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

Predicting Intimate Partner Violence Perpetration Among Young Adults Experiencing Homelessness in Seven U.S. Cities Using Interpretable Machine Learning

Young adults experiencing homelessness (YAEH) are at higher risk for intimate partner violence (IPV) victimization than their housed peers. This is often due to their increased vulnerability to abuse and victimization before and during homelessness, which can result in a cycle of violence in which YAEH also perpetrates IPV. Identifying and addressing factors contributing to IPV perpetration at an early stage can reduce the risk of IPV. Yet to date, research examining YAEH's IPV perpetration is scarce and has largely employed conventional statistical approaches that are limited in modeling this complex phenomenon. To address these gaps, this study used an interpretable machine learning approach to answer the research question: What are the most salient predictors of IPV perpetration among a large sample of YAEH in seven U.S. cities? Participants (N = 1,426) on average were 21 years old (SD = 2.09) and were largely cisgender males (59%) and racially/ethnically diverse (81% were from historically excluded racial/ethnic groups; i.e., African American, Latino/a, American Indian, Asian or Pacific Islander, and mixed race/ethnicity). Over one-quarter (26%) reported IPV victimization, and 20% reported IPV perpetration while homeless. Experiencing IPV victimization while homeless was the most important factor in predicting IPV perpetration. An additional 11 predictors (e.g., faced frequent discrimination) were positively associated with IPV perpetration, whereas 8 predictors (e.g., reported higher scores of mindfulness) were negatively associated. These findings underscore the importance of developing and implementing effective interventions with YAEH that can prevent IPV, particularly those that recognize the positive association between victimization and perpetration experiences.

Differences in Mental Health Between Female Sexual Minority and Heterosexual Youth with a Substance Use Disorder Who Are Experiencing Homelessness

Purpose: The purpose of this study was to examine differences in mental health outcomes of two groups within youth experiencing homelessness (YEH) and who have a substance use disorder (SUD): sexual minority (SM) and heterosexual females. Methods: This study used baseline data from four randomized clinical trials of substance use interventions for YEH with a SUD to examine differences in depression and suicidality between SM and heterosexual female youth. Participants were between 12 and 24 years of age. Meta-analytic methods were used to aggregate data across studies to estimate differences in mental health. Results: Results indicated that female SM-YEH had higher depression symptoms (Hedge's g [g]=0.20; 95% confidence interval [CI] 0.01-0.39), higher risk of a history of suicide behavior (risk ratio = 1.63; 95% CI: 1.17-2.27), and a greater number of suicide behaviors (g = 0.31; 95% CI: 0.09-0.54) compared to their heterosexual peers. These effect sizes were not moderated by age. Conclusion: Female SM-YEH had elevated levels of depression and suicidality compared to their heterosexual peers. The findings of this study align with research on mental health disparities between SM and heterosexual youth generally, which underscores the unique struggles and risks associated with identifying as a female SM-YEH with a SUD.

Mechanistic modeling of social conditions in disease-prediction simulations via copulas and probabilistic graphical models: HIV case study

As social and economic conditions are key determinants of HIV, the United States 'National HIV/AIDS Strategy (NHAS)', in addition to care and treatment, aims to address mental health, unemployment, food insecurity, and housing instability, as part of its strategic plan for the 'Ending the HIV Epidemic' initiative. Although mechanistic models of HIV play a key role in evaluating intervention strategies, social conditions are typically not part of the modeling framework. Challenges include the unavailability of coherent statistical data for social conditions and behaviors. We developed a method, combining undirected graphical modeling with copula methods, to integrate disparate data sources, to estimate joint probability distributions for social conditions and behaviors. We incorporated these in a national-level network model, Progression and Transmission of HIV (PATH 4.0), to simulate behaviors as functions of social conditions and HIV transmissions as a function of behaviors. As a demonstration for the potential applications of such a model, we conducted two hypothetical what-if intervention analyses to estimate the impact of an ideal 100% efficacious intervention strategy. The first analysis modeled care behavior (using viral suppression as proxy) as a function of depression, neighborhood, housing, poverty, education, insurance, and employment status. The second modeled sexual behaviors (number of partners and condom-use) as functions of employment, housing, poverty, and education status, among persons who exchange sex. HIV transmissions and disease progression were then simulated as functions of behaviors to estimate incidence reductions. Social determinants are key drivers of many infectious and non-infectious diseases. Our work enables the development of decision support tools to holistically evaluate the syndemics of health and social inequity.

School Suspension as a Predictor of Young Adult Homelessness: The International Youth Development Study

School suspension in adolescence has been shown to predict homelessness in young adulthood, suggesting that it may be a point of intervention to reduce young adult homelessness. Under zero tolerance policies, school suspension is more common in the United States relative to Australia. Multilevel modeling of cross-national longitudinal data from the International Youth Development Study tested prospective associations between adolescent problem behaviors, student-perceived likelihood of suspension/expulsion, school-level behavior management policy, and young adult homelessness. Population-based samples of participants from Washington State (United States) and Victoria (Australia) were surveyed at ages 13, 14, 15 (2002-2004), and 25 years (2014-15; n = 1945; 51% female). Over half of the young adults who reported homelessness within the previous year at age 25 had experienced school suspension. Individual-level school suspension in middle school predicted young adult homelessness. Higher levels of adolescent rebelliousness, non-violent and violent antisocial behavior, and substance use predicted a higher likelihood of school suspension at the person-level and were indirectly related to increased risk for homelessness at age 25. School behavior management policy was not related to a history of school suspension at either the person- or school-level once individual factors were controlled. Findings demonstrate the importance of school suspension as a risk factor for future homelessness and suggest that prevention programming that aims to mitigate substance use, antisocial behaviors, and school suspension may help to reduce young adult homelessness.

Youth experiencing homelessness at risk for suicide: psychosocial risk factors and service use patterns

OBJECTIVE

Young adults experiencing homelessness often suffer from adverse mental health outcomes and suicide is a leading cause of death. The objective of this study is to examine service use and psychosocial risk factors for suicide, in relation to suicide risk assessment, to inform strategies for engaging youth in suicide prevention services.

METHODS

A cross-sectional analysis of youth enrolled in a supportive housing randomized clinical trial. We categorized suicide risk into three groups (low-, moderate-, and high-risk) based on suicidal ideation and past-year suicide attempt. The service use patterns across these groups are described, as well as other psychosocial risk factors (psychiatric comorbidity, depressive symptoms, substance use, and sleep impairment).

RESULTS

Among 193 enrolled youth, 126 (65.3%), 32 (16.6%), and 35 (18.1%) were categorized as low-risk, moderate-risk, and high-risk for suicide, respectively. A high proportion of youth reported ever having been diagnosed with a psychiatric disorder (57.5%) and cannabis was the most heavily used substance. However, only a minority of youth received medical care or mental health services in the past 3 months, 40% and 34%, respectively. Even fewer youth received mental/emotional health services in the past 3 months (15%), though use was highest among the high-risk group (34%).

CONCLUSION

Understanding the needs of youth experiencing homelessness who are at risk for suicide is critical to developing interventions to alleviate their risk for suicide. Given that the use of medical and mental health care is low among this population, more active outreach strategies may be warranted to deliver prevention interventions.

Results of a Randomized Wait-List Controlled Trial of CAYA: A Nurse Case Management HIV Prevention Intervention for Youth Experiencing Homelessness

Youth experiencing homelessness (YEH) face challenges that increase their susceptibility to HIV/STIs. Nurse case management is effective in managing the complex needs of populations experiencing homelessness and reducing HIV risk. A randomized wait-list control study conducted between September 2019 to May 2023 evaluated the CAYA "Come As You Are" intervention. This nurse-led HIV prevention for YEH aged 16-25 years focused on the uptake of HIV prevention methods: pre- and post-HIV exposure prophylaxis (PrEP, nPEP), HIV/STI testing and treatment, sober sex, and condom use. Secondarily, we examined intervention impact on housing stability. Descriptive statistics were calculated by study arm. Multiple imputation (m = 10) was used for missing values and intervention effects were estimated from Bayesian multilevel models with noninformative priors. Participants (N = 450) were 21.1 years old on average, 62% Black, 11% Hispanic, 11% White, and 10% other race and reported being homeless for an average of 3 years. An intervention effect was found for PrEP use, which showed a larger increase from baseline to first follow-up (OR = 3.27; 95% Cr.I.: 1.13 to 10.14). No intervention impact was found for nPEP use, HIV and STI cases, sober sex, or condom use. Sheltering arrangements improved from baseline to the first follow-up in both groups with increase in shelter stability (OR = 3.85; 95% Cr.I.: 1.61 to 10.30) and decreased shelter transiency (OR = 0.29; 95% Cr.I.: 0.14 to 0.60). This study demonstrates that a personalized, nurse-led HIV prevention approach increased uptake of some but not all HIV prevention strategies among YEH. CLINICAL TRIAL REGISTRATION NUMBER: NCT03910218.

Associations of Homelessness With Primary Care and Acute Care Utilization Among Medicaid-Enrolled Youth

BACKGROUND

Youth comprise one-third of the US homeless population. However, little is known about how homelessness affects health care utilization.

OBJECTIVE

Examine associations of homelessness with hospitalization, primary care, and ED visits, varying by race/ethnicity, among Medicaid-enrolled youth.

RESEARCH DESIGN

A cross-sectional analysis was conducted using California Medicaid claims data on youth beneficiaries with complex needs. We examined the number of hospitalizations, preventable and nonpreventable ED, and primary care visits using a multivariate regression. We further explored the differential associations by race/ethnicity.

RESULTS

Approximately 17% of our sampled youth experienced homelessness in 2018 (N=90,202). Compared with their housed counterparts, youth experiencing homelessness had a 1.9 percentage point (pp) higher likelihood of frequent ED visits (95% CI: 1.7-2.2) but a 2.9 pp lower probability of any primary care visits (95% CI: -3.9 to -1.9). Homelessness was associated with 221 more ED visits (95% CI: 182-260), 100 more preventable ED visits (95% CI: 84-116), 19.9 more hospitalizations (95% CI: 12-27), but 56 fewer primary care visits (95% CI: -104 to -7), per 1000 youth. The associations of homelessness with total ED visits, preventable ED visits, and needed and nonpreventable ED visits were all higher among Whites and, particularly, Blacks than for Hispanics and Asians.

CONCLUSIONS

Medicaid-enrolled youth who experienced homelessness had more overall ED, preventable ED, and hospital visits, but fewer primary care visits than their housed peers. Our results suggest promoting primary care use should be considered among strategies to improve health and reduce costs.

Keeping young researchers out of harm's way: conducting youth participatory action research with young people experiencing homelessness

Introduction

Youth Participatory Action Research (YPAR) is an approach to conducting research with youth populations in order to effectively engage youth in research that impacts their lives. Young people experiencing homelessness (YEH) are vulnerable to power and social environments in ways that call attention to their experiences in research.

Methods

The context for this paper was a qualitative YPAR project to incorporate youth voice into the operations of a larger research study that hired youth as researchers. Participant-researchers provided feedback and consultation with senior staff in order to improve their access to resources, safety, and stability.

Results

Themes that emerged from thematic analysis of reflections, discussions, and meetings showed the need for consistent access to food, the risk of environmental violence targeting youth researchers, the structural and experiential barriers to professional engagement, and the benefits that young researchers experienced as part of their work in the study.

Discussion

Recommendations and lessons learned are described, notably to ensure that youth are paid and provided food, to construct effective safety plans during fieldwork, and to provide a flexible, inclusive, trauma-responsive approach to supervision of project tasks.

Understanding Homelessness Among Young People to Improve Outcomes

In the United States, an estimated 4.2 million young people experience homelessness during critical stages in their development-adolescence and emerging adulthood. While research on youth homelessness often emphasizes risk and vulnerability, the field must situate these issues within the developmental trajectories of adolescence and emerging adulthood to effectively prevent and end youth homelessness. This review uses the Risk Amplification and Abatement Model (RAAM) as a conceptual framework for contextualizing the landscape of youth homelessness research in the United States since 2010. An extension of ecological models of risk-taking, RAAM emphasizes both risk and resilience, positing that negative as well as positive socialization processes across interactions with family, peers, social services, and formal institutions affect key housing, health, and behavioral outcomes for youth experiencing homelessness. This review applies RAAM to our understanding of the causes and consequences of youth homelessness, recent interventions, and recommendations for future directions.

Making a Bad Situation Worse: Current and Potential Unintended Consequences of Juvenile Registration for Sexual Offences

Within the US, children and adolescents who engage in sexually abusive behavior are often subjected to sex offender registration and notification requirements, which contribute to stigmatization and forfeiture of their civil rights without empirical basis (Lancaster, 2011; Pickett et al., 2023; Zilney & Zilney, 2009). To date, 39 states subject children with adjudicated sexual offenses to sex offender registration requirements, with most recent estimates revealing that approximately 200,000 youth have been placed on sex offender registries within the US and many are now on the registry as adults (Pickett et al., 2020). This severe response-by both members of the public and policymakers-toward children who engage in inappropriate sexual behavior is imposed upon children and adolescents with adjudicated sexual offenses in an effort to meet goals of reducing sexual violence and increasing community safety. Within the current discourse, we review the history of registration and notification practices for adolescents with sexual offenses, describe what registration and notification policies entail, and then present empirical and theoretical evidence of the harmful outcomes associated with implementation of registration and notification requirements for sexual offenses. Thus, the predominant aim of this discourse is to encourage thoughtful and critical examination of registration and notification policies and their iatrogenic impacts.

Prevalence of youth experiencing homelessness and its association with suicidal thoughts and behaviors: Findings from a population-based study

Although various studies have examined factors associated with suicidal behaviors among youth, few studies have investigated the association between youth experiencing homelessness (YEH) and suicidal thoughts and behaviors (STBs) using a large nationally representative sample. The objectives of this study were to investigate prevalence of YEH and its association with STBs. Data for this study came from the 2021 Youth Risk Behavior Survey. An analytic sample of 17,033 youth aged 14-18 (51.7 % male) was analyzed using binary logistic regression. Of the 17,033 youth examined, 3 % experienced homelessness during the past 30 days, 21.3 % experienced suicidal ideation, 17.3 % made a suicide plan, and 10.9 % attempted suicide during the past 12 months. Controlling for demographic characteristics and feeling sad or hopeless, YEH was associated with 2.48 times higher odds of experiencing suicidal ideation (AOR=2.48, p<.001), 2.46 times higher odds of making a suicide plan (AOR=2.46, p<.001), and 4.38 times higher odds of making a suicide attempt (AOR=4.38, p<.001). The findings of this study highlight the importance of identifying youth who are at risk of experiencing homelessness to ensure early interventions are put in place to prevent suicidal behaviors.

Suicide prevention for substance using youth experiencing homelessness: study protocol for a randomized controlled trial

BACKGROUND

While research on substance using youth experiencing homelessness (YEH) is increasing, there is a dearth of information regarding effective prevention interventions for these youth. Suicide is the leading cause of death among YEH and most youth do not access services that may be available to them. Therefore, this study seeks to address this gap in the research literature with the goal to identify an effective suicide prevention intervention that can be readily adopted by communities that serve these youth.

METHODS

Three hundred (N = 300) YEH with recent substance use and suicidal ideation or a recent suicide attempt will be recruited from the streets as well as a drop-in center serving YEH. After the baseline assessment, all youth will be randomly assigned to Cognitive Therapy for Suicide Prevention (CTSP) + Services as Usual (SAU) (N = 150) or to SAU alone (N = 150). SAU includes outreach, advocacy, and service linkage whereas YEH who receive CTSP will also receive ten CTSP sessions and an optional nine booster sessions. Follow-up assessments will be conducted at 3, 6, 9, and 12 months post-baseline. Theoretically derived mediators (e.g., cognitive distortions) will be tested to shed light on mechanisms associated with change, and the moderating effects of sex, race, sexual orientation, and baseline service connection will be examined. In order to ease future dissemination of the intervention to agencies serving YEH, we will rigorously assess acceptability, feasibility, fidelity, and cost associated with the delivery of our intervention approach using a mixed-methods approach.

DISCUSSION

This study adds to a very small number of clinical trials seeking to prevent lethal suicide among a very high-risk group by addressing suicidal ideation directly rather than underlying conditions. It is hypothesized that youth receiving CTSP + SAU will show greater reductions in suicidal ideation (primary outcome), substance use, and depressive symptoms (secondary outcomes) over time compared to SAU alone, as well as improved risk and protective factors.

TRIAL REGISTRATION

NCT05994612. Date of Registration: August 16, 2023.

The influence of sexual violence on suicide risk among runaway youth in South Korea: The multiple additive moderating effect of peer attachment and parental attachment

BACKGROUND

Runaway youth without an adequate and safe place are vulnerable to sexual violence. Sexual violence is strongly associated with suicide risk, but peers and family are important factors in attenuating the negative outcomes of sexual violence; however, research on this relationship is insufficient because previous studies have focused only on runaway youth's problematic behavior.

OBJECTIVE

This study's specific aims were as follows: 1) to verify the association between sexual violence and suicide risk among runaway youth, and 2) to assess whether peer and parental attachment moderated the association between sexual violence and suicide risk among runaway youth.

PARTICIPANTS AND SETTING

The participants comprised 232 runaway youth (51.3 % girls); more than half were aged 17-19 years and approximately two-thirds of them had experienced child abuse.

METHODS

Self-administered questionnaires were provided to the participating runaway youth in youth shelters in South Korea. The data were analyzed using a multiple additive moderating model that simultaneously included moderating and control variables.

RESULTS

In total, 18.5 % of runaway youth were exposed to sexual violence (10.6 % boys, 26.1 % girls). Sexual violence victimization affected suicide risk among runaway youth. Peer attachment alleviated the negative relationship between sexual violence and suicide risk, and acted as a protective factor. Although the moderating effect of parental attachment was not significant, it significantly influenced suicide risk.

CONCLUSION

Our findings demonstrate that runaway youth are vulnerable to sexual violence victimization, especially severe types of sexual violence. Our study verified the role of peer and parental attachment in the association between sexual violence and suicide risk among runaway youth. These findings suggest the need to improve positive peer and parent relationships to mitigate suicide risk among runaway youth.

Substance use typologies among young people experiencing homelessness in seven cities across the United States: A latent class analysis

BACKGROUND

Substance use and other health-risk risk factors, including mental health, trauma, and sexual-risk behaviors, often co-occur among youth experiencing homelessness (YEH). The present study aimed to identify subgroups of YEH based on polysubstance use and the linkages to sociodemographic and health-risk characteristics.

METHODS

From June 2016 to July 2017, 1,426 YEH (aged 18-26 years) were recruited from seven cities (Houston, Los Angeles, Denver, Phoenix, New York City, St. Louis, San Jose). Participants provided information via a self-administered electronic survey on substance use, mental health, trauma, sexual risk behaviors, and sociodemographic characteristics. The majority of YEH identified as Black (37.3%), cisgender (92.8%), and heterosexual (69.2%). On average, YEH were 20.9 years (SD = 2.1). This study employed latent class analysis (LCA) to identify subgroups of YEH according to their substance use. Multinomial logistic regression analyses were conducted to identify sociodemographic and health-risk characteristics associated with class-membership.

RESULTS

Four latent classes of YEH substance use were identified: (1) high polysubstance use; (2) moderate stimulant and high marijuana, alcohol, and prescription drug use; (3) high marijuana, alcohol, and prescription drug use; (4) low/moderate marijuana and alcohol use. Multinomial logistic regression models indicated that geographic location, gender, race/ethnicity, mental health, trauma history, and sexual risk behaviors were significant correlates of substance use class membership among YEH.

CONCLUSIONS

These findings offer important implications for the prevention and treatment of substance use among YEH. Screening protocols should consider co-occurring risk factors such as traumatic experiences, sexual risk behaviors, and mental health history as indicators of polysubstance use.

Sleep and mental health among youth experiencing homelessness: A retrospective pilot diary study

OBJECTIVES

The goal of this study was to describe the nightly sleep conditions of youth experiencing homelessness, and examine the association between sleep and mental health, both cross-sectionally and using diary data.

METHODS

n = 147 youth (ages 16-24) experiencing homelessness completed a baseline survey assessing self-reported sleep and depressive and anxious symptoms. A subsample of n = 49 completed a follow-up 7-day diary study measuring nightly sleep conditions and daily depressive and somatic symptoms.

RESULTS

According to baseline data, the majority of the sample (71%) reported sleeping less than 7 hours per night on average, and feeling like they did not get adequate sleep, especially among youth identifying as LGBTQ. In a qualitative follow-up question, the plurality attributed poor sleep to mental health woes. Cross-sectionally, youth with lower levels of self-reported sleep quality (more daytime fatigue and insomnia) reported higher levels of depressive and anxious symptoms. The diary data indicated that the most common nightly complaints among shelter utilizers are lack of privacy, noise, and uncomfortable temperatures. Multilevel models suggest that poor sleep conditions predicted higher levels of somatic symptoms the following day, after controlling for baseline levels of depressive and anxious symptoms.

CONCLUSIONS

This study highlights the role environmental context plays in sleep health and its subsequent impacts. Individuals experiencing homelessness lack autonomy over their sleeping environments, and thus cannot make adjustments such as reducing disruptions such as noise, temperature, and light. Importantly, these less-than-ideal sleeping conditions contribute to pre-existing health disparities and may have long-term implications.

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

ABSTRACT

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

Predictors of Housing Trajectories Among Young Adults Experiencing Homelessness in Los Angeles

Experiencing homelessness during young adulthood is associated with negative health outcomes and understanding housing trajectories of young adults experiencing homelessness may aid in the development of evidence-based public health programs designed to serve this at-risk age group. In the present study, the authors examined baseline predictors of 24-month trajectories of housing stability and unsheltered housing among a sample of 271 young adults aged 18 to 25 recruited from drop-in centers in Los Angeles. In multivariate models, the authors found that identifying as multi-racial/other and better friendship quality at baseline were associated with less steep increases in the likelihood of stable housing over time. Being employed at baseline was associated with a less steep decrease in the probability of being unsheltered over time, while illicit drug use days associated with a steeper decrease in the probability of being unsheltered over time. Continued research is needed to establish important factors determining young adults' long-term housing trajectories in the effort to promote greater access and engagement with housing services.

Associations between service use and behavioral health trajectories among young adults experiencing homelessness

Purpose

To examine associations of service use (housing, mental health, substance use, education, and employment) with depression and substance use disorder (SUD) trajectories among young adults experiencing homelessness.

Method

Secondary data come from 276 young adults who participated in an intervention to reduce substance use and sexual risk behaviors. Participants were recruited from three drop-in centers in Los Angeles County from 2018 to 2020, and completed surveys at baseline, 3-, 6-, 12-, and 24-months post-baseline. Latent growth curve models examined trajectories of depression and SUD; service use in the past three months was used to predict growth trajectories.

Results

More frequent use of mental health services (but not other services) at baseline was associated with greater depression symptoms at baseline, linear declines in depression, and a quadratic increase in depression. Service use at baseline was not associated with likelihood of SUD at baseline or changes in SUD over time.

Conclusions

Young adults in most need of behavioral services are likely to receive services for mental health, but not SUD. Use of mental health services may reduce depression symptoms over time, but continuing care may be needed to prevent symptom returns. More work is needed to connect young adults with SUD treatment and improve effectiveness of these services.

Evaluating the Aspects of Quality of Life in Individuals with Substance Use Disorder: A Systematic Review Based on the WHOQOL Questionnaire

Substance Use Disorder (SUD) has become a significant public health concern and it profoundly impacts an individual's quality of life (QOL). This systematic review aimed to assess the QOL among patients with SUD, and to understand the differential impact of SUD on physical, mental, social, and environmental QOL domains, considering a variety of substances and identifying key factors that influence these outcomes. A comprehensive search was conducted in PubMed, Web of Science, Cochrane, and Scopus in January 2023, covering literature published until December 2022. The QOL was assessed using the World Health Organization Quality of Life (WHOQOL) instrument and the brief version of the WHOQOL, identifying the same four domains of QOL (physical, mental, social, and environmental). A total of 19 studies were selected for inclusion in the systematic review, based on individuals' polysubstance use, and excluding those using only nicotine or alcohol. The analysis included 6079 patients, with only 40.3% women, and a mean age of 36.6 years. The substances most commonly involved in SUD were cocaine (47.1%), alcohol (46.3%), and amphetamine (43.6%), considering most individuals being polysubstance users. The highest variability in QOL scores was observed in the physical domain. Mental disorders were reported in 68.3% of the patients, while long-term use of drugs, criminal history, unemployment, and low levels of education were identified as significant predictors for lower QOL by some of the studies. Similarly, sleep problems and teeth decay were also identified as significant worsening factors for QOL. This systematic review highlights that the WHOQOL survey is widely accepted and applicable for individuals with SUD worldwide. The results suggest a substantial negative impact of SUD on the QOL of affected individuals. The findings underscore the need for comprehensive interventions to address the physical, psychological, social, and environmental dimensions of QOL among individuals with SUD.

Longitudinal Associations between Homelessness and Substance Use: Investigating Demographic Differences for Young Adults in Treatment

Objective: To examine prospective, bidirectional associations between homelessness and substance use frequency among young adults receiving substance use treatment in the United States. We also investigated potential differences across demographic subgroups. Methods: Young adults (N = 3717, Mage = 20.1, 28% female, 7.3% sexual/gender minority, and 37% non-Hispanic White) receiving substance use treatment in the U.S. completed assessments at intake, 3 months, 6 months, and 12 months post-intake. Latent growth curve models with structured residuals (LGC-SR) were used to examine cross-lagged associations between homeless days and frequency of substance use and associated problems. Models were stratified by sex, race/ethnicity, and sexual and/or gender minority status. Results: Overall, days spent homeless (μ slope = -0.19, p = 0.046) and substance use frequency (μ slope 1 = -6.19, p < 0.001) significantly decreased during treatment, with no significant cross-lagged associations between homeless days and substance use frequency. However, results differed by race and ethnicity. For non-Hispanic White young adults, greater substance use at treatment entry was associated with steeper declines in homeless days between-persons (ϕ standardized = -0.14, p = 0.04). For African Americans, homeless days at treatment entry were associated with greater increases in substance use between-persons (ϕ standardized = 0.29, p = 0.04). No significant differences were found by sex or sexual/gender minority status. Conclusions: Despite overall declines in homelessness and substance use during treatment, these outcomes may unfold differently for non-Hispanic White and African American young adults. More support may be needed for African American young adults reporting homelessness at treatment entry.

Children in street situations' access to healthcare: qualitative findings from the Street Child World Cup 2022

BACKGROUND

Children in street situations (those who live or work on the street) are known to face barriers in accessing healthcare.

METHODS

The study combined a remote survey with 33 adult non-governmental organisation (NGO) staff members, in-depth interviews with staff members of 11 NGOs and 4 formerly street-connected adult young leaders and a questionnaire with 30 street-connected children from 15 countries participating in the Street Child World Cup event in Qatar in 2022. Data were analysed using thematic analysis.

RESULTS

The participating children have strong connections with supportive organisations and do tend to seek adult assistance when they are ill or injured, refuting the assertion of adult participants and the literature that children in street situations only seek healthcare in emergencies. Some barriers that children in street situations face when seeking healthcare are likely shared by other disadvantaged groups, including the cost of care, long waiting times, the quality of public healthcare and discrimination based on socioeconomic status. Children in street situations may face further discrimination based on assumptions about their lives, their appearance or hygiene levels. Identity documents are highlighted in the literature as a major barrier but seemed less important to the participants. Both adult and child participants emphasised the need for an accompanying adult to find appropriate services and be treated.

CONCLUSIONS

This study highlights the important work of organisations supporting street-connected children to access healthcare both during and after their time working or living on the street. It concludes that while some of the barriers to accessing healthcare that children in street situations face are not specific to this group, the absence of an adult caregiver differentiates many street-connected children from other disadvantaged groups. This also signals differences among children in street situations, with those with connections to family or organisations having more support.

Joint modeling HIV and HPV using a new hybrid agent-based network and compartmental simulation technique

Persons living with human immunodeficiency virus (HIV) have a disproportionately higher burden of human papillomavirus infection (HPV)-related cancers. Causal factors include both behavioral and biological. While pharmaceutical and care support interventions help address biological risk of coinfection, as social conditions are common drivers of behaviors, structural interventions are key part of behavioral interventions. Our objective is to develop a joint HIV-HPV model to evaluate the contribution of each factor, to subsequently inform intervention analyses. While compartmental modeling is sufficient for faster spreading HPV, network modeling is suitable for slower spreading HIV. However, using network modeling for jointly modeling HIV and HPV can generate computational complexities given their vastly varying disease epidemiology and disease burden across sub-population groups. We applied a recently developed mixed agent-based compartmental (MAC) simulation technique, which simulates persons with at least one slower spreading disease and their immediate contacts as agents in a network, and all other persons including those with faster spreading diseases in a compartmental model, with an evolving contact network algorithm maintaining the dynamics between the two models. We simulated HIV and HPV in the U.S. among heterosexual female, heterosexual male, and men who have sex with men (men only and men and women) (MSM), sub-populations that mix but have varying HIV burden, and cervical cancer among women. We conducted numerical analyses to evaluate the contribution of behavioral and biological factors to risk of cervical cancer among women with HIV. The model outputs for HIV, HPV, and cervical cancer compared well with surveillance estimates. Model estimates for relative prevalence of HPV (1.67 times) and relative incidence of cervical cancer (3.6 times), among women with HIV compared to women without, were also similar to that reported in observational studies in the literature. The fraction attributed to biological factors ranged from 22-38% for increased HPV prevalence and 80% for increased cervical cancer incidence, the remaining attributed to behavioral. The attribution of both behavioral and biological factors to increased HPV prevalence and cervical cancer incidence suggest the need for behavioral, structural, and pharmaceutical interventions. Validity of model results related to both individual and joint disease metrics serves as proof-of-concept of the MAC simulation technique. Understanding the contribution of behavioral and biological factors of risk helps inform interventions. Future work can expand the model to simulate sexual and care behaviors as functions of social conditions to jointly evaluate behavioral, structural, and pharmaceutical interventions for HIV and cervical cancer prevention.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Support Interventions for Young People in Housing Programs: A Rapid Literature Review

This rapid review synthesizes current original research studies concerning support interventions intended for young people who experienced homelessness and are housed through youth-focused housing programs. Peer-reviewed articles on interventions for young people between 13 and 25 years of age with experience of homelessness living in youth-focused housing published between January 2017 and May 2022 were search in Scopus, Web of Sciences, PubMed, and EBSCO. Ten articles were included in the review. Interventions examined in the reviewed literature included case management, psychosocial and mental health support interventions; social support through peer support, mentorship, and positive social networks; and socioeconomic inclusion through skill building. Evidence found in the current review provides directions for the development of promising practices.

Lessons learned from housing first, rapid rehousing trials with youth experiencing homelessness

BACKGROUND

Youth, 18 to 24 years, experiencing homelessness (YEH) are recognized as having developmental challenges dissimilar to older adults. Yet, research on efforts to end homelessness and prevent or intervene in drug use and mental health problems among youth have lagged behind that of adults. The Housing First (HF) Model which underlies Permanent Supportive Housing (PSH) and Rapid Re-Housing (RRH) has become preferred over treatment-first models.

METHODS AND RESULTS

We provide an overview of PSH and RRH studies to date and summarize our current understanding of their utility for use with YEH. Finally, we review our team's current and past randomized trials testing RRH with YEH, providing lessons learned and recommendations.

CONCLUSION

Current research efforts to guide best practices are hampered by a lack of fidelity to HF principles, lack of randomized design, and lack of focus on youth. Lessons learned and recommendations from our work are offered to facilitate the future work of those who seek to end homelessness and address drug use and mental health problems among youth.

Predicting Response to Services for Homeless Adolescents and Transition Age Youth (TAY) with Substance Use And/Or Mental Health Disorders: Implications for Youth Treatment and Recovery

PURPOSE

This paper examines patterns of response to a multi-disciplinary wrap-around program for homeless adolescents and transition-aged youth with substance use and/or mental health disorders.

METHOD

A cluster analysis of outcome data from 148 youth was conducted.

RESULTS

Cluster 1 (n = 67) demonstrated significant decreases in risky behavior (e.g., engaging in unprotected sex, crime, and substance use) and poor interpersonal relationships (e.g. more interaction with family and friends and lower rates of violence) but experienced relatively fewer interactions with family and friends. Cluster 2 (n = 57) demonstrated a significant decrease in poor life functioning (e.g., lower rates of employment/education, better quality of life, and less symptoms of internalizing disorders). Cluster 3 (n = 24) experienced significant increases in risky behavior, poor life functioning, and poor interpersonal relationships.

DISCUSSION

Clusters 1 and 2 improved over six months of care. Cluster 3 deteriorated despite receiving similar services and used more opioids and stimulants.

CONCLUSIONS

Peer engagement in programs for this population are important. Recommendations for cluster 3 include targeted outreach, medication assisted treatment, and additional research-supported treatments. Further research is needed to test these interventions over longer periods of time.

Victimization, safety, and overdose in homeless shelters: A systematic review and narrative synthesis

The objective of this prospectively registered systematic review was to identify the factors that contribute to sense of safety, victimization, and overdose risk in homeless shelters, as well as groups that are at greater risk of shelter-based victimization. Fifty-five articles were included in the review. Findings demonstrated that fears of violence and other forms of harm were prominent concerns for people experiencing homelessness when accessing shelters. Service users' perceptions of shelter dangerousness were shaped by the service model and environment, interpersonal relationships and interactions in shelter, availability of drugs, and previous living arrangements. 2SLGBTQ+ individuals were identified as being at heightened risk of victimization in shelters. No studies examined rates of shelter-based victimization or tested interventions to improve safety, with the exception of overdose risk. These knowledge gaps hinder the establishment of evidence-based practices for promoting safety and preventing violence in shelter settings.

The Association of Homelessness With Rates of Diabetes Complications: A Population-Based Cohort Study

OBJECTIVE

To estimate the rates of diabetes complications and revascularization procedures among people with diabetes who have experienced homelessness compared with a matched cohort of nonhomeless control subjects.

RESEARCH DESIGN AND METHODS

A propensity-matched cohort study was conducted using administrative health data from Ontario, Canada. Inclusion criteria included a diagnosis of diabetes and at least one hospital encounter between April 2006 and March 2019. Homeless status was identified using a validated administrative data algorithm. Eligible people with a history of homelessness were matched to nonhomeless control subjects with similar sociodemographic and clinical characteristics. Rate ratios (RRs) for macrovascular complications, revascularization procedures, acute glycemic emergencies, skin/soft tissue infections, and amputation were calculated using generalized linear models with negative binomial distribution and robust SEs.

RESULTS

Of 1,076,437 people who were eligible for inclusion in the study, 6,944 were identified as homeless. A suitable nonhomeless match was found for 5,219 individuals. The rate of macrovascular complications was higher for people with a history of homelessness compared with nonhomeless control subjects (RR 1.85, 95% CI 1.64-2.07), as were rates of hospitalization for glycemia (RR 5.64, 95% CI 4.07-7.81) and skin/soft tissue infections (RR 3.78, 95% CI 3.31-4.32). By contrast, the rates of coronary revascularization procedures were lower for people with a history of homelessness (RR 0.76, 95% CI 0.62-0.94).

CONCLUSIONS

These findings contribute to our understanding of the impact of homelessness on long-term diabetes outcomes. The higher rates of complications among people with a history of homelessness present an opportunity for tailored interventions to mitigate these disparities.

Delivering substance use prevention interventions for adolescents in educational settings: A scoping review

Currently, a proportion of adolescents use alcohol, tobacco, and illicit drugs, which inevitably harms their health and academic progress. Adolescence is a peak period for substance use initiation and a critical time for preventing substance use problems. Various entities, such as families, schools, and communities, have implemented a variety of interventions to alleviate adolescent substance use problems, and schools play a unique role. To explore the types, characteristics, and effectiveness of substance use interventions in educational settings for adole-scents, we conducted a scoping review and identified 32 studies after screening. We divided the 32 studies according to intervention type, including curriculum interventions focusing on cognitive-behavioral skill enhancement, exercise interventions, peer interventions and family-school cooperation, and electronic interventions. Except for the mixed results on electronic interventions, the results showed that the other interventions were beneficial to different extents in alleviating adolescent substance use problems. In addition, we analyzed and summarized the advantages and challenges of intervening in adolescent substance use in educational settings. Schools can use equipment and human resources to provide adolescents with various types of intervention measures, but they also face challenges such as stigmatization, ineffective coordination among multiple resources, and poor implementation effects. In the future, school-based intervention measures can fully utilize big data and artificial intelligence technology and collaborate with families and communities to intervene appro-priately while paying attention to the comorbidity risks of substance use disorders and psychological health issues.

Substance Use Disorders and Psychiatric Illness Among Transitional Age Youth Experiencing Homelessness

Objective

Transitional age youth experiencing homelessness (TAY-EH) bear a high burden of substance use disorders (SUDs) and psychopathology. However, limited data exist on the co-occurrence and interactions between these diagnoses in this marginalized group. This study sought to identify rates of single and co-occurring SUDs and psychiatric diagnoses among a sample of TAY-EH and to investigate associations between psychopathology and prevalence and severity of SUDs in this group.

Method

TAY-EH accessing a low-threshold social service agency in a large metropolitan area completed psychosocial and diagnostic interviews to assess for SUDs and psychopathology. Analyses examined rates of single and co-occurring disorders and associations between burden of psychopathology and presence and severity of SUDs.

Results

The assessment was completed by 140 TAY-EH; the majority were youth of color (54% Black/African American, 16% Latinx), and 57% identified as male. Rates of single and co-occurring psychiatric disorders and specific SUDs (cannabis use disorder [CUD] and alcohol use disorder [AUD]) were notably high. An increasing number of psychiatric diagnoses was significantly associated with elevated CUD/AUD prevalence and severity. Mood, anxiety, attention-deficit/hyperactivity, and antisocial personality disorders were significantly associated with elevated CUD/AUD prevalence and severity, as was suicidality (all p < .05).

Conclusion

This study reveals a complex overlay of SUDs and psychopathology facing TAY-EH, with a significant association between co-occurring psychopathology and severity of CUD/AUD. To the authors' knowledge, this is the first study to examine associations between specific psychopathology and severity of SUDs among TAY-EH. Further research into the mechanistic and temporal links between these conditions is needed to inform tailored treatment interventions.

Prevalence and Correlates of Non-Dating Sexual Violence, Sexual Dating Violence, and Physical Dating Violence Victimization among U.S. High School Students during the COVID-19 Pandemic: Adolescent Behaviors and Experiences Survey, United States, 2021

The COVID-19 pandemic created an environment of disruption and adversity for many adolescents. We sought to establish the prevalence of non-dating sexual violence, sexual dating violence, and physical dating violence victimization among adolescents during the COVID-19 pandemic and to investigate whether experiences of disruption and adversity placed adolescents at greater risk for these forms of interpersonal violence. We conducted a secondary analysis of data from the Adolescent Behavior and Experiences Survey, collected January to June 2021 from a nationally representative sample of U.S. high school students (N = 7,705). Exposures included abuse by a parent; economic, housing, and food and nutrition insecurity; interpersonal connectedness; and personal well-being. Among female students, 8.0% experienced non-dating sexual violence; 12.5% experienced sexual dating violence; and 7.7% experienced physical dating violence. Among male students, 2.2% experienced non-dating sexual violence; 2.4% experienced sexual dating violence; and 4.9% experienced physical dating violence. Among female students, both emotional and physical abuse by a parent was related to non-dating sexual violence, emotional abuse was related to sexual dating violence, and physical abuse was related to physical dating violence. Among males, emotional abuse by a parent was related to physical dating violence and physical abuse by a parent was related to sexual dating violence. Hunger was associated with sexual and physical dating violence among female students and homeless was associated with physical dating violence among male students. Although there were differences by sex, abuse by a parent, hunger, and homelessness created precarity that may have increased the likelihood that adolescents would be exposed to risky peer or dating relationships. Adolescents need support that stops and prevents experiences of non-dating sexual and dating violence connected to interventions that address adversities experienced during the COVID-19 pandemic.

Gender Minority Youth Experiencing Homelessness and Corresponding Health Disparities

PURPOSE

Pediatricians and youth service providers frequently interface with vulnerable populations, including gender minority youth (e.g., transgender, nonbinary, gender questioning, and other gender diverse individuals) and youth experiencing homelessness. The purposes of this study are to estimate the prevalence of homelessness and types of homelessness experienced among gender minority youth and their corresponding health outcomes.

METHODS

Data for this study came from gender minority (n = 3,194) and cisgender (n = 93,337) high school students who answered questions on transgender status and homelessness status in the 2017 and 2019 Youth Risk Behavior Survey (YRBS). We compared the prevalence of homelessness between gender minority and cisgender youth and assessed where youth experiencing homelessness had slept in the prior month: shelters, nonparental homes, streets, hotel, or other locations. Finally, logistic regression models and marginal effects (ME) were used to examine health outcomes at the intersection of gender minority status and homelessness.

RESULTS

22% of gender minority youth reported homelessness during the prior month. Cisgender youth were significantly less likely to report being homeless (3%). Transgender youth experiencing homelessness were significantly more likely to live on the streets than cisgender youth experiencing homelessness (ME = 0.20; 95% CI = 0.10-0.30; p < .001). Gender minority youth experiencing homelessness reported elevated health-risk behaviors in excess of nonhomeless gender minority youth and cisgender youth experiencing homelessness.

DISCUSSION

Public health campaigns, housing interventions, and youth service providers should consider and create tailored programs to secure housing and to promote the health of gender minority youth experiencing homelessness.

Longitudinal patterns of childhood homelessness and early adolescent trajectories of internalising and externalising behaviour

BACKGROUND

Child homelessness has been associated with elevated mental health problems during early adolescence, a period of onset for psychiatric problems. Prior literature has relied on cross-sectional studies, limiting the understanding of temporality and trajectories of psychopathology. We extend prior literature by examining associations between child homelessness and internalising and externalising symptom trajectories in early adolescence, with consideration of timing and persistence of homelessness.

METHODS

Using population-based longitudinal data from the Avon Longitudinal Study of Parents and Children, we used multilevel models to examine the effects of homelessness prior to age 9, the timing of homelessness (eg, early vs middle childhood) and cumulative exposure to homelessness on internalising and externalising trajectories across ages <0-9 years. We also tested for sex differences in these associations.

RESULTS

Of the 8391 participants, 5.5% reported exposure to homelessness at least once before age 9. Children who experienced homelessness had elevated internalising and externalising symptoms compared with their consistently housed peers, with excess risk evident among children who first experienced homelessness in middle childhood (relative to early childhood) and children who experienced recurrent homelessness. We did not observe changes in symptom trajectories over the course of 4 years. Men who experienced homelessness displayed a more pronounced risk of internalising symptoms relative to women and men who did not experience homelessness.

CONCLUSION

Childhood homelessness is associated with persistently elevated internalising and externalising symptoms across early adolescence compared with their consistently housed peers. Interventions and policies to address family homelessness may lead to better mental health among adolescents.

A new mixed agent-based network and compartmental simulation framework for joint modeling of related infectious diseases- application to sexually transmitted infections

Background

A model that jointly simulates infectious diseases with common modes of transmission can serve as a decision-analytic tool to identify optimal intervention combinations for overall disease prevention. In the United States, sexually transmitted infections (STIs) are a huge economic burden, with a large fraction of the burden attributed to HIV. Data also show interactions between HIV and other sexually transmitted infections (STIs), such as higher risk of acquisition and progression of co-infections among persons with HIV compared to persons without. However, given the wide range in prevalence and incidence burdens of STIs, current compartmental or agent-based network simulation methods alone are insufficient or computationally burdensome for joint disease modeling. Further, causal factors for higher risk of coinfection could be both behavioral (i.e., compounding effects of individual behaviors, network structures, and care behaviors) and biological (i.e., presence of one disease can biologically increase the risk of another). However, the data on the fraction attributed to each are limited.

Methods

We present a new mixed agent-based compartmental (MAC) framework for jointly modeling STIs. It uses a combination of a new agent-based evolving network modeling (ABENM) technique for lower-prevalence diseases and compartmental modeling for higher-prevalence diseases. As a demonstration, we applied MAC to simulate lower-prevalence HIV in the United States and a higher-prevalence hypothetical Disease 2, using a range of transmission and progression rates to generate burdens replicative of the wide range of STIs. We simulated sexual transmissions among heterosexual males, heterosexual females, and men who have sex with men (men only and men and women). Setting the biological risk of co-infection to zero, we conducted numerical analyses to evaluate the influence of behavioral factors alone on disease dynamics.

Results

The contribution of behavioral factors to risk of coinfection was sensitive to disease burden, care access, and population heterogeneity and mixing. The contribution of behavioral factors was generally lower than observed risk of coinfections for the range of hypothetical prevalence studied here, suggesting potential role of biological factors, that should be investigated further specific to an STI.

Conclusions

The purpose of this study is to present a new simulation technique for jointly modeling infectious diseases that have common modes of transmission but varying epidemiological features. The numerical analysis serves as proof-of-concept for the application to STIs. Interactions between diseases are influenced by behavioral factors, are sensitive to care access and population features, and are likely exacerbated by biological factors. Social and economic conditions are among key drivers of behaviors that increase STI transmission, and thus, structural interventions are a key part of behavioral interventions. Joint modeling of diseases helps comprehensively simulate behavioral and biological factors of disease interactions to evaluate the true impact of common structural interventions on overall disease prevention. The new simulation framework is especially suited to simulate behavior as a function of social determinants, and further, to identify optimal combinations of common structural and disease-specific interventions.

Self-Identification of Mental Health Problems Among Young Adults Experiencing Homelessness

Young adults experiencing homelessness (YAEH) have high rates of mental health problems but low rates of mental health service use. This study examined identification of mental health problems among YAEH in seven U.S. cities and its relationship to service use. YAEH that screened positive for depression, psychological distress, or Post Traumatic Stress (n = 892) were asked whether they felt they had a mental health problem. One-third identified as having a mental health problem (35%), with 22% endorsing not sure. Multinomial logistic regression models found that older age, cisgender female or gender-expansive (compared to cisgender male), and LGBQ sexual orientation, were positively associated with self-identification and Hispanic race/ethnicity (compared to White) was negatively associated. Self-identification of a mental health problem was positively associated with use of therapy, medications, and reporting unmet needs. Interventions should target understanding mental health, through psychoeducation that reduces stigma, or should reframe conversations around wellness, reducing the need to self-identify.

Health of Young Adults Experiencing Social Marginalization and Vulnerability: A Cross-National Longitudinal Study

People who experience social marginalization and vulnerability have uniquely complex health needs and are at risk of poor health outcomes. Regression analyses using longitudinal data from a cross-national, population-based sample of young adults participating in the International Youth Development Study, tested associations between social marginalization and vulnerabilities and physical health, mental health, and substance use outcomes. Participants from Victoria, Australia, and Washington State in the US were surveyed at ages 25 (2014) and 29 years (2018; N = 1944; 46.7% male). A history of adverse childhood experiences (ACEs), LGBT identity, financial insecurity, and justice system involvement at age 25 predicted poor health outcomes at age 28, including lower perceived health status, risk for chronic illness, depression and anxiety symptoms, and diagnosed mental health/substance use disorders. Tests of model equivalence across states showed that a history of ACEs was more strongly related to health status and serious injury at age 28 and justice system involvement at age 25 was more strongly related to age 28 serious injury in Victoria than in Washington State. Findings strengthen the case for future population-based research identifying life-course interventions and state policies for reducing poor health and improving health equity among members of socially marginalized groups.

The Use of Technology to Provide Mental Health Services to Youth Experiencing Homelessness: Scoping Review

BACKGROUND

There is growing interest in using information and communication technologies (ICTs) to improve access to mental health services for youth experiencing homelessness (YEH); however, limited efforts have been made to synthesize this literature.

OBJECTIVE

This study aimed to review the research on the use of ICTs to provide mental health services and interventions for YEH.

METHODS

We used a scoping review methodology following the Arksey and O'Malley framework and guidelines from the Joanna Briggs Institute Manual for Evidence Synthesis. The results are reported according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement and the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews). A systematic search was conducted from 2005 to 2021 in MEDLINE, Embase, CINAHL, PsycInfo, Cochrane, Web of Science, and Maestro and in ProQuest Thesis and Dissertations, Papyrus, Homeless Hub, and Google Scholar for gray literature. Studies were included if participants' mean age was between 13 and 29 years, youth with mental health issues were experiencing homelessness or living in a shelter, ICTs were used as a means of intervention, and the study provided a description of the technology. The exclusion criteria were technology that did not allow for interaction (eg, television) and languages other than French or English. The data were analyzed using descriptive statistics and qualitative approaches. Two reviewers were involved in the screening and data extraction process in consultation with a third reviewer. The data were summarized in tables and by narrative synthesis.

RESULTS

From the 2153 abstracts and titles screened, 12 were included in the analysis. The most common types of ICTs used were communication technologies (eg, phone, video, and SMS text messages) and mobile apps. The intervention goals varied widely across studies; the most common goal was reducing risky behaviors, followed by addressing cognitive functioning, providing emotional support, providing vital resources, and reducing anxiety. Most studies (9/11, 82%) focused on the feasibility of interventions. Almost all studies reported high levels of acceptability (8/9, 89%) and moderate to high frequency of use (5/6, 83%). The principal challenges were related to technical problems such as the need to replace phones, issues with data services, and phone charging.

CONCLUSIONS

Our results indicate the emerging role of ICTs in the delivery of mental health services to YEH and that there is a high level of acceptability based on early feasibility studies. However, our results should be interpreted cautiously, considering the limited number of studies included in the analysis and the elevated levels of dropout. There is a need to advance efficacy and effectiveness research in this area with larger and longer studies.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.1136/bmjopen-2022-061313.

Geolocation Patterns, Wi-Fi Connectivity Rates, and Psychiatric Symptoms amongst Urban Homeless Youth Using Self-Report and Smartphone Data: Pilot Study (Preprint)

BACKGROUND

Despite significant research done on youth experiencing homelessness, few studies have examined movement patterns and digital habits in this population. Examining these digital behaviors may provide useful data to design new digital health intervention models for youth experiencing homelessness. Specifically, passive data collection (data collected without extra steps for a user) may provide insights into lived experience and user needs without putting an additional burden on youth experiencing homelessness to inform digital health intervention design.

OBJECTIVE

The objective of this study was to explore patterns of mobile phone Wi-Fi usage and GPS location movement among youth experiencing homelessness. Additionally, we further examined the relationship between usage and location as correlated with depression and posttraumatic stress disorder (PTSD) symptoms.

METHODS

A total of 35 adolescent and young adult participants were recruited from the general community of youth experiencing homelessness for a mobile intervention study that included installing a sensor data acquisition app (Purple Robot) for up to 6 months. Of these participants, 19 had sufficient passive data to conduct analyses. At baseline, participants completed self-reported measures for depression (Patient Health Questionnaire-9 [PHQ-9]) and PTSD (PTSD Checklist for DSM-5 [PCL-5]). Behavioral features were developed and extracted from phone location and usage data.

RESULTS

Almost all participants (18/19, 95%) used private networks for most of their noncellular connectivity. Greater Wi-Fi usage was associated with a higher PCL-5 score (P=.006). Greater location entropy, representing the amount of variability in time spent across identified clusters, was also associated with higher severity in both PCL-5 (P=.007) and PHQ-9 (P=.045) scores.

CONCLUSIONS

Location and Wi-Fi usage both demonstrated associations with PTSD symptoms, while only location was associated with depression symptom severity. While further research needs to be conducted to establish the consistency of these findings, they suggest that the digital patterns of youth experiencing homelessness offer insights that could be used to tailor digital interventions.

An examination of housing interventions among youth experiencing homelessness: an investigation into racial/ethnic and sexual minority status

OBJECTIVES

The purpose of this study is to explore main and interaction effects of minority and multiple minority statuses on exits from homelessness and the stability of homelessness exits overtime.

METHODS

This study utilized the Homeless Management Information System administrative data of 10 922 youth experiencing homelessness collected from a convenience sample of 16 geographically diverse communities across the USA between 2015-17. Using multinomial logistic regression analyses and logistic regression, main effects and interaction effects of racial/ethnic minority identity and sexual/gender minority identity were examined on various homelessness exits (n = 9957) and housing sustainability (n = 5836).

RESULTS

Black youth, relative to White youth, were disproportionately exiting homelessness through incarceration (P < 0.001). Black and Latinx youth were less likely to successfully self-resolve their homelessness (both P < 0.05). Black heterosexual and Black and Latinx non-heterosexual youth were most frequently lost to the homeless system (all P < 0.01). Black youth, relative to White youth, were approximately half as likely to remain stably housed after returning to family (P < 0.01).

CONCLUSIONS

With respect to housing exits and exit stability, Black and Latinx heterosexual youth are consistently at a disadvantage. Homelessness/housing systems and programs need to conduct a deeper investigation into how they implement and develop equitable outreach and engagement practices.

Quality of life and its correlated factors among patients with substance use disorders: a systematic review and meta-analysis

Background

Patients with substance use disorder (SUD) usually report lower quality of life (QoL) than other patients and as much as patients with other mental disorders. The present study investigated variables associated with QoL domains among patients with SUD.

Methods

Studies in English published before December 1^st 2021, were searched for on PubMed, Scopus, Cochrane, and Web of Science to identify primary studies on factors associated with QoL domains among patients with SUD. After reviewing for study duplicates, the full-texts of selected papers were assessed for eligibility using PECO (Participants, Exposures, Comparison and Outcome) criteria: (a) participants: patients with SUD; (b) exposures: sociodemographic factors, clinical, and service use variables; (c) comparison: patient groups without SUD; and (d) outcomes: four domains of QoL (physical, mental, social, and environmental domains). Three researchers recorded the data independently using predefined Excel spreadsheets. The Newcastle–Ottawa Scale (NOS) was used for assessing risk of bias and rated each study in terms of exposure, outcome, and comparability. Pooled odds ratios (ORs) and β coefficient were utilized at a 95% confidence level, and because sampling methods differed between studies’ pooled estimates, a random effects model was utilized.

Results

After the assessment of over 10,230 papers, a total of 17 studies met the eligibility criteria. Five studies (1260 participants) found that patients with SUD who were older were less likely to have a good physical Qol (OR = 0.86, 95% CI = 0.78, 0.95). Two studies (1171 participants) indicated that patients with SUD who were homeless were less likely to have a good environmental Qol (β = -0.47, p = 0.003). However, a better mental QoL was observed in four studies (1126 participants) among those receiving support from their family or friends (social networks) (OR = 1.05, 95% CI = 1.04, 1.07). Two studies (588 participants) showed that those using cocaine were less likely to have a good mental QoL (OR = 0.83, 95% CI = 0.75, 0.93). Two studies (22,534 participants) showed that those using alcohol were less likely to have a good physical QoL (β = -2.21, p = 0.001). Two studies (956 participants) showed that those having severe substance use disorders were less likely to have a good mental (β = -5.44, p = 0.002) and environmental (β = -0.59, p = 0.006) QoL respectively. Four studies (3515 participants) showed that those having mental disorders were less likely to have a good physical QoL (β = -1.05, p = 0.001), and another three studies (1211 participants) that those having mental disorders were less likely to have a good mental QoL (β = -0.33, p = 0.001). Finally, two studies (609 and 682 participants) showed that individuals who experienced trauma symptoms or mental disorders were less likely to have good social and environmental QoL, respectively (OR = 0.78, 95% CI = 0.61, 1.00) and (OR = 0.92, 95% CI = 0.9, 0.94).

Conclusions

The findings suggest the need for mental health services to improve the QOL among patients with SUD but further study is needed. Cocaine may cause behavioral changes which can increase the possibility of reckless and suicidal behaviors. Therefore, identifying cocaine user access, adherence, and satisfaction with treatment is recommended as an important component of adaptive functioning. Interventions that help patients with SUD get support from people within their social networks who support their recovery are also essential to their QoL.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13690-022-00940-0.

Perceived safety in community and service settings among young adults experiencing homelessness: Differences by sexual and gender identity

Homelessness poses risks to the health and safety of young adults; particularly among sexual and gender minority (SGM) young adults. The current study sought to better understand service use and perceived safety in community and service settings among SGM and cisgender heterosexual (cis-hetero) young adults experiencing homelessness. Data come from a mixed-method, ecological momentary assessment study (n = 80; 43% sexual minority; 10% gender minority) in Los Angeles, California. Participants reported their current location (service vs. nonservice setting) and perceived safety. Multilevel modeling examined associations between identity, location, and perceived safety; qualitative interviews with 20 SGM participants added context to quantitative findings. Overall, service location was associated with greater perceived safety (β = .27, p < .001). Compared to cis-hetero participants, cisgender sexual minorities (β = -.23, p = .03) and sexual and gender minorities (β = -.50, p = .002) reported lower perceived safety in service settings (vs. nonservice settings). Qualitative interviews revealed themes and subthemes detailing safe/unsafe spaces and interpersonal conflict in the community, and relationships with staff, peers, transphobia, and positive experiences in service settings.

Mental illness among 500 people living homeless and referred for psychiatric evaluation in Lisbon, Portugal

BACKGROUND

Our goal was to identify the demographic profile of the people living homeless with mental illness in Lisboa, Portugal, and their relationship with the national healthcare system. We also tried to understand which factors contribute to the number and duration of psychiatric admissions among these homeless people.

METHODS

We used a cross-sectional design, collecting data for 4 years among homeless people, in Lisboa, Portugal, that were referred as possible psychiatric patients to Centro Hospitalar Psiquiátrico de Lisboa (CHPL). In total, we collected data from 500 homeless people, then cross-checked these people in our CHPL hospital electronic database and obtained 467 patient matches.

RESULTS

The most common psychiatric diagnosis in our sample was drug abuse (34%), followed by alcohol abuse (33%), personality disorder (24%), and acute stress reaction (23%). Sixty-two percent of our patients had multiple diagnoses, a subgroup with longer follow-ups, more psychiatric hospitalizations, and longer psychiatric hospitalizations. The prevalence of psychotic disorders was high: organic psychosis (17%), schizophrenia (15%), psychosis not otherwise specified (14%), and schizoaffective disorder (11%), that combined altogether were present in more than half (57%) of our homeless patients.

CONCLUSION

The people living homeless with multiple diagnoses have higher mental health needs and worse determinants of general health. An ongoing effort is needed to identify and address this subgroup of homeless people with mental illness to improve their treatment and outcomes.

Mental Health Service Experiences Among Transition-Age Youth: Interpersonal Continuums that Influence Engagement in Care

Purpose. Transition-age youth (TAY) who have experienced or are experiencing complex trauma, system involvement and homelessness are at increased risk for serious mental health needs and related challenges. However, these vulnerable and historically marginalized TAY typically have low rates of mental health service engagement. This study examines how and why TAY experiencing system involvement, homelessness, and serious mental health and substance use symptoms engage in mental health services, and what facilitates and/or hinders their engagement in services. Methods. Twenty-one TAY completed a virtual interview about their previous and current mental health service experiences, and why they did or did not engage with mental health services. A modified grounded theory qualitative analysis approach was used to understand how participants' personal sense of meaning interacted with programmatic factors to construct participant experiences with mental health services. Results. Most participants (81%, n = 17) received mental health services, namely psychiatry (76%, n = 16) and counseling/therapy (48%, n = 10), and peer support (10%, n = 2). Participants described their mental health service experiences along three interpersonal and relational continuums between themselves and their providers: feeling (mis)understood, being treated with (dis)respect, and experiencing (dis)trust. Discussion. Study findings reveal that for these particularly vulnerable and marginalized TAY, relational and interpersonal factors significantly influenced their engagement in mental health services. Study findings call for providers to re-imagine their working alliance with highly vulnerable TAY through culturally-attuned practices that promote understanding, respect, and trust. Findings also call for TAY-serving programs and policies to re-imagine peer support as a mental health service option for this highly vulnerable population.

Systematic review: Rates of psychopathology, substance misuse, and neuropsychological dysfunction among transitional age youth experiencing homelessness

BACKGROUND AND OBJECTIVES

Transitional age youth experiencing homelessness (TAY-EH) bear a disproportionate burden of morbidity and mortality related to psychopathology, substance use disorders (SUD), and neuropsychological dysfunction. Prior reviews examining these conditions are now nearly a decade old, have focused on younger adolescent populations, or have utilized nonsystematic approaches. To our knowledge, no prior reviews have reported on all three of these domains in an integrated fashion. Here, we provide a contemporary, critical synthesis of the literature on the functioning of TAY-EH in North America within these three domains.

METHODS

Based upon PRISMA guidelines, a search of PubMed, Medline, and PsycInfo databases was conducted, including literature published between January 2015 and June 2021.

RESULTS

The initial search yielded 2024 citations; 104 underwent full text review and 32 met inclusion criteria, with a final aggregate sample size of 13,516. Studies revealed elevated rates of mood disorders, PTSD, anxiety disorders, and alcohol misuse. There is insufficient data to draw generalizable conclusions regarding neuropsychological functioning, other SUD, or other psychiatric diagnoses. No studies reported on co-occurrence of disorders among or between the domains of psychopathology, SUD, and neuropsychological dysfunction. Four studies used structured interviews for diagnoses, with the remainder relying upon brief screeners or self-report measures.

CONCLUSIONS AND SCIENTIFIC SIGNIFICANCE

To our knowledge, this is the first systematic review to provide integrated findings on psychopathology, SUD, and neuropsychological dysfunction among TAY-EH. Further research using structured, DSM-based tools is needed to characterize rates of single and co-occurring conditions to inform tailored treatment interventions.

Exploring Mental Health and Holistic Healing through the Life Stories of Indigenous Youth Who Have Experienced Homelessness

Indigenous youth are the fastest growing population in Canada, yet are marked by profound and disproportionate personal, societal, political, and colonial barriers that predispose them to mental health challenges, employment and educational barriers, and experiences of housing insecurity and homelessness. It is only from the perspectives and experiences of Indigenous community members themselves that we can gain appropriate insights into effective supports, meaningful interventions, and accessible pathways to security. This paper will explore the mental health of Indigenous youth who are at risk of, or who have experienced, homelessness, as well as the lifelong perspectives, teachings, and guidance from Indigenous Elders and traditional knowledge keepers; their perspectives are weaved throughout, in order to provide a more effective means to addressing holistic healing and the mental health needs of Indigenous homeless youth. As educators, researchers and clinicians who have sought to understand this issue in more depth, our analysis aims to raise awareness about the complexities of Indigenous youth homelessness and push back against systemic barriers that contribute to homelessness, fail young people, and subject them to oppression. We also offer recommendations from a clinical perspective in order for clinicians, researchers and those working within communities to serve our Indigenous youth with a diverse set of methods that are tailored and ethical in their approach.

Use of technology to provide mental health services to youth experiencing homelessness: a scoping review protocol

INTRODUCTION

Despite the importance to address mental health issues as early as possible, youth experiencing homelessness (YEH) often lack prompt and easy access to health services. Recently, there has been a surge of studies focusing on leveraging technology to improve access to mental health services for YEH; however, limited efforts have been made to synthesise this literature, which can have important implications for the planning of mental health service delivery. Thus, this scoping review aims to map and synthesise research on the use of information and communication technologies (ICTs) to provide mental health services and interventions to YEH.

METHODS AND ANALYSIS

A scoping review of the literature will be conducted, following Arksey and O'Malley's proposed methodology, the Preferred Reporting Items for Systematic reviews and Meta-Analyses Extension for Scoping Reviews and recent guidelines from the Joanna Briggs Institute. All peer-reviewed papers using ICTs as a means of intervention will be considered, as well as grey literature. Only documents in English or French will be included in the analysis. First, 10 electronic databases will be consulted. Next, all data will be extracted into Covidence. Then, two reviewers will independently conduct the screening and data extraction process, in the case of discrepancies, a third reviewer will be included. Finally, data will be synthesised according to our objectives.

ETHICS AND DISSEMINATION

Ethics approval is not required, as data will be collected from published literature. Findings will be disseminated through conference presentations and peer-reviewed journals.

Rates and correlates of well-being among youth experiencing homelessness

Mental health concerns have been well studied among youth experiencing homelessness, yet few studies have explored factors that contribute to well-being in this population. The current cross-sectional study examined rates and correlates of well-being among youth experiencing homelessness. This is a descriptive, secondary analysis of the baseline data from a clinical intervention study. Ninety-nine youth (aged 16-25) who were experiencing homelessness were recruited in Chicago. Approximately 40% of the sample reported average or above average well-being relative to existing benchmarks. Having medical insurance, a mobile phone, and a history of more severe childhood trauma were unique cross-sectional predictors of worse well-being (all ps < 0.034). A significant portion of our sample experienced well-being. Having access to certain resources may be counterintuitive indicators of poorer well-being among youth experiencing homelessness, perhaps because they are indicators of greater need or increased social comparison among these youth.

Understanding the Health and Health-Related Social Needs of Youth Experiencing Homelessness: A Photovoice Study

PURPOSE

Homelessness is a major public health problem facing millions of youths across the United States (U.S.), with lesbian gay, bisexual, transgender, questioning (LGBTQ+) youths and youths of color being disproportionately at higher risk. This study obtains an understanding of the health and health-related social needs of youths experiencing homelessness during the coronavirus disease (COVID-19) pandemic.

METHODS

A total of 14 youths between the ages of 14 and 24 who (a) lived, worked, or attended school in New Britain, Connecticut (CT) and (b) had at least one experience of homelessness or housing insecurity worked with the research team to conduct a needs assessment regarding youth homelessness. Using photovoice, a community-based participatory research method, participants created photo narratives to share their stories and recommendations for community change. The main goals of photovoice are to enable participants to (1) record and represent their everyday realities; (2) promote critical dialogue and knowledge about person and community strengths and concerns; and (3) reach policy makers.

RESULTS

Most of the participants identified as youths of color, and half of the participants identified as members of the LGBTQ+ community. Three major themes that appeared in the youths' narratives include the following: mental health and substance use challenges, trouble accessing basic human needs, and lack of a social support system.

CONCLUSION

This study uplifts and empowers a vulnerable population to increase visibility around a major public health challenge from their own lived experiences. Despite the challenges that were voiced, many participants shared a sense of hope and resiliency. The major themes endorsed by the youths has the potential of informing practitioners and policy makers of how to better address the needs of youths experiencing homelessness, particularly those most at risk.