The effect of early maltreatment, victimization, and partner violence on HIV risk behavior among homeless young adults

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.

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.

Determinants of depression and anxiety in homeless people: A population survey of homeless people in Hong Kong

BACKGROUND

There are growing concerns about the homeless and mental health issues globally. This study aims to examine the mental health situation of homelessness and the determinants of anxiety and depression of them in Hong Kong.

METHOD

The data from the largest territory-wide study of the homeless population in 2021 was analyzed. Descriptive statistics and logistic regressions were used to investigate the association between mental health and socioeconomic variables, including demographic background, economic indicators, COVID-19 worries, government measures, and respect by others. The symptoms of depression and anxiety were assessed using Patient Health Questionnaire (PHQ) and General Anxiety Disorder (GAD).

RESULTS

The results showed that being female, food insecurity, and chronic diseases were the risk factors for anxiety and depression. A high level of respect by others was the protective factor for depression (adjusted OR 0.37, 95% CI [0.23, 0.61]) and anxiety (adjusted OR 0.40, 95% CI [0.24, 0.68]), compared to a low level of respect in the multivariate model.

CONCLUSIONS

Providing medical outreach services, additional resources for social services, implementation of homeless-friendly policies, and a progressive supply of public and transitional housing would help enhance the well-being of the homeless population.

Resourcefulness of homeless young people who practise sex work in Pakistan: a qualitative study

Background Many homeless young people in Pakistan use sex work as a way to generate income, particularly if they have few other options for work. Because it is highly stigmatised, little attention has been paid to the strategies homeless young people use to practise sex work, and what this suggests about their capacities and strengths. Methods Semi-structured interviews were conducted with 29 homeless young people (aged 16-25years) from Rawalpindi, Pakistan, including nine cisgender heterosexual men, six cisgender heterosexual women, seven cisgender gay men, and seven transgender heterosexual women. Results Participants sought memberships in street-based peer groups where financial gains were contingent on dancing and sex work. To practise their work successfully, participants learned novel skills and mobilised material resources available to them on the streets. Participants talked about how they acquired and benefitted from skills related to beautification, dancing, communication, and sexual services to achieve the necessary standards for entertainment and sex work. Access to material resources like makeup, clothes, rented rooms, mobile phones and condoms made dancing and sex work possible and safer for participants. Conclusions Participants' improvisation with limited resources on the streets has important implications for policy and programs. Showcasing the resourcefulness and capacities of young people encourages a different way of thinking about them. This potential could be utilised in productive ways if they were given the chance to receive mainstream and technical education, better health support and access to the formal job market.

Sexual risk-taking among homeless young people in Pakistan

Homeless young people who engage in sex work are at increased risk of HIV and other sexually transmitted infections like chlamydia, gonorrhoea, syphilis and herpes. Semi-structured interviews were conducted with 29 homeless young people between the ages of 16 and 25 years from Rawalpindi, Pakistan, to explore how sexual practices were mediated through social and contextual conditions. Participants engaged in sex for a range of reported reasons, most commonly to generate income, but also to build intimacy and to establish intimate partnerships which could bring physical protection and social and emotional support. Although participants were aware of the sexual health risks attached to condomless sex, they engaged in it due to the social obligations of intimate partnerships, financial considerations and to better manage potentially violent situations. Instead of condoms, participants used alternate methods like withdrawal, oral sex, post-sex douching and specific sexual positions. These were not always useful, and some methods might have inadvertently increased their risk of HIV. The study findings suggest that an integrated health promotion approach that goes beyond the health sector and a singular emphasis on risk awareness may help reduce young people's risk of homelessness and sexual health risks.

Efficacy of a Just-in-Time Adaptive Intervention to Promote HIV Risk Reduction Behaviors Among Young Adults Experiencing Homelessness: Pilot Randomized Controlled Trial

BACKGROUND

People experiencing homelessness have higher rates of HIV than those who are stably housed. Mental health needs, substance use problems, and issues unique to homelessness such as lack of shelter and transiency need to be considered with regard to HIV prevention. To date, HIV prevention interventions for young adults experiencing homelessness have not specifically addressed modifiable real-time factors such as stress, sexual or drug use urge, or substance use, or been delivered at the time of heightened risk. Real-time, personalized HIV prevention messages may reduce HIV risk behaviors.

OBJECTIVE

This pilot study tested the initial efficacy of an innovative, smartphone-based, just-in-time adaptive intervention that assessed predictors of HIV risk behaviors in real time and automatically provided behavioral feedback and goal attainment information.

METHODS

A randomized attention control design was used among young adults experiencing homelessness, aged 18-25 years, recruited from shelters and drop-in centers in May 2019. Participants were randomized to either a control or an intervention group. The intervention (called MY-RID [Motivating Youth to Reduce Infection and Disconnection]) consisted of brief messages delivered via smartphone over 6 weeks in response to preidentified predictors that were assessed using ecological momentary assessments. Bayesian hierarchical regression models were used to assess intervention effects on sexual activity, drug use, alcohol use, and their corresponding urges.

RESULTS

Participants (N=97) were predominantly youth (mean age 21.2, SD 2.1 years) who identified as heterosexual (n=51, 52%), male (n=56, 57%), and African American (n=56, 57%). Reports of sexual activity, drug use, alcohol use, stress, and all urges (ie, sexual, drug, alcohol) reduced over time in both groups. Daily drug use reduced by a factor of 13.8 times over 6 weeks in the intervention group relative to the control group (Multimedia Appendix 4). Lower urges for sex were found in the intervention group relative to the control group over the duration of the study. Finally, there was a statistically significant reduction in reports of feeling stressed the day before between the intervention and control conditions (P=.03).

CONCLUSIONS

Findings indicate promising intervention effects on drug use, stress, and urges for sex in a hard-to-reach, high-risk population. The MY-RID intervention should be further tested in a larger randomized controlled trial to further investigate its efficacy and impact on sexual risk behaviors.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03911024; https://clinicaltrials.gov/ct2/show/NCT03911024.

Self-Esteem and Resilience Differences Among Street Children Compared to Non-street Children in Limpopo Province of South Africa: A Baseline Study

The phenomenon of street children is a challenging global social problem. Using an independent sample group design, this study explored the differences in self-esteem and resilience among street children and non-street children. A total of 300 (N = 300) street children with ages ranging from 8 to 18 years were selected using a purposive sampling method, while a total of 300 (N = 300) non-street children with ages ranging from 8 to 18 years were selected using a simple random sample to participate in this study. A questionnaire with three sections was used to collect data. Results of an independent sample t-test revealed that street children reported low self-esteem and poor resilience compared to non-street children. The study, therefore, concluded that street children and non-street children differ on self-esteem and resilience. It is recommended that social skills training be provided for the street children population.

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.

Gender Differences in the Path From Sexual Victimization to HIV Risk Behavior Among Homeless Youth

Experiencing sexual victimization prior to becoming homeless is common among homeless youth and is associated with increased HIV risk behavior. This study examined mediating variables that underlie this association, adding to the understanding of gender differences in these paths. Participants were homeless youth in Los Angeles recruited through service access centers who completed a computerized self-administered interview in English or Spanish using an iPad. Findings indicate a high presence of sexual victimization across both genders. Female participants experienced posttraumatic stress disorder and subsequent engagement with exchange sex, whereas male participants were primarily involved in substance use risk pathways. Results indicate paths in the association between sexual victimization and HIV risk behavior differ between male and female homeless youth. Gender-specific, mental-health-informed interventions targeting sexual risk reduction are warranted.

Child Maltreatment and Risky Sexual Behavior

Risky sexual behavior is a serious public health problem. Child sexual abuse is an established risk factor, but other forms of maltreatment appear to elevate risky behavior. The mechanisms by which child maltreatment influence risk are not well understood. This study used data from 859 high-risk youth, followed through age 18. Official reports of each form of maltreatment were coded. At age 16, potential mediators (trauma symptoms and substance use) were assessed. At age 18, risky sexual behavior (more than four partners, unprotected sex, unassertiveness in sexual refusal) was assessed. Neglect significantly predicted unprotected sex. Substance use predicted unprotected sex and four or more partners but did not mediate the effects of maltreatment. Trauma symptoms predicted unprotected sex and mediated effects of emotional maltreatment on unprotected sex and on assertiveness in sexual refusal and the effects of sexual abuse on unprotected sex. Both neglect and emotional maltreatment emerged as important factors in risky sexual behavior. Trauma symptoms appear to be an important pathway by which maltreatment confers risk for risky sexual behavior. Interventions to reduce risky sexual behavior should include assessment and treatment for trauma symptoms and for history of child maltreatment in all its forms.

Childhood Maltreatment and Revictimization in a Homeless Population

We examined the hypothesis that exposure to childhood maltreatment increases the vulnerability to Adult Victimization (AV) in a homeless population (N = 500). We also investigated the effects of specific types (emotional, physical, and sexual) and cumulative experience of childhood maltreatment on AV, and whether gender moderates these relationships. All three groups with AV experience (emotional, physical, and sexual) indicated higher exposure to childhood abuse and cumulative maltreatment, and those who were sexually victimized as an adult showed higher exposure to childhood neglect. In addition, exposure to childhood maltreatment had type-specific and cumulative effects on AV. Exposure to all types of childhood abuse maintained a strong direct association with AV, regardless of demographic characteristics, including age, ethnicity, marital status, education level, and housing situation. In addition, exposure to physical neglect showed a significant relationship with Adult Sexual Victimization. Cumulative experience of childhood maltreatment was consistently associated with cumulative risk of experiencing AV. Gender had no significant effect on these relationships. Findings suggest that intervention programs in homeless population should consider the history of childhood maltreatment and its characteristics to increase the effectiveness of intervention strategies for AV in this population.

Effects of Abusive Parenting, Caretaker Arrests, and Deviant Behavior on Dating Violence among Homeless Young Adults

Though dating violence is widespread among young adult homeless populations, its risk factors are poorly understood by scholars. To address this gap, the current study uses a social learning theory to examine the effects of abusive parenting and caretaker arrests on dating violence among 172 homeless young adults. Results from path analyses revealed that child physical abuse and caretaker arrests were positively associated with engaging in a greater number of school fights, which, in turn, was strongly and positively correlated with participating in more deviant subsistence strategies (e.g., stealing) since being on the street. Young people who participated in a greater number of delinquent acts were more likely to report higher levels of dating violence. Study results highlight the extent of social learning within the lives of homeless young adults, which is evident prior to their leaving home and while they are on the street.

An Exploratory Factor Analysis of Coping Styles and Relationship to Depression Among a Sample of Homeless Youth

The extent to which measures of coping adequately capture the ways that homeless youth cope with challenges, and the influence these coping styles have on mental health outcomes, is largely absent from the literature. This study tests the factor structure of the Coping Scale using Exploratory Factor Analysis (EFA) and then investigates the relationship between coping styles and depression using hierarchical logistic regression with data from 201 homeless youth. Results of the EFA indicate a 3-factor structure of coping, which includes active, avoidant, and social coping styles. Results of the hierarchical logistic regression show that homeless youth who engage in greater avoidant coping are at increased risk of meeting criteria for major depressive disorder. Findings provide insight into the utility of a preliminary tool for assessing homeless youths' coping styles. Such assessment may identify malleable risk factors that could be addressed by service providers to help prevent mental health problems.

Child Abuse, Street Victimization, and Substance Use Among Homeless Young Adults

Although previous research documents high rates of child abuse, street victimization, and substance use among homeless youth, few studies have investigated these three constructs simultaneously, and thus little is known about how various forms of victimization are uniquely associated with substance use among this population. The purpose of this article is to examine the relationship among child sexual and physical abuse, street victimization, and partner violence with substance use among 172 homeless young adults. Path analysis results revealed that males and those who reported parental drug problems were significantly more likely to have higher rates of substance use. Those who suffered more childhood physical and sexual abuse and those who experienced more types of relationship violence were more likely to report greater frequency of substance use. The intersection of various forms of victimization with substance use may have important implications for service providers working with this population.

Prevalence of childhood abuse among people who are homeless in Western countries: a systematic review and meta-analysis

PURPOSE

This article systematically reviews studies of prevalence of childhood experience of physical and sexual abuse in adult people who are homeless in Western countries.

METHODS

Medline, PsychInfo, and the Cochrane Library were searched using the keywords: homeless*, child* abuse, child* trauma, and child* adversity and the bibliographies of identified articles were reviewed. Sources of heterogeneity in the prevalence rates were explored by meta-regression analysis.

RESULTS

Twenty-four reports published between January 1990 and August 2013 in three countries provided estimates obtained from up to 9,730 adult individuals who were homeless. Prevalence of reported childhood physical abuse ranged from 6 to 94% with average prevalence of 37%, 95% CI [25, 51]. Reported sexual abuse ranged from 4 to 62%, with average prevalence estimated as 32%, 95% CI [23, 44] for female and 10% for male, 95% CI [6, 17]. Substantial heterogeneity was observed among the studies (I2 ≥ 98%). Including moderators greatly reduced but did not eliminate this heterogeneity. Moderator analyses suggested that reported physical abuse tended to be higher for predominately white samples and tended to be lower for younger samples. Sexual abuse was far more prevalent in predominately female samples and slightly higher in non-US samples and convenience samples.

CONCLUSIONS

The findings of this study suggest that childhood physical and sexual abuse is more prevalent among the homeless in Western countries than in the global population. Physical abuse appears to be particularly prevalent in younger samples and sexual abuse rates are higher in predominately female samples. Further investigation is needed to advance our understanding of how trauma informed treatment and care for the homeless effectively can take into account the service user's experiences of childhood abuse.

Early parenting: the roles of maltreatment, trauma symptoms, and future expectations

The psychosocial determinants of early parenting are still not well understood. The current study used data on 115 girls in the Capella Project, who were followed longitudinally for the first 18 years of life. Potential predictors of early parenting assessed were child maltreatment, trauma symptoms, and girls' expectations for their socioeconomic outcomes. Cox regression survival analyses were conducted to predict time to the birth of first child. Significant unique predictors of early parenting included neglect, anxiety, low depression, and low expectations of going to college. Practice and research implications of these findings include the importance of neglect for risk of early parenting, the importance of ongoing trauma symptoms in youth, and the potentially protective influence of expectations of going to college.

Is there an emotional cost of completing high school? Ecological factors and psychological distress among LGBT homeless youth

This study explored the nexus of home and school climate on the psychological distress of lesbian, gay, bisexual, and transgender (LGBT) homeless youth, as well as their experiences during high school. Of the LGBT homeless youth (N = 89) surveyed, 39.3% reported not completing high school. Most participants did not seek support from school staff nor did they report attending a school with a Gay-Straight Alliance. Significantly higher levels of psychological distress were found among high school graduates and those reporting LGBT harassment at home; however, harassment experienced at school was not statistically related to psychological distress. Findings are discussed.

Substance use predictors of victimization profiles among homeless youth: a latent class analysis

Although a substantial body of literature demonstrates high prevalence of street victimization among homeless youth, few studies have investigated the existence of victimization classes that differ on the type and frequency of victimization experienced. Nor do we know how substance use patterns relate to victimization classes. Using latent class analysis (LCA), we examined the existence of victimization classes of homeless youth and investigated substance use predictors of class membership utilizing a large purposive sample (N=601) recruited from homeless youth-serving host agencies in three disparate regions of the U.S. Results of the LCA suggest the presence of three distinct victimization profiles - youth fit into a low-victimization class, a witness class, or a high-victimization class. These three victimization classes demonstrated differences in their substance use, including rates of substance abuse/dependence on alcohol and/or drugs. The presence of distinct victimization profiles suggests the need for screening and referral for differential services.

Experiences of community and parental violence among HIV-positive young racial/ethnic minority men who have sex with men

Adolescents and young adults (ages 13-24) in the USA are frequently exposed to violence in their community and home. While studies have examined the prevalence and impact of violence exposure among adolescents, there is a lack of data focusing specifically on adolescent men of color who have sex with men. Eight demonstration sites funded through a Special Projects of National Significance (SPNS) Initiative recruited 363 HIV-positive racial/ethnic minority young men who have sex with men (YMSM) for a longitudinal study between 2006 and 2009. Over two-thirds of participants (83.8%) had witnessed community violence, 55.1% in the prior three months. Witnessing violence committed with a deadly weapon was significantly associated with being African-American, having ever used drugs, and drinking alcohol in the prior two weeks. Fear of violence in the community was significantly associated with depressive symptomatology, having less than a high school degree, not possessing health insurance, and site of enrollment. Having been emotionally or physically abused by a parent or caretaker was significantly associated with depressive symptomatology, attempting suicide, site of enrollment, and increased age. Witnessing violence with a deadly weapon was significantly associated with alcohol and drug use but not with high-risk sexual behaviors. As this was one of the first studies on the prevalence and correlates of violence exposure among racial/ethnic minority YMSM living with HIV, the findings can be used to inform the development of culturally appropriate resilience-focused interventions to address the aftereffects of violence exposures and help develop social support systems outside of the family.

The intersection of intimate partner violence and HIV in U.S. women: a review

The purposes of this study were to (a) review original research in the United States on the intersection of HIV risk and intimate partner violence (IPV) in women, and (b) identify trends that promote nursing and public health prevention and intervention strategies. Twenty-three original, peer-reviewed articles in the medical literature from 2008 to April 2012 were reviewed. Articles were eligible for inclusion if they addressed both HIV and IPV in women. Studies identified relationships between intimate partner victimization and HIV risk behaviors. Other factors compounding the complex relationship between IPV and increased HIV risk in women included sexual decision-making, male behavior, and substance use. A promising trend was found in the publication of studies addressing interventions. Prospective studies are needed to determine causality and temporal associations. Nursing interventions should focus on identifying women at risk for IPV, assessing HIV exposure risks, and providing culturally sensitive interventions and preventive measures.

The relationship between victimization and substance use among homeless and runaway female adolescents

Each year, thousands of female adolescents run away from home due to sexual abuse, yet they continue to be victims of sexual assault once on the street. To date, few studies have examined how various forms of victimization are related to different types of substance use. The purpose of this article is to investigate the relationship between street exposure, childhood abuse, and different forms of street victimization with alcohol and marijuana use among 137 homeless and runaway female adolescents. Results from path analysis revealed that child sexual abuse was positively linked to trading sex and sexual and physical victimization. In addition, those who have traded sex experienced greater physical victimization, and who have spent more time away from home, used alcohol more frequently. Moreover, trading sex and experiencing more types of sexual victimization were positively linked to more frequent marijuana usage. Age, age at first run, longest time away from home, sexual abuse, and trading sex had significant indirect effects on alcohol and/or marijuana use. Together, these factors accounted for 27% of the variance in alcohol use and 37% of the variance in marijuana use.

A cluster analysis of service utilization and incarceration among homeless youth

Our paper examines service usage (e.g., shelter) as well as a typology of individuals who are most likely to use groupings of services among 249 homeless youth. Our results revealed that the majority of homeless young people have used food programs (66%) and street outreach (65%) on at least one occasion within the past year. Cluster analysis of services revealed four distinct groups: (1) basic survival service use, characterized by above average shelter, food, and outreach service use, but below average on counseling, substance abuse/mental health services, and incarceration; (2) multiple service use, which included above average use of all six services; (3) incarceration experience, characterized by above average incarceration experience, but below average use of all other five services; and (4) minimal service use, which included slightly above average use of counseling, but below average use of all other services. These findings have the potential to provide important information that may assist with targeting services to homeless youth.

Psychiatric symptom typology in a sample of youth receiving substance abuse treatment services: associations with self-reported child maltreatment and sexual risk behaviors

Latent profile analysis (LPA) was used to classify 394 adolescents undergoing substance use treatment, based on past year psychiatric symptoms. Relations between profile membership and (a) self-reported childhood maltreatment experiences and (b) current sexual risk behavior were examined. LPA generated three psychiatric symptom profiles: Low-, High- Alcohol-, and High- Internalizing Symptoms profiles. Analyses identified significant associations between profile membership and childhood sexual abuse and emotional neglect ratings, as well as co-occurring sex with substance use and unprotected intercourse. Profiles with elevated psychiatric symptom scores (e.g., internalizing problems, alcohol abuse and dependence symptoms) and more severe maltreatment histories reported higher scores for behavioral risk factors for HIV/STI exposure. Heterogeneity in psychiatric symptom patterns among youth receiving substance use treatment services, and prior histories of childhood maltreatment, have significant implications for the design and delivery of HIV/STI prevention programs to this population.