records to synthesize 61 CMOCs. Our revised programme theory highlights the importance of four main considerations: 'preparing a service', 'producing and disseminating information', 'outreach activities' and 'facilitating interactions'. When designing dental programmes for YAEH, we recommend considering the importance of prior service planning (including resourcing of emergency dental care, training staff and incorporating safety measures), creating positive experiences, flexibility, patient-centeredness, being informative and reassuring, creating an enabling environment (including strong communication, building rapport and avoiding negative judgements), having realistic expectations and designing services that empower patients.

CONCLUSIONS

Improving dental access of YAEH requires attention to multiple levels. Services can achieve positive outcomes by understanding the complexity of YAEH lives, and creating contextual circumstances that encourage their attendance.

The Second National Canadian Homeless Youth Survey: Mental Health and Addiction Findings: La Deuxième Enquête Nationale Auprès des Jeunes Sans Abri : Résultats en Matière De Santé Mentale et de Toxicomanie

OBJECTIVE

Youth experiencing homelessness represent a major social problem in Canada and, as demonstrated in the first national survey of this population conducted in 2015, are experiencing significant mental health challenges. The present study examines the findings of a second national survey completed in 2019. These findings afford the opportunity to examine the reliability of the findings of the first study with another large, representative sample and to attempt to articulate the unique characteristics of youth experiencing the greatest distress among this at-risk population.

METHODS

This study analyzed the mental-health-related data from the 2019 Without a Home-National Youth Homelessness Survey that was administered through convenience sampling at 98 agencies serving homeless youth in 49 communities across Canada. The survey was cross-sectional and self-administered, assessing a range of demographic information, pre- and post-homelessness variables, and mental health indicators. Multinomial logistic regression and linear regression were implemented to evaluate associations with distress level.

RESULTS

Survey data were obtained from 1,375 youth accessing Canadian homeless services in 9 provinces. Thirty-five percent reported at least 1 suicide attempt, and 33.1% reported a drug overdose requiring hospitalization. The findings of this survey replicated most of the key findings from the 2015 survey. The current findings emphasized, for this high-risk population, the heightened adversity faced by young women, Lesbian, Gay, Bisexual, Transgender, Queer, Two-Spirit (LGBTQ2S), and Indigenous subpopulations, as well as the centrality of violence exposure in determining risk and distress. Sexual violence, in particular, emerged as a key factor in the identification of youth experiencing the greatest distress with risk buffered by contact with family.

CONCLUSIONS

These findings can inform prevention and intervention policies and services and reinforce the importance of attending to violence exposure and trauma as central to the mental health trajectories of youth who have experienced homelessness.

A Latent Class Analysis of Lifetime Victimization Among Homeless Youth

Homeless youth experience high rates of child physical and sexual abuse, and many are revictimized on the streets. Despite their high rates of victimization, few studies have examined whether specific victimization types (e.g., sexual vs. physical) cluster together and for whom (e.g., sexual minority youth). As such, the purpose of this study was to identify clusters of homeless youth based on their exposure to different forms of child abuse and street victimization, to examine what factors distinguish each cluster, and how unique clusters are related to youths' mental health using data collected at two time points. The sample included 150 youth experiencing homelessness in the Midwest. Latent class analysis was used to identify clusters of youth. Three latent classes emerge: The low exposure class had significantly lower rates of child physical and emotional abuse and threats compared with the medium- and high-exposure groups. The high exposure group had significantly higher rates of child sexual abuse compared with the other groups. Females, sexual minority youth, and those who have lived in more foster care homes were more likely to be in the high exposure group compared with the low and/or medium exposure groups. Multivariate results revealed that those in the medium and high exposure cluster groups had higher rates of Wave 1 depressive symptoms and Wave 1 anxiety compared with youth in the low exposure cluster. Overall, although these young people experience high rates of abuse and victimization both at home and while on the street, there are gradations in these experiences such that certain victimization experiences subgroups are at heightened risk for poor mental health.

Can Better Emotion Regulation Protect Against Interpersonal Violence in Homeless Youth Social Networks?

Homeless youth experience all types of violence at higher rates than their housed counterparts. This is typically the result of many contributing factors including childhood experiences of trauma, subsistence survival strategies, and exposure to perpetrators while living on the streets. Reducing violence in the lives of homeless youth is imperative and can contribute to a young person's ability to safely and successfully exit the streets and lead a long and productive life in society. However, developing public health and social interventions to reduce violence in adolescent and young adult populations is difficult due to the complex interplay of extrinsic and intrinsic drivers of this phenomenon. Los Angeles area homeless youth (N = 366) were asked questions regarding recent violence experiences, emotion regulation, and their social network. Multivariable logistic regressions tested the overall effect of emotion regulation on violence, controlling for age, gender, race, sexual identity, experience of childhood abuse, and data collection site. In this sample, 56% of youth endorsed fighting in the previous year, and those who reported more difficulties with emotion regulation were significantly more likely to fight. In addition, youth who scored below the mean on difficulties with regulation and belonged to networks characterized by low-difficulty peers were 60% less likely to report fighting. Emotion regulation skills represent a malleable target for intervention that may contribute to reduced propensity for violence in this population. Implications for network-based interventions to improve individual emotion regulation and reduce overall violence among homeless youth and other at-risk populations are discussed.

Bullying at School and on the Street: Risk Factors and Outcomes Among Homeless Youth

Though rates of bullying among general population youth are high, there is elevated prevalence among certain subgroups, in particular sexual minority homeless youth. Enduring bullying can have devastating consequences, including poor mental health, revictimization, and substance abuse. The current study compares risk factors (i.e., sexual orientation, gender, and child abuse) for being bullied both at school and on the street among homeless youth. We also examine the associations of both contexts of bullying (i.e., at school and on the street) with physical and sexual victimization while on the street, with illicit drug use. From July 2014 to October 2015, we interviewed 150 homeless youth aged 16 to 22 years in shelters and on the streets from two Midwestern cities. Our sample was 51% female and 22% identified as lesbian, gay, or bisexual (LGB). Results revealed that LGB youth experienced more frequent bullying at school and were more likely to have ever used one or more illicit drugs at least a few times compared with heterosexual youth. Moreover, youth who experienced more child abuse prior to leaving home were also victimized more often at school (school bullying) and on the street (street bullying). Young people who experienced more sexual and physical street victimization were more likely to report illicit drug use compared with those who had fewer street victimization experiences. Overall, youth who experience victimization in one context (i.e., home) are at heightened risk for being bullied in additional contexts (i.e., school). These findings have important policy and service intervention implications, such that service providers should attend to homeless youth's multiple social contexts of victimization and the potential for youth's illicit drug use as a coping mechanism.

Social Problem-Solving and Suicidal Ideation Among Homeless Youth Receiving a Cognitive Therapy Intervention: A Moderated Mediation Analysis

Despite the high prevalence of suicidal ideation and attempts among homeless youth, little research has examined how suicide prevention interventions influence suicide-related risk and protective factors, and ultimately produce positive outcome in suicidality in this population. Drawing on the Diathesis-Stress Model and the Interpersonal Theory of Suicide, the current study examined whether participation in Cognitive Therapy for Suicide Prevention (CTSP) moderated the mediation link between social problem-solving, perceived burdensomeness and thwarted belongingness, and suicidal ideation among a sample of homeless youth experiencing suicidal ideation. Social problem-solving refers to a set of cognitive, emotional, and behavioral coping responses in the face of stressful situations, and it is identified as a potent protective factor in alleviating perceived burdensomeness and thwarted belongingness, and reducing suicidal ideation. Participants included 150 homeless youth (M age = 20.99, range = 18-24; 41% female) who were randomly assigned to Cognitive Therapy for Suicide Prevention (CTSP) + Treatment as Usual (TAU) (n = 75) or Treatment as Usual alone (n = 75). Participants were assessed at baseline, 3, 6, and 9 months post-baseline. Findings showed that perceived burdensomeness mediated the association of social problem-solving with suicidal ideation only among youth participating in the CTSP condition. These findings provide evidence to support the promising effects of CTSP in enhancing the protective effects of social problem-solving on suicidal ideation through the mediating effects of perceived burdensomeness. Findings also have implications for improving intervention effectiveness with a community-based population at high risk of suicide.

Examining Sleep Disturbance Among Sheltered and Unsheltered Transition Age Youth Experiencing Homelessness

BACKGROUND

The estimated 3.5-million transition age youth (TAY) who experience homelessness in the United States annually are routinely exposed to inadequate sleep environments and other psychosocial risk factors for deficient sleep. Although staying in a shelter versus being unsheltered may facilitate sleep, research suggests that perceived safety wherever one sleeps may be just as important. In this study, which is the first known study to investigate sleep disturbances among TAY experiencing homelessness, we examine associations of sleep disturbances with sheltered status and perceived safety of usual sleep environment.

METHODS

We surveyed TAY (aged 18-25) experiencing homelessness in Los Angeles, CA about their sleep, psychosocial health, and living situations. Participants (n=103; 60% sheltered) self-reported sleep disturbances using the Patient-Reported Outcomes Measurement Information System Sleep Disturbance short form, while individual items assessed sheltered status and perceived safety where they usually slept. Regression analyses examined associations of sheltered status and perceived sleep environment safety with sleep disturbance, adjusting for age, sex, race, self-rated health, depression symptoms, serious mental illness, high-risk drinking, and severe food insecurity.

RESULTS

Twenty-six percent of participants reported moderate-severe sleep disturbances. Sleep disturbance was not associated with sheltered status, but was positively associated with feeling unsafe in one's sleep environment, depression symptoms, severe food insecurity, and decreased age.

CONCLUSIONS

Our findings suggest that sleep disturbances among TAY experiencing homelessness are associated more closely with how safe one feels rather than one's sheltered status. This highlights the importance of providing safe places to live for sheltered and unsheltered TAY.

Relationship Between Vaccination Status and Biopsychosocial Characteristics in Sheltered Adolescents

Introduction

Homeless youth are a vulnerable population. A volunteer clinic supported by medical students in northeastern Pennsylvania provides shelter and healthcare to adolescents seeking refuge. We set out to determine the immunization status of youth in the shelter and evaluate for associations of immunization deficiency with demographics or biopsychosocial factors.

Methods

After IRB approval, a retrospective cohort study was performed from existing clinical records at the shelter 2/2015-9/2019. Chart abstraction included variables such as demographics (including age, sex, and race/ethnicity), biopsychosocial factors (including childhood trauma/abuse history, substance abuse history, and sexual activity), and immunization history.

Results

A total of 440 charts were analyzed. When comparing demographics of patients that had complete vaccine regimens versus those who did not, the race was statistically significant (p=.006). The most prominent difference in race was seen for Black/African American patients; only 19.57% had a completed vaccine regimen documented. Regarding immunization history, vaccine schedules of hepatitis B, measles mumps rubella (MMR), inactivated polio vaccine (IPV), and varicella were most likely to be complete; pneumococcal conjugate vaccine (PCV) 13, rotavirus, influenza, and human papillomavirus vaccine (HPV) were least likely. There was no association found between a completed vaccine regimen and biopsychosocial variables. A larger portion of females (37.35%) completed the HPV vaccine compared to males (23.14%) (p=.009).

Conclusions

In this single-site study, this vulnerable, at-risk population of sheltered adolescents lacked the vaccinations recommended by the Centers for Disease Control and Prevention. Racial disparities further compounded this vulnerability for Black/African American teens. Additionally, a significantly greater number of female patients received the HPV vaccine compared to males.

Learning to endure: A qualitative examination of the protective factors of homeless transgender and gender expansive youth engaged in survival sex

Background: Transgender and gender expansive (TGE) youth face a number of adversities that are associated with deleterious consequences, including mental health problems, substance misuse, suicide, and homelessness. However, there is evidence that TGE youth still demonstrate resilience under extraordinary conditions. Aims: Therefore, this study examined how TGE youth who are homeless and engaging in survival sex describe and understand the protective factors present in their lives. Methods: In-depth qualitative interviews were conducted with 57 TGE youth living in a large U.S. city. Participants were 17-26 years old (M = 19.88, SD = 1.55), and identified as transgender woman (53%), transgender man (16%), and other (32%; gender-queer, gender-fluid, androgynous, or non-binary). Youth identified as Black (40%), multiracial (35%), Latinx (16%), White (5%), and as another race (3%). Researchers conducted a secondary analysis of qualitative data using thematic analysis. Results: We identified three themes to capture youth's understanding of their protective factors: relying on oneself and others to avoid violence, accessing gender-affirming health and mental health care, and proactively maintaining sexual health. Participants described strategies for mitigating risk of harm while attempting to meet their basic needs. Additionally, they discussed the importance of having gender-affirming health and mental health services. Participants also expressed keen awareness of their sexual health risks and making calculated, often proactive decisions about their sexual health. Conclusion: The protective factors described by TGE youth reflect the unique ways in which hyper-marginalized youth must navigate their own survival and well-being, and align with literature suggesting resilience is not mutually exclusive from risk. By focusing on TGE youth, this research privileges the experiences of individuals historically underrepresented in research and encourages future research to incorporate these perspectives into policies and programs.

A Multilevel Intervention Framework for Supporting People Experiencing Homelessness with Pets

Simple Summary

Approximately one in 10 people experiencing homelessness have pets. Despite pets having psychosocial benefits for their owners, pets can also present challenges for people experiencing homelessness related to meeting their basic needs and obtaining housing. This article proposes a framework of policy, public, and service interventions for improving the health and well-being of pet owners experiencing homelessness. At the policy level, the framework proposes an increase of pet-friendly emergency shelters, access to market rental housing and veterinary medicine, and the use of a Housing First approach. At the public level, educational interventions are needed to improve knowledge and reduce stigma about the relationship between homelessness and pet ownership. At the service delivery level, direct service providers can support pet owners experiencing homelessness by recognizing their strengths, connecting them to community services, being aware of the risks associated with pet loss, providing harm reduction strategies, documenting animals as emotional support animals, and engaging in advocacy. By targeting policies and service approaches that exacerbate the hardships faced by pet owners experiencing homelessness, the framework is a set of deliberate actions to better support this vulnerable group.

Abstract

Approximately one in 10 people experiencing homelessness have pets. Despite the psychosocial benefits derived from pet ownership, systemic and structural barriers can prevent this group from meeting their basic needs and exiting homelessness. A multilevel framework is proposed for improving the health and well-being of pet owners experiencing homelessness. Informed by a One Health approach, the framework identifies interventions at the policy, public, and direct service delivery levels. Policy interventions are proposed to increase the supply of pet-friendly emergency shelters, access to market rental housing and veterinary medicine, and the use of a Housing First approach. At the public level, educational interventions are needed to improve knowledge and reduce stigma about the relationship between homelessness and pet ownership. Direct service providers can support pet owners experiencing homelessness by recognizing their strengths, connecting them to community services, being aware of the risks associated with pet loss, providing harm reduction strategies, documenting animals as emotional support animals, and engaging in advocacy. By targeting policies and service approaches that exacerbate the hardships faced by pet owners experiencing homelessness, the framework is a set of deliberate actions to better support a group that is often overlooked or unaccommodated in efforts to end homelessness.

Exploring the Relationship between Foster Care Experiences and Social Network Engagement Among a Sample of Homeless Former Foster Youth

INTRODUCTION

Recent research has begun to demonstrate high rates of poor behavioral health outcomes among homeless former foster, but with relatively little attention in the scientific literature. Because social networks have been shown to impact behavioral health outcomes, we need to better understand the network characteristics of homeless young adults with a history of foster care.

METHODS

Data were collected from 184 homeless former foster youth at a drop-in center in Hollywood, California. A series of logistic regressions were conducted for network engagement behaviors that may be impacted by foster care experiences.

RESULTS

Youth were largely African American, Latino, and Mixed race, approximately 22 years old, and majority male. Significant results from the logistic regressions indicated that youth experiencing homelessness for the first time before exiting foster care were more likely to have alters engaging in condomless sex, and youth with higher numbers of foster care placements were more likely to have alters engaging in methamphetamine use.

CONCLUSION

These results suggest that certain foster care experiences impact the types of alters with which youths engage. Time spent in placement was significantly associated with alter behaviors, evident from homeless experiences and multiple foster care placements, negatively impacting the types of alters with which youths are connected, and thusly the risk factors for the youth themselves. Frequent network disruptions may be associated with engagement with risky alters. Included are intervention-based implications for providers as well as structural-based implications for child welfare systems.

Factors Associated With HIV Testing Among Atlanta's Homeless Youth

Homeless youth experience increased risk of contracting HIV, making HIV testing imperative in this population. We analyzed factors associated with HIV testing among homeless youth in Atlanta, Georgia using data from the 2015 Atlanta Youth Count and Needs Assessment. The analysis included 693 homeless youth aged 14-25 years, of whom 88.4% reported ever being tested for HIV, and 74.6% reported being tested within the previous year. Prevalence of ever testing for HIV was significantly higher among youth who reported risk factors for HIV (sexually active, transactional sex, or ever having an STI). Higher prevalence of testing within the last year was significantly associated with experiencing physical abuse or transactional sex. However, reporting ≥ 4 sexual partners or not using condoms were not associated with higher testing. Although testing prevalence among homeless youth was high, homeless youth engaging in certain high risk behaviors could benefit from further promotion of HIV testing.

A comparison of frequency of alcohol and marijuana use using short message service surveying and survey questionnaires among homeless youth

BACKGROUND

There are several benefits to using short message service surveying (SMS) to gather data on substance use from homeless youth, including capturing data "in the moment" and verifying the timing of one behavior relative to another. Though SMS is a valuable data collection tool with highly mobile populations that otherwise are difficult to longitudinally sample, the reliability of SMS compared with surveys is largely unknown with homeless youth. Examining the reliability of SMS is important because these data can provide a more nuanced understanding of the relationships between various risk behaviors, which may lead to better intervention strategies with these youth.

OBJECTIVES

We compared past 30-day survey and SMS data for youth's alcohol and marijuana use.

METHODS

Interviewed 150 homeless youth (51% female) using surveys and SMS.

RESULTS

Past 30-day survey and SMS data revealed moderately strong correlations for alcohol (rs  = .563) and marijuana (rs  = .564). Regression analysis revealed that independent variables were similarly associated with alcohol and marijuana use when comparing survey and SMS data with two exceptions: heterosexual youth reported less alcohol use in SMS data compared to survey data (β = -.212; p < .05 vs. β = -.006; p > .05, respectively) and youth whose parents had alcohol problems reported less marijuana use in survey data compared to SMS data (β = -.277; p < .01 vs. β = -.150; p > .05, respectively).

CONCLUSION

Findings indicate SMS and surveys are both reliable methods of gathering data from homeless youth on substance use.

Short Message Service Surveying With Homeless Youth: Findings From a 30-Day Study of Sleeping Arrangements and Well-Being

Little is known about the location and consistency of sleeping arrangements among youth experiencing homelessness (YEH) and how this is linked to their well-being. This study addresses this gap using ecological momentary assessment (EMA) via short message service (SMS) surveying with 150 YEH over 30 days, to examine how various sleeping arrangements are associated with depression, marijuana use, support received, and service utilization. Results revealed that the average number of consecutive days youth stayed at any particular location varied considerably. Youth who stayed more frequently with a friend/partner or in a transitional living facility (TLF) reported fewer days of being depressed, whereas staying with a friend/ partner was associated with using marijuana more frequently. Finally, youth staying with a friend/partner, stranger, or TLF reported using services on fewer days. Because sleeping arrangements change almost daily, on average, this has important public health implications for agencies finding permanent housing for YEH.

"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.

Community-based oral health interventions for people experiencing homelessness: a scoping review

OBJECTIVE

To determine the characteristics of community-based oral health interventions for people experiencing homelessness.

BASIC RESEARCH DESIGN

A scoping review was conducted, adhering to the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses: Scoping Reviews) checklist. A search strategy was developed using MeSH terms and key words, and used to search the following electronic databases: Medline/PubMed, CINAHL, ProQuest Assia, Scopus, Web of Science and PsychNet. Key journals and reference lists were also hand-searched. Two reviewers then read the abstracts of all papers, excluding duplicates and papers that did not meet the eligibility criteria. The reviewers then read to full-texts of the studies to be included in the review.

RESULTS

Eighteen studies met the inclusion criteria and were included in the study. These studies were predominantly evaluations of community-based dental services or other oral health interventions. Several recommendations were extracted. Interventions should involve co-design with homeless service users; multidisciplinary working, collaboration with dental practitioners, and working with educational establishments. The location of community-based services was also found to be of importance.

CONCLUSION

This review has highlighted several recommendations, as well as gaps in the literature. These gaps suggest a need for more non-clinical oral health interventions for the homeless population, and a closer look at the role that non-dental practitioners can play in the delivery of oral health care.

Childhood Disadvantage, Social and Psychological Stress, and Substance Use Among Homeless Youth: A Life Stress Framework

We used a life stress framework to examine linkages between distal or primary stressors (e.g., child abuse) and proximal or secondary stressors (e.g., street victimization) and their association with substance use among 150 youth experiencing homelessness in the Midwestern United States. Results revealed that numerous primary stressors such as number of times youth ran from home and number of foster care placements were associated with secondary stressors, such as anxiety, total duration of homelessness, and street victimization. Only street physical victimization (e.g., been beaten up since leaving home) was associated with greater substance use. Our findings provide a more holistic picture of both distal and proximal life stressors that these young people experience and reveal the complexity of issues that service providers must acknowledge when working with this population.

Evaluating the Effects of a Rent Subsidy and Mentoring Intervention for Youth Transitioning Out of Homelessness: Protocol for a Mixed Methods, Community-Based Pilot Randomized Controlled Trial

Background

Although the risk factors associated with young people entering and becoming entrenched in street life have been thoroughly investigated, peer-reviewed evidence is scarce to nonexistent for rigorous interventions targeting social integration outcomes for young people who have experienced homelessness. From the limited research that has been done, emerging evidence signals that, although structural supports such as subsidized housing and social service providers are important, these resources alone are insufficient to help young people integrate into the mainstream society.

Objective

The overarching aim of this study is to assess whether and how rent subsidies and mentorship influence social integration outcomes for formerly homeless young people living in market rent housing in 3 Canadian cities. The primary outcome measures for this study are community integration (psychological and physical) and self-esteem at 18 months. Secondary outcomes include social connectedness, hope, and academic and vocational participation at 18 months. Exploratory outcomes include income, perceived housing quality, engulfment, psychiatric symptoms, and participant perspectives of intervention barriers and facilitators.

Methods

This is a convergent mixed methods, open-label, 2-arm parallel randomized controlled trial (RCT) with 1:1 allocation embedded within a community-based participatory action research (CBPAR) framework. The intervention will provide 24 young people (aged 16-26 years), who have transitioned out of homelessness and into market rent housing within the past year, with rent subsidies for 24 months. Half of the young people will also be randomly assigned an adult mentor who has been recruited and screened by 1 of our 3 community partners. Data collection will occur every 6 months, and participants will be followed for 30 months.

Results

Ethical approval for this study has been obtained from the Providence, St Joseph’s, and St Michael’s Healthcare Research Ethics Board (number 18-251). Enrollment took place from April 2019 to September 2019. Preliminary analysis of the baseline quantitative and qualitative data is underway.

Conclusions

This pilot RCT will be the first to test the impact of economic and social support on meaningful social integration for formerly homeless young people living in market rent housing. We believe that the mixed methods design will illuminate important contextual factors that must be considered if the intervention is to be scaled up and replicated elsewhere. Importantly, the CBPAR framework will incorporate the perspectives of the community, including formerly homeless young people, who are in the best position to determine what might work best in the context of their lives.

Trial Registration

Clinicaltrials.gov NCT03779204; https://clinicaltrials.gov/ct2/show/NCT03779204.

International Registered Report Identifier (IRRID)

DERR1-10.2196/15557

Understanding Daily Depression, Drinking, and Marijuana Use among Homeless Youth using Short Message Service Surveying

We used short message service surveying (SMS) with 150 homeless youth to examine the time ordering of feeling depressed with drinking alcohol, using marijuana, and using substances with friends. Multilevel binary logistic regression results revealed that youth who were depressed earlier in the day were more likely to drink alcohol later that day. Among depressed youth, heterosexual youth were less likely to drink alcohol than lesbian, gay, and bisexual (LGB) youth. Depressed youth had increased odds of using marijuana by a factor of 1.6, while heterosexual youth, compared to LGB youth, were 80% less likely to use marijuana. Females were 82% less likely and heterosexual youth 75% less likely to use substances with friends compared to males and LGB youth, respectively. These findings improve upon prior retrospective studies by using SMS to understand time ordering between feeling depressed and substance use in the same day.

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.

Factors that Promote Resilience in Homeless Children and Adolescents in Ghana: A Qualitative Study

Several studies conducted on street youth have focused on causes of homelessness, their engagement in risky sexual behaviours and the prevalence of STIs, including HIV/AIDS. Although homeless youth are considered resilient, sparse literature exists on factors that promote resilience in this vulnerable group. Using a qualitative approach, semi-structured interviews were conducted with 16 purposively selected homeless children and youth (with a mean age of 14 years) from the Central Business District of Accra, Ghana. Thematic analysis was used to analyse the data. Findings showed that a strong religious belief, sense of humour, engagement in meaningful social interactive activities, reciprocal friendship, adherence to cultural norms and support from community-based organizations were identified as factors that help homeless youth cope with the multiple challenges of street life. Strengthening such protective factors could help ameliorate the impact of adverse conditions of these street youth.

Improving mental health services for homeless youth in downtown Montreal, Canada: Partnership between a local network and ACCESS Esprits ouverts (Open Minds), a National Services Transformation Research Initiative

AIM

In many parts of the world, there is growing concern about youth homelessness. Homeless youth are particularly vulnerable to psychological distress, substance use and mental disorders, and premature mortality caused by suicide and drug overdose. However, their access to and use of mental health care is very limited.

METHODS

The Réseau d'intervention de proximité auprès des jeunes (RIPAJ), a Montreal network of over 20 community stakeholders providing a wide array of cohesive services, was created to ease homeless youth's access to mental health and psychosocial services. Its philosophy is that there should be no "wrong door" or "wrong timing" for youth seeking help. In 2014, the network partnered with the pan-Canadian transformational research initiative, ACCESS Esprits ouverts.

RESULTS

Created through this partnership, ACCESS Esprits ouverts RIPAJ has been promoting early identification through outreach activities targeting homeless youth and agencies that serve them. An ACCESS Clinician was hired to promote and rapidly respond to help-seeking and referrals. By strengthening connections within RIPAJ and using system navigation, the site is working to facilitate youth's access to timely appropriate care and eliminate age-based transitions between services. A notable feature of our program, that is not usually evident in homelessness services, has been the engagement of the youth in service planning and design and the encouragement of contact with families and/or friends.

CONCLUSION

Challenges remain including eliminating any remaining age-related transitions of care between adolescent and adult services; and the sustainability of services transformation and network coordination. Nonetheless, this program serves as an example of an innovative, much-needed, community-oriented model for improving access to mental health care for homeless youth.

Cumulative Adversity Profiles Among Youth Experiencing Housing and Parental Care Instability

This study applies cumulative adversity and stress proliferation theories to examine risk and protective resource profiles of youth with three different levels of housing and parental care instability. Data derive from a state representative sample (n=27,087) of school-based adolescent students. ANCOVA analyses identified significant differences in sociodemographic and psychosocial functioning variables for youth with 0, 1, or 2 forms of housing and parental care instability, with more deleterious functioning being observed among youth with greater levels of instability. Those experiencing either or both housing and parental care instability are more represented by males, sexual minorities, and youth of color; psychosocial risk and protective factors demonstrated consistent differences between instability groups. Dimensions of cumulative adversity operate with social marginalities (e.g., race, sexual minority status) relative to instability, with higher frequency of victimization, lower grades, diminished self-regulation capabilities and school engagement, weakened psychological health, and strained family and peer relationships. The paper discusses theorized mechanisms through which cumulative adversity conveys effects as well as implications for social work prevention and resilience-fostering strategies in schools and other youth-serving settings.

Homelessness and incarceration associated with relapse into stimulant and opioid use among youth who are street-involved in Vancouver, Canada

INTRODUCTION AND AIMS

While much research has sought to identify the factors associated with initiation and cessation of various forms of drug use among vulnerable youth, little is known about relapse into drug use in this population. We sought to characterise relapse into stimulant and opioid use among street-involved youth in Vancouver, Canada.

DESIGN AND METHODS

Data were collected between 2005 and 2017 from the At-Risk Youth Study, a prospective cohort study of street-involved youth who use illicit drugs in Vancouver. Multivariable extended Cox regression was utilised to identify factors associated with relapse into illegal stimulants and/or opioids among youth who had previously ceased using stimulants and/or opioids for 6 months or longer.

RESULTS

Among 246 participants who reported a period of cessation lasting 6 months or longer, 165 (67.1%) relapsed at some point during study follow-up. Youth who were recently incarcerated (adjusted hazard ratio [AHR]: 1.46), homeless (AHR: 1.43), or had a history of daily stimulant use (AHR: 1.48) were significantly more likely to report relapse, while youth of who identified as white (AHR: 0.74) were significantly less likely to report relapse (all P < 0.05).

DISCUSSION AND CONCLUSIONS

Relapse into stimulants and/or opioids was common among youth in our setting, and incarceration, homelessness, and daily stimulant use were found to be positively associated with relapse among youth. Findings suggest that increased access to youth housing supports and alternatives to the criminalisation of drug use may help to reduce the rates of relapse into stimulants and/or opioids in this population.

Incarceration history, social network composition, and substance use among homeless youth in Los Angeles

Background: Homeless youth in the United States have high rates of substance use. Existing research has identified social network composition and street-associated stressors as contributing factors. Incarceration is a highly prevalent stressor for homeless youth. Its effect on youth's social network composition and substance use, however, has been neglected. Aims: This study investigated the direct and indirect associations between incarceration history and substance use (through social networks) among homeless youth in Los Angeles, California. Methods: A sample of 1047 homeless youths were recruited between 2011 and 2013. Computerized self-administrated surveys and social network interviews were conducted to collect youth's sociodemographic characteristics, incarceration history, social network composition, and substance use. Bootstrapping was used to identify the direct and indirect associations between youth's incarceration history and substance use. Results: Incarceration history was positively associated with youth's cannabis, methamphetamine, and injection drug use. The percentage of cannabis-using peers partially mediated the associations between incarceration history and youth's cannabis, cocaine, and heroin use. The percentage of methamphetamine-using peers partially mediated the associations between incarceration history and youth's methamphetamine, cocaine, and injection drug use. The percentage of heroin-using peers partially mediated the association between incarceration history and youth's heroin use. Moreover, the percentage of peers who inject drugs partially mediated the associations between incarceration history and youth's methamphetamine, heroin, and injection drug use. Discussion: Incarceration history should be taken to a more central place in future research and practice with homeless youth in the United States.

Enhancing Risk Detection Among Homeless Youth: A Randomized Clinical Trial of a Promising Pilot Intervention

Homeless youth frequently experience victimization, and youth with histories of trauma often fail to detect danger risks, making them vulnerable to subsequent victimization. The current study describes a pilot test of a skills-based intervention designed to improve risk detection among homeless youth through focusing attention to internal, interpersonal, and environmental cues. Youth aged 18 to 21 years ( N = 74) were recruited from a shelter and randomly assigned to receive usual case management services or usual services plus a 3-day manualized risk detection intervention. Pretest and posttest interviews assessed youths' risk detection abilities through vignettes describing risky situations and asking youth to identify risk cues present. Separate 2 (intervention vs. control) × 2 (pretest vs. posttest) mixed ANOVAs found significant interaction effects, as intervention youth significantly improved in overall risk detection compared with control youth. Post hoc subgroup analyses found the intervention had a greater effect for youth without previous experiences of indirect victimization than those with previous indirect victimization experiences.

A comparison of risk factors for various forms of trauma in the lives of lesbian, gay, bisexual and heterosexual homeless youth

Numerous homeless youth experience trauma prior to leaving home and while on the street. Bullying and trading sex (i.e. exchanging sexual favors for survival items such as food) are additional forms of trauma experienced by many homeless youth. Although lesbian, gay, and bisexual (LGB) homeless youth experience higher rates of child abuse compared to their heterosexual counterparts, there is a paucity of research comparing these two groups. As such, we compare whether difficulties finding items of necessity (e.g. food) and different forms of trauma including child sexual abuse, being bullied, trading sex, and street sexual victimization significantly differ for LGB and heterosexual homeless youth. Bivariate results reveal that LGB youth have more trouble finding shelter and are more likely to trade sex compared to heterosexual youth. Logistic regression results show that trading sex is correlated with street sexual victimization. In the second model, we find that being female, experiencing more child sexual abuse, and ever having traded sex are all positively linked with street sexual victimization. LGB youth are over-represented among homeless youth populations and are also more likely to trade sex; therefore, these young people need services that are widely accessible and specific to their needs.

Internet and Social Media Access Among Youth Experiencing Homelessness: Mixed-Methods Study

Background

Youth experiencing homelessness are at a risk for a variety of adverse outcomes. Given the widespread use of the internet and social media, these new technologies may be used to address their needs and for outreach purposes. However, little is known about how this group uses these resources.

Objective

This study investigated how homeless adolescents use these technologies for general and health-related purposes, whether the scope of their use changes with housing status, and their interest in a website dedicated to youth experiencing homelessness.

Methods

A convenience sample of youth aged 18 to 21 years was recruited from a youth-specific homeless shelter. All participants completed a 47-item survey, with 10 individuals completing a semistructured interview. Descriptive statistics, exact testing, logistic regression, and generalized estimating equation modeling was performed for quantitative data analysis. Interviews were transcribed verbatim, and NVivo 10 (QSR International) was employed to facilitate double coding and thematic analysis.

Results

A total of 87 participants completed the survey with a mean age of 19.4 (SD 1.1) years. While experiencing homelessness, 56% (49/87) accessed the internet at least once a day, with 86% (75/87) accessing once a week. Access to a smartphone was associated with a 3.03 greater odds of accessing the internet and was the most frequently used device (66% of participants, 57/87). While experiencing homelessness, subjects reported a 68% decreased odds in internet access frequency (odds ratio [OR] 0.32, P<.001), 75% decreased odds in spending greater amounts of time on the internet (OR 0.25, P<.001), and an 87% decreased odds of social media use (OR 0.13, P=.01). Ten participants completed the semistructured interview. Several themes were identified, including (1) changes in internet behaviors while experiencing homelessness, (2) health status as a major concern and reason for Internet use, and (3) interest in a website dedicated to youth experiencing homelessness. While experiencing homelessness, participants indicated their behaviors were more goal-oriented and less focused on leisure or entertainment activities.

Conclusions

While homeless youth experience changes in the frequency, amount of time, and specific uses of the internet and social media, study participants were able to access the internet regularly. The internet was used to search health-related topics. Given the importance of smartphones in accessing the internet, mobile-optimized websites may be an effective method for reaching this group.

Do Programs for Runaway and Homeless Youth Work? A Qualitative Exploration From the Perspectives of Youth Clients in Diverse Settings

Runaway and homeless youth (RHY) comprise a large population of young people who reside outside the control and protection of parents and guardians and who experience numerous traumas and risk factors, but few buffering resources. Specialized settings have developed to serve RHY, but little is known about their effects. The present cross-sectional qualitative descriptive study, grounded in the positive youth development approach and the Youth Program Quality Assessment model, addressed this gap in the literature. From a larger sample of 29 RHY-specific settings across New York State, RHY ages 16–21 from 11 settings were purposively sampled for semi-structured in-depth interviews on their transitions into homelessness, experiences with settings, and unmet needs (N = 37 RHY). Data were analyzed with a theory-driven and inductive systematic content analysis approach. Half of participants (54%) were female; almost half (49%) identified as non-heterosexual; and 42% were African American/Black, 31% were Latino/Hispanic, and 28% were White/other. Results indicated that because RHY are a uniquely challenged population, distrustful of service settings and professional adults and skilled at surviving independently, the population-tailored approaches found in RHY-specific settings are vital to settings’ abilities to effectively engage and serve RHY. We found the following four major themes regarding the positive effects of settings: (1) engaging with an RHY setting was emotionally challenging and frightening, and thus the experiences of safety and services tailored to RHY needs were critical; (2) instrumental support from staff was vital and most effective when received in a context of emotional support; (3) RHY were skilled at survival on the streets, but benefited from socialization into more traditional systems to foster future independent living; and (4) follow-through and aftercare were needed as RHY transitioned out of services. With respect to gaps in settings, RHY highlighted the following: (1) a desire for better management of tension between youths’ needs for structure and wishes for autonomy and (2) lack of RHY input into program governance. This study advances our understanding of RHY, their service needs, and the ways settings meet these needs, as well as remaining gaps. It underscores the vital, life-changing, and even life-saving role these settings play for RHY.

Predicting Sexual Behaviors Among Homeless Young Adults: Ecological Momentary Assessment Study

BACKGROUND

Homeless youth continue to be disproportionately affected by HIV compared with their housed peers, with prevalence rates as high as 13%. Yet, HIV prevention in this high-risk population has been only marginally effective.

OBJECTIVE

The aim of this study was to use ecological momentary assessments to examine real-time factors to determine the predictors of sexual activity among homeless youth.

METHODS

Youth experiencing homelessness aged between 18 and 24 years were recruited from a drop-in center in Houston, Texas, between August 2015 and May 2016. All the participants received a study-issued mobile phone that prompted brief ecological momentary assessments (EMAs) 5 times a day for 21 days. EMA items assessed near real-time sexual behaviors, cognitions, stress, affect, environmental factors, and environmental circumstances.

RESULTS

Participants (N=66) were predominantly male (41/66, 64%) and black (43/66, 66%) with a median age of 20 years. The mean number of EMAs completed by each participant was 45 out of 105 possible observations. During the study, 70% (46/66) of participants were sexually active and reported condomless sex in 102 of the 137 cases of sexual intercourse (74.5%). In total, 82% (38/46) of the youth who reported having sex during the 3 weeks of data collection also reported engaging in high-risk sexual activities, including having condomless sex (24/46, 53%), having multiple sexual partners on the same day (12/46, 26%), trading sex (7/46, 16%), and sharing needles while injecting drugs (1/46, 3%). Of those, 71% (27/38) were engaged in multiple sexual risk behaviors. The predictive model was based on observations from 66 subjects who reported 137 cases of sexual intercourse over 811 days; sexual orientation, race, mental health, drug use, and sexual urge were included as predictors in the parsimonious generalized linear mixed model selected on the basis of the Akaike information criterion. The estimated odds ratios (ORs) were notable for same-day drug use (OR 2.17, 95% CI 4.48-17.31; P<.001) and sexual urge (OR 1.44, 95% CI 1.60-11.28; P=.004). The performance of the risk estimator was satisfactory, as indicated by the value of 0.834 for the area under the receiver operating characteristic curve.

CONCLUSIONS

Real-time EMA data can be used to predict sexual intercourse among a sample of high-risk, predominately unsheltered homeless youth. Sexual urge and drug use accounts for increased odds of engaging in sexual activity on any given day. Interventions targeting sexual urge and drug use may help predict sexual activity among a population at high risk of HIV.

Employment Outcomes From a Randomized Controlled Trial of Two Employment Interventions With Homeless Youth

OBJECTIVE

Limited research exists on how employment interventions contribute to employment outcomes for homeless youth. This study examines the comparative efficacy of 2 interventions-Social Enterprise Intervention (SEI) and Individual Placement and Support (IPS)-provided to homeless youth with mental illness in a randomized controlled trial.

METHOD

Participants were recruited from 1 homeless youth agency in Los Angeles, CA, and randomized to the SEI (n = 36) or IPS (n = 36) conditions. Over 20 months, SEI participants received 4 SEI components, and IPS participants received IPS services based on 8 principles. Data were collected at baseline and follow-up for the primary employment outcome (paid employment) and 5 secondary employment outcomes.

RESULTS

Over 20 months, 39% of SEI participants and 32% of IPS participants reported any paid employment. Across both groups, participants who reported working at baseline had nearly 8 times the odds of working at follow-up (OR = 7.91, p < 0.05). No statistically significant differences were detected across the full sample or between groups on the primary or secondary employment outcomes.

CONCLUSIONS

Future effectiveness research is needed to compare the long-term employment outcomes of the SEI and IPS with a more heterogeneous sample of homeless youth using customized homelessness support services and more nuanced employment outcomes.

Understanding the Link between Victimization and Alcohol Use among Homeless Youth Using Ecological Momentary Assessment

Most prior research on victimization and alcohol use among homeless youth is retrospective and thus does not allow researchers to determine the sequencing of these events. We address this gap using ecological momentary assessment via short message service surveying with homeless youth during 30 days. Multilevel binary logistic regression results revealed that experiencing physical or sexual victimization on a specific day was positively associated with youth's drinking alcohol later that day. Because ecological momentary assessment via short message service allows for such specificity, we can link a specific victimization experience with a current drinking episode. Thus, the time ordering of daily events in the current study is a significant improvement over prior research. Understanding the timing between victimization and drinking alcohol is also important for intervention with this underserved population.

Drug use patterns and predictors among homeless youth: Results of an ecological momentary assessment

BACKGROUND

Alcohol and drug use is associated with significant morbidity and mortality and is highly prevalent among homeless youth. Ecological Momentary Assessments (EMA) have been used to examine the effect of urges on drug use, though not among homeless youth.

OBJECTIVES

We assessed the patterns of drug use and the correlation between real-time contextual factors and drug use using EMA collected daily. We identified predictors of drug use among a sample of homeless youth 18-25 years old in Houston, Texas.

METHODS

Homeless youth (n = 66, 62% male) were recruited from a drop-in center between September 2015 and May 2016. We used generalized linear mixed models and cross-validation methods to determine the best predictive model of drug use.

RESULTS

The overall drug use was high: 61% and 32% of participants reported using drugs or alcohol at least one day, respectively. Marijuana and synthetic marijuana use (i.e., Kush, K2, incense packs) were reported most frequently; 86% and 13% of the total drug use EMAs, respectfully. Drug use urge was reported on 26% of days and was the highest on drug use days. Drug use was predicted by discrimination, pornography use, alcohol use, and urges for drugs, alcohol, and to steal.

CONCLUSIONS

EMA can be used to predict drug use among homeless youth. Drug use treatment among homeless youth should address the role of experiencing discrimination, pornography and alcohol use, and urge management strategies on drug use. Research is needed to determine if EMA informed just-in-time interventions targeting these predictors can reduce use.

Health status of marginalised young people in unstable accommodation

AIM

More than 26 000 Australians aged 12-24 years experience homelessness, yet data on the health status of homeless youth remain limited. The aim of this study was to describe the health of young people attending a youth health service in Western Sydney who were experiencing homelessness.

METHODS

Retrospective case note review for clients aged 12-25 years attending Youth Health Services in Western Sydney. Extracted data included: homelessness status; demographics; physical health issues; mental health issues; involvement with juvenile justice; and disengagement from education or employment.

RESULTS

Just under half of the 180 clients attending a Youth Health Service in Western Sydney were homeless, and an additional 15 young people who were not currently homeless nominated homelessness as a presenting issue. In comparison with currently domiciled young people, homeless youth were less likely to have a regular general practitioner and more likely to nominate a physical health concern as a presenting issue, although there was no difference between groups in terms of diagnosed mental or physical health conditions. Considered as a whole, the sample showed high rates of acute physical symptoms, physical trauma, psychological distress and self-harm.

CONCLUSIONS

Youth homelessness is associated with risk of both poor physical and mental health. As much of youth homelessness is hidden, health-care providers need to ensure that they inquire about homelessness status, and have an awareness of potentially complex multi-morbidities in the physical and mental health of young marginalised people presenting to health services.

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.

Impact of a Supportive Housing Program on Housing Stability and Sexually Transmitted Infections Among Young Adults in New York City Who Were Aging Out of Foster Care

Former foster youth are at increased risk of housing instability and sexually transmitted infections (STIs) during the transitional period following foster care. We measured housing stability using sequence analysis and assessed whether a supportive housing program in New York, New York, was effective in improving housing stability and reducing STIs among former foster youth. Matched administrative records identified 895 former foster youth who were eligible for the housing program during 2007-2010. The main outcomes included housing stability (as determined from episodes of homelessness, incarceration, hospitalization, and residence in supportive housing) and diagnosed STI case rates per 1,000 person-years during the 2 years after baseline. Marginal structural models were used to assess impacts of the program on these outcomes. Three housing stability patterns (unstable housing, stable housing, and rare institutional dwelling patterns) were identified. The housing program was positively associated with a pattern of stable housing (odds ratio = 4.4, 95% confidence interval: 2.9, 6.8), and negatively associated with diagnosed STI rates (relative risk = 0.3, 95% confidence interval: 0.2, 0.7). These positive impacts on housing stability and STIs highlight the importance of the supportive housing program for youths aging out of foster care and the need for such programs to continue.

Can Better Emotion Regulation Protect against Suicidality in Traumatized Homeless Youth?

A substantial majority of homeless youth and young adults (HYA) experience abuse prior to and during homelessness. HYA also have high rates of posttraumatic stress disorder (PTSD) and suicidal behavior. This study investigated relationships between traumatic experiences, PTSD symptoms, substance use, and the protective effects of emotion regulation on outcome variables suicidal ideation and suicide attempts. Data were drawn from a sample of 398 HYA interviewed at 3 drop-in centers in Los Angeles County. A bivariate logistic regression modeling strategy was employed to examine relationships among demographic characteristics and dependent and independent variables. Trauma prior to homelessness and trauma prior to and after homelessness were positively associated with suicidal ideation, whereas emotional awareness and control demonstrated negative associations. PTSD symptoms were positively associated with suicide attempts, whereas emotional awareness and control demonstrated negative associations. Better emotion regulation is associated with reduced odds of suicidal ideation and attempts in HYA and may protect against effects of traumatic experiences. Interventions targeting emotion regulation skills in HYA to reduce suicidality associated with traumatic experiences merit additional investigation.

The 2015 National Canadian Homeless Youth Survey: Mental Health and Addiction Findings

OBJECTIVE

This study was designed to provide a representative description of the mental health of youth accessing homelessness services in Canada. It is the most extensive survey in this area to date and is intended to inform the development of mental health and addiction service and policy for this marginalized population.

METHODS

This study reports mental health-related data from the 2015 "Leaving Home" national youth homelessness survey, which was administered through 57 agencies serving homeless youth in 42 communities across the country. This self-reported, point-in-time survey assessed a broad range of demographic information, pre-homelessness and homelessness variables, and mental health indicators.

RESULTS

Survey data were obtained from 1103 youth accessing Canadian homelessness services in the Nunavut territory and all Canadian provinces except for Prince Edward Island. Forty-two per cent of participants reported 1 or more suicide attempts, 85.4% fell in a high range of psychological distress, and key indicators of risk included an earlier age of the first episode of homelessness, female gender, and identifying as a sexual and/or gender minority (lesbian, gay, bisexual, transgender, queer, and 2 spirit [LGBTQ2S]).

CONCLUSIONS

This study provides clear and compelling evidence of a need for mental health support for these youth, particularly LGBTQ2S youth and female youth. The mental health concerns observed here, however, must be considered in the light of the tremendous adversity in all social determinants faced by these youth, with population-level interventions best leveraged in prevention and rapid response.

Bidirectional Intimate Partner Violence and Drug Use Among Homeless Youth

Intimate partner violence (IPV) among homeless youth (HY) is common, yet it has continuously been understudied, especially in relation to substance use. As part of a longitudinal study of Los Angeles area HY, drop-in service seeking youth completed a self-administered questionnaire. The presented results are from the third panel of data collection ( N = 238), and the Revised Conflict Tactics Scale (CTS2) was used to assess IPV behavior regarding the participant's most recent intimate relationship. Approximately 38% of participants reported IPV behavior in their most recent relationship, and the majority of this behavior was bidirectional. It was unlikely that a HY was only a victim or only a perpetrator. Multivariable models revealed that bidirectional IPV was related to increased odds of recent methamphetamine; whereas sole perpetration was associated with an increased likelihood of ecstasy use. Specific substance use and IPV are closely related to risk behaviors for HY. Comprehensive interventions should be developed to address both these risk behaviors.