Motivation to quit cigarettes and alternative tobacco products: prevalence and correlates among youth experiencing homelessness.

Use of alternative tobacco products, as well as regular cigarettes, is widespread among unaccompanied youth experiencing homelessness. However, little is known about their level of motivation for quitting use of these products, factors associated with motivation to quit, or how these might vary by type of tobacco product. Unaccompanied homeless youth were sampled from 25 street and service sites in Los Angeles County (N = 469). All participants were past month tobacco users who completed a survey on their tobacco-related behaviors and cognitions, including motivation to quit, as well as background characteristics. Among self-reported users of each product, motivation to quit in the next 30 days was highest for regular cigarettes (33%), followed by e-cigarettes/vaporizers (30%), little cigars/cigarillos (25%), cigars (20%), and natural cigarettes (20%). Between 33 and 49% of youth, depending on product, were not thinking about quitting at all. Correlates of lower motivation to quit differed somewhat by product type, with the most consistent being race, more frequent use, lower perceived riskiness of the product, and using the product because of its good taste or smell. Results from this study identify a set of psychosocial and behavioral factors, some that are common across tobacco products and others that are product-specific, that may be particularly important to address in efforts to reduce tobacco use among youth experiencing homelessness. Future regulations on the sale of flavored tobacco products may also serve to increase motivation to quit in this population.

Racial Differences in Cigarette Smoking Among Homeless Youth.

INTRODUCTION: Several studies have reported pronounced racial/ethnic differences in smoking behavior among homeless youth. Better understanding the factors underlying racial/ethnic differences in daily smoking among homeless youth may help inform programs to reduce smoking in this population. METHODS: Data come from a probability sample of homeless youth in Los Angeles County collected between 2008 and 2009. The sample includes 116 African American, 99 Hispanic, and 119 White youth with ages ranging from 13 to 24 years. Chi-square tests were used to test the differences in daily smoking among African American, Hispanic, and White youth. Propensity score and doubly robust methods were used to produce a less biased estimate of the association between daily smoking and race/ethnicity after having removed the effect of potential confounders. RESULTS: The daily smoking rate for White youth was 70.1%, more than 31 percentage points than the rates for either African American or Hispanic youth. Propensity score analysis revealed that the majority of the racial/ethnic differences in smoking rates could be explained by differences in homelessness severity, although background characteristics and comorbidity were relevant as well. CONCLUSIONS: As programs are developed to reduce smoking among homeless youth, results suggest that additional outreach may be needed to engage White youth in services. Also, smoking prevention programs may benefit from incorporating a social network-based approach that assists youth in fostering relationships with lower-risk peers, as well as addressing other forms of substance use. Incorporating these elements may help reduce the large racial/ethnic disparities in daily smoking among homeless youth. IMPLICATIONS: This report extends the small existing literature on racial/ethnic differences in smoking among homeless youth in two important respects. First, it confirms differences in daily smoking, an important indicator of dependence, across racial/ethnic groups. Second, it seeks to understand the extent to which differences in smoking can be explained by demographic characteristics (other than race/ethnicity), background factors, homelessness severity, and comorbidity characteristics known to be associated with substance use among homeless youth.

Motivation to Quit and Interest in Cessation Treatment Among Homeless Youth Smokers.

INTRODUCTION: Approximately 70% of unaccompanied homeless youth are current smokers. Although a few studies have described smoking behavior among homeless youth, none have focused on how to help homeless youth quit smoking. As such, there are significant gaps in understanding their interest in quitting and what strategies might best fit their specific needs. METHODS: Unaccompanied homeless youth were randomly sampled from street sites in Los Angeles County (N = 292). All were current smokers who completed a survey on their smoking-related behaviors and cognitions. RESULTS: 65.7% of youth had quit for at least 24hr during the past year, and 43.4% were motivated to quit. Previous quit attempts tended to be unassisted, but 58.6% reported that they would be interested in formal cessation treatment. Multivariate analyses indicated that motivation to quit was higher among youth who were older, Black or Hispanic (vs. White), and who asked about smoking by a service provider, but it was lower among those who were more nicotine dependent. Being interested in cessation treatment was more likely among youth who were asked about smoking by a service provider, anticipated more barriers to quitting, and were motivated to quit; it was less likely among youth who had slept outdoors during the past 30 days. DISCUSSION: Smoking cessation is often considered a low priority for homeless youth. However, many are motivated to quit and are interested in smoking cessation products and services. Implications for developing and engaging homeless youth in cessation treatment are discussed.

To use or not to use: a stage-based approach to understanding condom use among homeless youth.

This study used a stage-based approach to understand condom use behavior in a representative sample of 309 sexually active homeless youth recruited from shelters, drop-in centers, and street sites in Los Angeles County. Focusing on the youth's most recent sexual event, the three stages of condom use examined were: (1) whether the partners decided prior to the event about using condoms; (2) whether a condom was available at the event; and (3) whether a condom was used at the event. Logistic regression analysis was used to identify attitudinal, relationship, and contextual correlates of each of these three stages. Deciding ahead of time about condom use was associated with being Hispanic, level of education, condom attitudes, and various relationship characteristics (e.g., partner type, monogamy, relationship abuse), with the nature of these associations varying depending on the type of decision (i.e., deciding to use, deciding to not use). Condom availability was more likely to be reported by males, if the event was described as being special in some way, or if the event lacked privacy. Condom use was more likely among youth with more positive condom attitudes and among youth who decide ahead of time to use a condom, but less likely among those in monogamous relationships or when hard drugs were used prior to sex. Whether sexual intercourse is protected or unprotected is the end result of a series of decisions and actions by sexual partners. Results from this study illustrate how condom use can be better understood by unpacking the stages and identifying influential factors at each stage. Each stage may, in and of itself, be an important target for intervention with homeless youth.

Alternative tobacco product use and smoking cessation among homeless youth in los angeles county.

INTRODUCTION: Approximately 70% of homeless youth smoke cigarettes, but their use of alternative tobacco products (ATPs) is unknown. This paper reports on ATP use among past-month smokers in Los Angeles County, including whether it differs by demographic characteristics, homelessness severity, past-year quit attempts, and readiness to quit smoking. Given the growing popularity of e-cigarettes, we also report on perceptions of harm and reasons for using this product. METHODS: We surveyed 292 unaccompanied homeless youth who were randomly sampled from street sites. Participants had smoked at least 100 cigarettes during their lifetime and 1 cigarette during the past month. RESULTS: Seventy-two percent of youth reported past-month ATP use (e-cigarettes = 51%; little cigars/cigarillos = 46%; hookah = 31%; other smokeless tobacco product = 24%; chewing tobacco/moist snuff = 19%). Current ATP use was unrelated to most demographic characteristics or having a past-year quit attempt. However, youth who planned to quit smoking in the next 30 days were significantly less likely to report current use of hookahs, other smokeless tobacco products, or e-cigarettes. Among lifetime e-cigarette users, the most common reasons for use included not having to go outside to smoke (38%) and being able to deal with situations or places where they cannot smoke (36%); it was less common to report using e-cigarettes to quit smoking (17%-18%). DISCUSSION: Dual use of ATPs among homeless youth smokers is common and is more likely among those who have no immediate plans to quit smoking. Effective and easily disseminable strategies for reducing all forms of tobacco use among homeless youth are urgently needed.

Physical activity surveillance in parks using direct observation.

INTRODUCTION: Primary features of observational public health surveillance instruments are that they are valid, can reliably estimate physical activity behaviors, and are useful across diverse geographic settings and seasons by different users. Previous studies have reported the validity and reliability of Systematic Observation of Play and Recreation in Communities (SOPARC) to estimate park and user characteristics. The purpose of this investigation was to establish the use of SOPARC as a surveillance instrument and to situate the findings from the study in the context of the previous literature. METHODS: We collected data by using SOPARC for more than 3 years in 4 locations: Philadelphia, Pennsylvania; Columbus, Ohio; Chapel Hill/Durham, North Carolina; and Albuquerque, New Mexico during spring, summer, and autumn. RESULTS: We observed a total of 35,990 park users with an overall observer reliability of 94% (range, 85%-99%) conducted on 15% of the observations. We monitored the proportion of park users engaging in moderate-to-vigorous physical activity (MVPA) and found marginal differences in MVPA by both city and season. Park users visited parks significantly more on weekend days than weekdays and visitation rates tended to be lower during summer than spring. CONCLUSION: SOPARC is a highly reliable observation instrument that can be used to collect data across diverse geographic settings and seasons by different users and has potential as a surveillance system.

Predisposing, enabling and need correlates of mental health treatment utilization among homeless men.

There is significant unmet need for mental health treatment among homeless men, but little is known about the correlates of treatment utilization in this population. Within the framework of the Behavioral Model for Vulnerable Populations, this study examines predisposing, enabling and need factors that may be associated with mental health care utilization. Participants were a representative sample of 305 heterosexually active homeless men utilizing meal programs in the Skid Row region of LA. Logistic regression examined the association between predisposing, enabling and need factors and past 30 day mental health service utilization on Skid Row. Results indicated that while need, operationalized as positive screens for posttraumatic stress disorder or depression, was associated with recent mental health care utilization, predisposing and enabling factors were also related to utilization. African-American homeless men, and those men who also reported substance abuse treatment and drop-in center use, had increased odds of reporting mental health care utilization.

Effects of medical comorbidity on anxiety treatment outcomes in primary care.

OBJECTIVE: To evaluate the effects of medical comorbidity on anxiety treatment outcomes. METHODS: Data were analyzed from 1004 primary care patients enrolled in a trial of a collaborative care intervention for anxiety. Linear-mixed models accounting for baseline characteristics were used to evaluate the effects of overall medical comorbidity (two or more chronic medical conditions [CMCs] versus fewer than two CMCs) and specific CMCs (migraine, asthma, and gastrointestinal disease) on anxiety treatment outcomes at 6, 12, and 18 months. RESULTS: At baseline, patients with two or more CMCs (n = 582; 58.0%) reported more severe anxiety symptoms (10.5 [95% confidence interval {CI} = 10.1-10.9] versus 9.5 [95% CI = 9.0-10.0], p = .003) and anxiety-related disability (17.6 [95% CI = 17.0-18.2] versus 16.0 [95% CI = 15.3-16.7], p = .001). However, their clinical improvement was comparable to that of patients with one or zero CMCs (predicted change in anxiety symptoms = -3.9 versus -4.1 at 6 months, -4.6 versus -4.4 at 12 months, -4.9 versus -5.0 at 18 months; predicted change in anxiety-related disability = -6.4 versus -6.9 at 6 months, -6.9 versus -7.3 at 12 months, -7.3 versus -7.5 at 18 months). The only specific CMC with a detrimental effect was migraine, which was associated with less improvement in anxiety symptoms at 18 months (predicted change = -4.1 versus -5.3). CONCLUSIONS: Effectiveness of the anxiety intervention was not significantly affected by the presence of multiple CMCs; however, patients with migraine displayed less improvement at long-term follow-up. Trial Registration ClinicalTrials.com Identifier: NCT00347269.

Trajectories of change in anxiety severity and impairment during and after treatment with evidence-based treatment for multiple anxiety disorders in primary care.

BACKGROUND: Coordinated Anxiety Learning and Management (CALM) is a model for delivering evidence-based treatment for anxiety disorders in primary care. Compared to usual care, CALM produced greater improvement in anxiety symptoms. However, mean estimates can obscure heterogeneity in treatment response. This study aimed to identify (1) clusters of participants with similar patterns of change in anxiety severity and impairment (trajectory groups); and (2) characteristics that predict trajectory group membership. METHODS: The CALM randomized controlled effectiveness trial was conducted in 17 primary care clinics in four US cities in 2006-2009. 1,004 English- or Spanish-speaking patients age 18-75 with panic, generalized anxiety, social anxiety, and/or posttraumatic stress disorder participated. The Overall Anxiety Severity and Impairment Scale was administered repeatedly to 482 participants randomized to CALM treatment. Group-based trajectory modeling was applied to identify trajectory groups and multinomial logit to predict trajectory group membership. RESULTS: Two predicted trajectories, representing about two-thirds of participants, were below the cut-off for clinically significant anxiety a couple of months after treatment initiation. The predicted trajectory for the majority of remaining participants was below the cut-off by 9 months. A small group of participants did not show consistent improvement. Being sicker at baseline, not working, and reporting less social support were associated with less favorable trajectories. CONCLUSIONS: There is heterogeneity in patient response to anxiety treatment. Adverse circumstances appear to hamper treatment response. To what extent anxiety symptoms improve insufficiently because adverse patient circumstances contribute to suboptimal treatment delivery, suboptimal treatment adherence, or suboptimal treatment response requires further investigation.

Understanding heterosexual condom use among homeless men.

This study uses an event-based approach to examine individual, relationship, and contextual correlates of heterosexual condom use among homeless men. Structured interviews were conducted with a predominantly African American sample of 305 men recruited from meal lines in the Skid Row area of Los Angeles. Men reported on their most recent heterosexual event involving vaginal or anal intercourse. Adjusting for demographic characteristics only, condom use was more likely when men had higher condom use self-efficacy, greater HIV knowledge, or talked to their partner about condoms prior to sex. Condom use was less likely when men held more negative attitudes towards condoms, the partner was considered to be a primary/serious partner, hard drug use preceded sex, or sex occurred in a public setting. Condom attitudes, self-efficacy, partner type, and communication were the strongest predictors of condom use in a multivariate model that included all of the above-mentioned factors. Associations of unprotected sex with hard drug use prior to sex and having sex in public settings could be accounted for by lower condom self-efficacy and/or less positive condom attitudes among men having sex under these conditions. Results suggest that it may be promising to adapt existing, evidence-based IMB interventions for delivery in non-traditional settings that are frequented by men experiencing homelessness to achieve HIV risk reduction and thus reduce a significant point of disparity for the largely African American population of homeless men.

Unprotected sex among heterosexually active homeless men: results from a multi-level dyadic analysis.

HIV is a serious public health problem for homeless populations. Homeless men who have sex with women have received less attention in the HIV risk literature than other homeless populations. This research uses multi-level modeling to investigate the context of unprotected sex among heterosexually active homeless men in the Skid Row area of Los Angeles. Based on interviews with 305 randomly selected men who discussed 665 of their recent female sexual relationships, this project investigates the correlates of unprotected sex during the past 6 months at the partnership, individual, and social network levels. Several different measures of relationship closeness and lack of communication about HIV/condoms were associated with unprotected sex. Controlling for relationship factors, men's negative attitudes towards condoms, mental health, and higher number of male sex partners also were associated with having unprotected sex with female partners. We discuss the implications of these findings for health interventions.

Sex trade behavior among heterosexually active homeless men.

Sex trade behavior is fairly common among homeless adults and may contribute to higher rates of HIV/AIDS in this population. This study provides a detailed examination of the sex trade-related attitudes and behaviors of homeless men by: (1) determining the prevalence of sex trade-related behaviors, including sex with female sex workers (FSWs); (2) identifying risk factors for having sex with FSWs; and (3) comparing men's relationships with FSWs and non-FSWs in terms of relationship qualities and HIV-related risk behaviors, such as condom use. Structured interviews were conducted with a probability sample of 305 heterosexually active homeless men recruited from meal lines in Los Angeles. Recent sex with a FSW was reported by 26 % of men, and more likely among those who were older, used crack cocaine, had more sex partners, believed that sometimes men just need to have sex no matter what, and were embedded in networks that were denser and where risky sex was more normative. Compared to non-FSW partners, men with FSW partners felt less emotionally close to them, were more likely to believe the partner had never been tested for HIV, and were more likely to have sex with them under the influence of drugs or alcohol; however, they were not more likely to talk about using condoms or to use condoms with FSWs. Whether the relationship was considered "serious" was a stronger correlate of condom use than whether the partner was a FSW. Implications of these findings for HIV prevention efforts among homeless adults are discussed.

Race and beliefs about mental health treatment among anxious primary care patients.

Large racial disparities in the use of mental health care persist. Differences in treatment preferences could partially explain the differences in care between minority and nonminority populations. We compared beliefs about mental illness and treatment preferences between adult African-Americans, Hispanics, Asian Americans, Native Americans, and White Americans with diagnosed anxiety disorders. Measures of beliefs about mental illness and treatment were drawn from the National Comorbidity Survey Replication and from our previous work. There were no significant differences in beliefs between the African-Americans and the White Americans. The beliefs of the Hispanics and the Native Americans were most distinctive, but the differences were small in magnitude. Across race/ethnicity, the associations between beliefs and service use were generally weak and statistically insignificant. The differences in illness beliefs and treatment preferences do not fully explain the large, persistent racial disparities in mental health care. Other crucial barriers to quality care exist in our health care system and our society as a whole.

Masculinity and HIV Risk among Homeless Men in Los Angeles.

HIV continues to be a serious public health problem for men who have sex with women (MSW), especially homeless MSW. Although consideration of gender has improved HIV prevention interventions, most of the research and intervention development has targeted how women's HIV risk is affected by gender roles. The effect of gender roles on MSW has received relatively little attention. Previous studies have shown mixed results when investigating the association between internalization of masculine gender roles and HIV risk. These studies use a variety of scales that measure individual internalization of different aspects of masculinity. However, this ignores the dynamic and culturally constructed nature of gender roles. The current study uses cultural consensus analysis (CCA) to test for the existence of culturally agreed upon masculinity and gender role beliefs among homeless MSW in Los Angeles, as well as the relationship between these beliefs and HIV-related behaviors and attitudes. Interviews included 30 qualitative and 305 structured interviews with homeless MSW in Los Angeles's Skid Row area. Analysis identified culturally relevant aspects of masculinity not represented by existing masculinity scales, primarily related to barriers to relationships with women. Behaviors, attitudes, and knowledge related to HIV were significantly associated with men's level of agreement with the group about masculinity. The findings are discussed in light of implications for MSW HIV intervention development.

Measurement Properties of a Park Use Questionnaire.

We determined the criterion validity and test-retest reliability of a brief park use questionnaire. From five US locations, 232 adults completed a brief survey four times and wore a global positioning system (GPS) monitor for three weeks. We assessed validity for park visits during the past week and during a usual week by examining agreement between frequency and duration of park visits reported in the questionnaire to the GPS monitor results. Spearman correlation coefficients (SCC) were used to measure agreement. For past week park visit frequency and duration, the SCC were 0.62-0.65 and 0.62-0.67, respectively. For usual week park visit frequency and duration, the SCC were 0.40-0.50 and 0.50-0.53, respectively. Usual park visit frequency reliability was 0.78-0.88 (percent agreement 69%-82%) and usual park visit duration was 0.75-0.84 (percent agreement 64%-73%). These results suggest that the questionnaire to assess usual and past week park use had acceptable validity and reliability.

Unprotected sex of homeless youth: results from a multilevel dyadic analysis of individual, social network, and relationship factors.

Homeless youth have elevated risk of HIV through sexual behavior. This project investigates the multiple levels of influence on unprotected sex among homeless youth, including social network, individual, and partner level influences. Findings are based on analyses of an exploratory, semi-structured interview (n = 40) and a structured personal network interview (n = 240) with randomly selected homeless youth in Los Angeles. Previous social network studies of risky sex by homeless youth have collected limited social network data from non-random samples and have not distinguished sex partner influences from other network influences. The present analyses have identified significant associations with unprotected sex at multiple levels, including individual, partner, and, to a lesser extent, the social network. Analyses also distinguished between youth who did or did not want to use condoms when they had unprotected sex. Implications for social network based HIV risk interventions with homeless youth are discussed.

Behavioral health and social normative influence: correlates of concurrent sexual partnering among heterosexually-active homeless men.

Sexual concurrency poses significant HIV/STI transmission risk. The correlates of concurrency have not been examined among homeless men. A representative sample of 305 heterosexually active homeless men utilizing meal programs in the Skid Row area of Los Angeles reported on their mental health, substance use, and social network characteristics. Nearly 40% of men reported concurrency with one of their four most recent sex partners. Results indicated that HIV seropositivity (OR = 4.39, CI: 1.10, 17.46; P = 0.04), PTSD (OR = 2.29, CI: 1.05, 5.01; P = 0.04), hard drug use (OR = 2.45, CI: 1.07, 5.58; P = 0.03), and the perception that network alters engage in risky sex (OR = 3.72, CI: 1.49, 9.30; P = 0.01) were associated with increased odds of concurrency. Programs aimed at reducing HIV/STI transmission in this vulnerable population must take into account the roles that behavioral health and social networks may play in sexual concurrency.

Substance use and other risk factors for unprotected sex: results from an event-based study of homeless youth.

This study used an event-based approach to understand condom use in a probability sample of 309 homeless youth recruited from service and street sites in Los Angeles County. Condom use was significantly less likely when hard drug use preceded sex, the relationship was serious, the partners talked about "pulling out", or sex occurred in a non-private place (and marginally less likely when heavier drinking preceded sex, or the partnership was monogamous or abusive). Condom use was significantly more likely when the youth held positive condom attitudes or were concerned about pregnancy, the partners talked about condom use, and the partners met up by chance. This study extends previous work by simultaneously examining a broad range of individual, relationship, and contexual factors that may play a role in condom use. Results identify a number of actionable targets for programs aimed at reducing HIV/STI transmission and pregnancy risk among homeless youth.

Sex and relationships on the street: how homeless men judge partner risk on Skid Row.

Homeless men in the U.S. represent a large and growing population, and have elevated rates of HIV/AIDS and sexual risk behaviors, including unprotected sex with women. We conducted qualitative interviews (n = 30) with homeless men using shelters and meal lines in downtown Los Angeles (Skid Row) to better understand how such men view the risks of sexual encounters with female partners. Men living on Skid Row perceived multiple risks, including HIV and unwanted pregnancy as well as emotional trauma, loss of resources, exacerbation of drug addiction, and physical attack. Respondents described using visual and behavioral cues, social reputation, geographical location, feelings of trust, perceived relationship seriousness, and medically inaccurate "folk" beliefs to judge whether partners were risky and/or condom use was warranted. Medically inaccurate beliefs suggest the potential utility of evidence-based interventions to change such beliefs. We also consider implications for relationships on the street and housing interventions.

Use of complementary and alternative medicine in a large sample of anxiety patients.

OBJECTIVE: To examine a large sample of patients with anxiety and the association between types of complementary and alternative treatments that were used, demographic variables, diagnostic categories, and treatment outcomes. METHOD: Cross-sectional and longitudinal survey during the Coordinated Anxiety Learning and Management (CALM) study that assessed this intervention against the Usual Care in a sample of patients with anxiety recruited from primary care. Interviewer-administered questionnaires via a centralized telephone survey by blinded assessment raters. The interviews were done at baseline, 6, 12, and 18 months of the study. A total of 1004 adults ages 18-75 who met DSM-IV criteria for Generalized Anxiety Disorder (GAD), Panic Disorder, Social Anxiety Disorder, or Post-Traumatic Stress Disorder. We assessed medication/herbal use, the use of any alternative therapies, and combined Complementary and Alternative Medicine (CAM) use. RESULTS: We found an extensive (43%) use of a variety of CAM treatments that is consistent with previous study results in populations with anxiety. Only a few significant demographic or interventional characteristics of CAM users were found. Users most often had a diagnosis of GAD, were older, more educated, and had two or more chronic medical conditions. CAM users who had a 50% or more drop in anxiety scores over 18 months were less likely to report continued use of alternative therapies. CONCLUSIONS: The study confirms the importance of awareness of CAM use in this population for possible interference with traditional first-line treatments of these disorders, but also for finding the best integrative use for patients who require multiple treatment modalities.