Nominal Versus Realized Costs of Recruiting and Retaining a National Sample of Sexual Minority Adolescents in the United States: Longitudinal Study.

BACKGROUND: Web-based recruitment for research studies is becoming increasingly popular and necessary. When compared with the traditional methods of recruitment, these methods may enable researchers to reach more diverse participants in less time. Social media use is highly prevalent among adolescents, and the unique context of social media may be particularly important for the recruitment of sexual minority young people who would not be captured by traditional methods. OBJECTIVE: This paper described the details of a national web-based study recruitment approach aimed at sexual minority adolescents across the United States, focusing on important details of this relatively novel approach, including cost, time efficiency, and retention outcomes. METHODS: This study recruited sexual minority adolescents aged 14-17 years living in the United States through targeted advertisements on Facebook, Instagram, and YouTube and through respondent-driven sampling (RDS). Potential participants completed eligibility screening surveys and were automatically directed to a baseline survey if they were eligible. After baseline survey completion, additional data checks were implemented, and the remaining participants were contacted for recruitment into a longitudinal study (surveys every 6 months for 3 years). RESULTS: Recruitment lasted 44 weeks, and 9843 participants accessed the initial screening survey, with 2732 (27.76%) meeting the eligibility criteria and completing the baseline survey. Of those, 2558 (93.63%) were determined to have provided nonfraudulent, usable study data and 1076 (39.39%) subsequently enrolled in the longitudinal study. Of the baseline sample, 79.05% (2022/2558) was recruited through Facebook and Instagram, 3.05% (78/2558) through YouTube, and 17.9% (458/2558) through RDS. The average cost of recruiting a participant into the study was US $12.98, but the recruitment cost varied by method or platform, with a realized cost of US $13 per participant on Facebook and Instagram, US $24 on YouTube, and US $10 through RDS. Participant differences (sex assigned at birth, race and ethnicity, sexual orientation, region, and urbanicity) were identified between platforms and methods both in terms of overall number of participants and cost per participant. Facebook and Instagram were the most time efficient (approximately 15 days to recruit 100 participants), whereas RDS was the least time efficient (approximately 70 days to recruit 100 participants). Participants recruited through YouTube were the most likely to be longitudinally retained, followed by Facebook and Instagram, and then RDS. CONCLUSIONS: Large differences exist in study recruitment cost and efficiency when using social media and RDS. Demographic, region, and urbanicity differences in recruitment methods highlight the need for attention to demographic diversity when planning and implementing recruitment across platforms. Finally, it is more cost-effective to retain than recruit samples, and this study provided evidence that with thorough screening and data quality practices, social media recruitment can result in diverse, highly involved study populations.

The Development of Proud & Empowered: An Intervention for Promoting LGBTQ Adolescent Mental Health.

Sexual and gender minority adolescents (SGMA) experience higher rates of internalizing psychopathology, including depression, anxiety, self-harm, and posttraumatic stress disorder. The primary explanation for these mental health disparities is minority stress theory, which suggests that discrimination, violence, and victimization are key drivers of chronic minority stress and place SGMA at higher risk of mental health concerns. To help address these concerns, the authors undertook a nearly 8-year process of developing Proud & Empowered, a school-based intervention to help SGMA cope with minority stress experiences. This manuscript details the intervention development process, including: (a) identifying the mechanisms of change (Stage 0), (b) building the intervention (Stage 1A, Part 1), (c) acceptability testing and program revision (Stage 1A, Part 2), (d) feasibility and pilot testing (Stage 1B, Part 1), (e) modification of the intervention to improve implementability (Stage 1B, Part 2), and (f) the final intervention.

Health Care Needs of Young Adults Who Have Experienced Homelessness.

INTRODUCTION: Young adults experiencing homelessness have poorer overall health compared with the general population. However, not much is known about how health care needs may change in the transition from homelessness to supportive housing. This study utilizes the Gelberg-Andersen Behavioral Model for Vulnerable Populations to examine unmet health care needs among young adults currently experiencing homelessness and formerly homeless young adults living in supportive housing. METHODS: This study includes data from 192 young adults who were either residing in a supportive housing program (n=103) or were "unhoused" (eg, residing on the street, staying in emergency shelters; n=89) in Los Angeles, CA, between 2017 and 2019. Hierarchical modeling examined unmet health care needs and factors that may enable those needs to be met, controlling for predisposing and other need factors. RESULTS: Controlling for predisposing and other need characteristics, this study identified increased enabling factors among those residing in supportive housing, the most widely applied intervention for homelessness. Participants who resided in supportive housing were more likely to report at least 1 type of unmet need than youth who did not have access to housing. Additional findings regarding the association of enabling factors and unmet need yield mixed results based on the type of unmet need. DISCUSSION: The acknowledgment of unmet needs may, in fact, be a byproduct of shifting priorities, which often occurs in the transition from homelessness to housing. Understanding the unmet need and health implications of this transition has relevance for practice as we work to better support formerly homeless young adults in meeting the needs that they identify.

The Effect of Momentary Affect on Substance Use among Young Adults Who Experience Homelessness.

IntroductionLittle is known about the momentary patterns and predictors of substance use among young adults who experience homelessness. To enhance understanding of substance use patterns, smartphone-based ecological momentary assessment (EMA) was utilized to examine the real-time association between affect and substance use. Methods: 251 young adults (aged 18-27) with history of homelessness were recruited from supportive housing programs and drop-in facilities in Los Angeles. Exploratory factor analysis was used to examine the latent structure of positive and negative affective states and mixed-effects logistic regression models were completed separately for both the full remaining sample (n = 227) and a subsample of alcohol or cannabis users (n = 145) to evaluate whether positive or negative affect predicted lead, recent, or lagged substance use. Results: Greater positive affect within-person was associated with greater odds of alcohol or cannabis use within the past two hours, and participants who reported feeling more negative than their peers experienced greater odds of reporting use within the past 4 h and the following two hours. Conclusion: Results suggest that individuals experience a heightened positive mood compared to their own average mood, concurrently or immediately after engaging in alcohol or cannabis use. Heightened positive mood might be an anticipatory effect of drinking or cannabis use. Future research should consider a longer study period to capture multiple drinking or drug use events over a longer period and consider more environmental exposures that may influence the frequency or intensity of substance use.

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 (ß = .27, p < .001). Compared to cis-hetero participants, cisgender sexual minorities (ß = -.23, p = .03) and sexual and gender minorities (ß = -.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.

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

BACKGROUND: The estimated 3.5-million transition age youth (TAY) who experience homelessness in the United States annually are routinely exposed to inadequate sleep environments and other psychosocial risk factors for deficient sleep. Although staying in a shelter versus being unsheltered may facilitate sleep, research suggests that perceived safety wherever one sleeps may be just as important. In this study, which is the first known study to investigate sleep disturbances among TAY experiencing homelessness, we examine associations of sleep disturbances with sheltered status and perceived safety of usual sleep environment. METHODS: We surveyed TAY (aged 18-25) experiencing homelessness in Los Angeles, CA about their sleep, psychosocial health, and living situations. Participants (n=103; 60% sheltered) self-reported sleep disturbances using the Patient-Reported Outcomes Measurement Information System Sleep Disturbance short form, while individual items assessed sheltered status and perceived safety where they usually slept. Regression analyses examined associations of sheltered status and perceived sleep environment safety with sleep disturbance, adjusting for age, sex, race, self-rated health, depression symptoms, serious mental illness, high-risk drinking, and severe food insecurity. RESULTS: Twenty-six percent of participants reported moderate-severe sleep disturbances. Sleep disturbance was not associated with sheltered status, but was positively associated with feeling unsafe in one's sleep environment, depression symptoms, severe food insecurity, and decreased age. CONCLUSIONS: Our findings suggest that sleep disturbances among TAY experiencing homelessness are associated more closely with how safe one feels rather than one's sheltered status. This highlights the importance of providing safe places to live for sheltered and unsheltered TAY.

Investigating Sleep Disturbance and Its Correlates Among Formerly Homeless Adults in Permanent Supportive Housing.

BACKGROUND: Adults experiencing homelessness have a high burden of sleep disturbance, which may be reduced by accessing permanent supportive housing. OBJECTIVES: To assess sleep disturbances and their correlates, including demographics, activity level, health status, age-related health issues (eg, functionality and cognitive impairment), substance use, and homelessness history in a sample of permanent supportive housing (PSH) tenants. RESEARCH DESIGN: Cross-sectional survey design. SUBJECTS: A total of 237 formerly homeless adults between 45 and 80 years old. MEASURES: The Patient-Reported Outcomes Measurement Information System (PROMIS) Sleep Disturbance short form was used to measure sleep disturbance. RESULTS: Twenty-eight percent of our sample had PROMIS scores indicative of a moderate or severe sleep disturbance. Functional impairment, pain, and mental health comorbidities were associated with increased sleep disturbance in multivariable linear regression analyses. The number of years a person experienced homelessness was inversely associated with sleep disturbance. CONCLUSIONS: This study supports the need to screen for sleep disturbances among PSH tenants. The findings suggest that supportive services in PSH may need to include integrated physical and behavioral health care, pain management, and interventions designed to address activities of daily livings to improve tenant sleep. They also suggest that improved sleep may help reduce PSH tenant pain, impairment, and mental health symptoms among PSH tenants.

Examining HIV Risk and Exchange Sex Among Current and Formerly Homeless Young Adults.

This study investigated HIV risk among homeless and formerly homeless young adults by examining risky sex behaviors (e.g., condomless sex, exchange sex, and sex with multiple persons) using 90-day and daily recall methods. Data came from a sample of young adults (aged 18-27) with current (n = 101) or past (n = 109) homelessness experience in Los Angeles, California, recruited between 2017 and 2019. Baseline surveys queried demographics and sexual history. Daily retrospective surveys queried sexual events. Multiple logistic regressions were used to test the effects of demographic characteristics including homelessness history, relationship status, substance use, and sexual history on risky sex outcomes. In this sample, 26% reported never using a condom during anal or vaginal sex in the past 90 days, 5% reported testing positive for HIV, 82% had limited to no knowledge of preexposure prophylaxis, and 8% reported having had exchange sex during a 7-day measurement period, with those experiencing homelessness more likely to report. The study suggests supportive housing can reduce the occurrence of exchange sex but that HIV prevention services are still needed in homeless and housing programs to promote safe sexual practices.

Reducing behavioral health symptoms by addressing minority stressors in LGBTQ adolescents: a randomized controlled trial of Proud & Empowered.

BACKGROUND: Minority stress may lead to poorer mental health for sexual and gender minority adolescents, yet no interventions have been tested through an RCT to address these concerns. METHODS: We report on an RCT of an intervention-Proud & Empowered-with four high schools. Measures assess the intervention's impact on mental health symptoms. RESULTS: Compared to the control, participants in the treatment condition reported significant differences in minority stress, anxiety, and depressive symptoms. Moderation analyses showed that the intervention significantly moderated the relationship between minority stress and PTSD (b = -1.28, p = .032), depression (b = -0.79, p = .023), and suicidality (b = 0.14, p = .012) symptoms; those in the intervention condition had mitigated relationships between measures of stress and health outcomes compared to those in the control condition. CONCLUSIONS: Results suggest that Proud & Empowered help reduce mental health symptoms and exposure to minority stressors and build coping strategies. TRIAL REGISTRATION: The intervention was registered on clinicaltrials.gov on August 1, 2019 under Trial # NCT04041414 .

Sexual Minority Stress, Mental Health Symptoms, and Suicidality among LGBTQ Youth Accessing Crisis Services.

Sexual and gender minority youth are at elevated risk for suicide. Studies have separately established the relation between minority stress and mental health symptoms, as well as minority stress and suicidality. However, no known research has simultaneously examined different mental health mechanisms whereby minority stress may be associated with different suicidal experiences (e.g., suicidal ideation, suicide attempts). The present study used data from a national sample of 572 sexual and gender minority youth aged 12 to 24 (mean age = 17.59; SD = 3.13) recruited from an LGBTQ youth-focused suicide crisis prevention provider. Nearly one-third of the sample (30.2%) identified as transgender, genderqueer, or questioning. Nearly one quarter of the sample (24.3%) identified as gay, 17.1% as pansexual, 16.8% as bisexual, and 15.2% as lesbian. Structural equation modeling was used for mediation analyses to explain suicidal ideation and suicide attempts. Serial mediation models were determined to be the best fit for both suicide-related outcomes. Minority stress was associated with depressive and PTSD symptoms, which were linked with suicidal ideation and attempt through hopelessness. The findings supported the hypotheses that minority stress would be associated with suicidality not just directly, but also indirectly through multiple mental health symptom pathways.

DOES THE TIMING OF INCARCERATION IMPACT THE TIMING AND DURATION OF HOMELESSNESS? EVIDENCE FROM "THE TRANSITIONS TO HOUSING" STUDY.

Compared to their non-homeless peers, chronically homeless adults are much more likely to have a history of incarceration. In turn, homelessness is associated with increased morbidity, lack of access to adequate healthcare services, and decreased life expectancy. This study investigates whether age at first incarceration is associated with age at first homeless experience and with lifetime duration of literal homelessness. Study participants are homeless adults entering permanent supportive housing (PSH) in Los Angeles County, California, that have experienced incarceration prior to their first experience of homelessness (n=230). Multivariate linear regressions were conducted to determine association between age at first incarceration with: 1) age at first literal homelessness and 2) lifetime duration of literal homelessness. Results indicate that incarceration as a juvenile and young adult is significantly associated with earlier literal homelessness experiences and may be associated with longer durations of literal homelessness, for adults entering PSH. Moreover, women incarcerated as juveniles and entering PSH first experienced literal homelessness earlier than comparable men. Our findings suggest the need for long-term supportive services for persons incarcerated before 25 years old, especially for women. Moreover, these findings refine the working knowledge that prior incarceration increases risk for prolonged homelessness and can help agencies complete more accurate risk assessments.

Risk behaviour and access to HIV/AIDS prevention services among formerly homeless young adults living in housing programmes.

Young adults who experience homelessness have high rates of sexually transmitted infections (STIs) including HIV. Homelessness services programmes that provide housing to young adults have the capacity to reduce STI risk profiles. This study analysed data from 140 formerly homeless adults who moved into a housing programme in Los Angeles County between the ages of 18 and 25 years to investigate risk behaviour and access to HIV/AIDS prevention services. More than three quarters of participants reported sexual activity (vaginal or anal sex) in the prior 3 months, with 63% reporting any unprotected vaginal or anal sex, 29% reporting unprotected sex with a nonserious partner, 40% reporting multiple partners, and 11% reporting exchange sex. About three quarters reported a past-year HIV test. About half of the sample had never heard of pre-exposure prophylaxis (PrEP), 12% had heard of it but didn't know what it was, 25% reported knowing a little bit, and 15% said they knew a lot about PrEP. Slightly more than 4% of the overall sample reported being HIV positive. These findings suggest that housing programmes may be a prime location to implement HIV prevention services.

Exploring the Association of Community Integration in Mental Health among Formerly Homeless Individuals Living in Permanent Supportive Housing.

Supportive housing has been widely used among persons experiencing chronic homelessness and/or mental health conditions. While it has been demonstrated to be effective in addressing homelessness among populations with complex needs, community integration remains a challenge. Community integration is the extent to which individuals live, participate, and socialize in their community and consists of three aspects: physical, social, and psychological. The study utilized data from the Transitions to Housing project that followed formerly homeless individuals (N = 383) throughout their first year of residence in permanent supportive housing (PSH). The study set out to examine which aspects of community integration are associated with mental health symptoms in this population. Five nested multivariate linear regression models were conducted and then compared. The model that accounted for demographics, substance use, neighborhood quality, and all three aspects of community integration simultaneously was the best fit and explained the most variance in mental health symptoms (24%). The complete model suggested higher levels of psychological integration were significantly associated with decreased mental health symptoms in this sample. This finding suggests fostering a sense of belonging among PSH residents could improve mental health outcomes. Implications for practice and future research are discussed.

Real-Time Data Collection to Examine Relations Between Physical Activity and Affect in Adults With Mental Illness.

Adults with serious mental illness engage in limited physical activity, which contributes to significant health disparities. This study explored the use of both ecological momentary assessments (EMAs) and activity trackers in adults with serious mental illness to examine the bidirectional relationship between activity and affect with multilevel modeling. Affective states were assessed up to seven times per day using EMA across 4 days. The participants (n = 20) were equipped with a waist-worn accelerometer to measure moderate to vigorous physical activity. The participants had a mean EMA compliance rate of 88.3%, and over 90% of completed EMAs were matched with 30-min windows of accelerometer wear. The participants who reported more positive affect than others had a higher probability of engaging in moderate to vigorous physical activity. Engaging in more moderate to vigorous physical activity than one's usual was associated with more negative affect. This study begins to address the effect of momentary mood on physical activity in a population of adults that is typically difficult to reach.

Provider perspectives of housing programs for young adults experiencing homelessness.

OBJECTIVE: Qualitative methods were used to investigate the perspectives of service providers working in Permanent Supportive Housing, Transitional Living Programs, and Rapid Rehousing for young adults who have experienced homelessness. The primary aim was to explore how housing models were designed, implemented, and the extent to which there is variability in how providers approach their work with young adults. METHODS: Data come from 26 housing service providers purposively sampled from supportive housing providers across the United States between October 2017 and July 2018. Interview transcripts were analyzed using a comparative case summary approach, grouped by program model. RESULTS: Three themes emerged from the qualitative analysis related to how specific housing models were developed (Stranded between systems: "No model to follow"), the strategies that providers took to support residents toward independence and self-sufficiency (Working toward independence and self-sufficiency: "No one-sized approach"), and the various roles that individual providers discussed fulfilling in their work with young adults (Shifting roles: "Whatever type of figure is needed"). DISCUSSION: While the overarching goals of supportive housing span across housing models, the methods and philosophies of service delivery differ, mirroring the programmatic structure of the model. Results point to a competing philosophies approach to housing as it delivers different philosophically oriented programming models for similar youth through Transitional Living Programs, Permanent Supportive Housing, and Rapid Rehousing models.

Food Insecurity Among Formerly Homeless Individuals Living in Permanent Supportive Housing.

OBJECTIVES: To assess the role of health-related factors, health care, nutrition, and socioeconomic factors in food insecurity prevalence in a sample of previously homeless adults living in permanent supportive housing. METHODS: In 2016 to 2017, we recruited and completed survey interviews with permanent supportive housing residents aged 45 years and older in Los Angeles, California (n = 237). We conducted univariable and multivariable analyses to determine the odds and covariates of low or very low food security, according to the US Department of Agriculture's definition and measure. RESULTS: Two thirds of residents (67%) reported low or very low food security. In the multivariable analyses, several variables were positively associated with this outcome, including accessing food aid or being late in paying bills. The odds of low or very low food security decreased by 8% for every $100 increase in monthly income. CONCLUSIONS: The prevalence of food insecurity in our sample exceeded rates among similarly aged low-income adults in the general population and adults who are currently homeless. This suggests that food insecurity, along with other indicators of socioeconomic disadvantage, remains a threat to health equity for formerly homeless individuals even after they transition to stable housing.

Do HIV risk and prevention behaviors change over time among adults in permanent supportive housing?

Persons experiencing homelessness have a disproportionate burden of HIV infection and high rates of HIV risk behavior. Permanent supportive housing (PSH) has been identified as a primary solution to homelessness, but little is known about HIV sexual risk behavior among persons in PSH, nor about how HIV risk and prevention behavior may change as persons move from homelessness into PSH. Utilizing longitudinal data from 421 persons prior to moving in and over their first year living in PSH, this study assesses change over time in HIV risk and prevention behavior utilizing generalized linear mixed models. Results reveal changes in sexual risk behavior over time, including an overall increase in the rate of sexual activity, but a decrease in rates of some sexual risk behaviors, including condomless sex and multiple partners. While decreasing overall, the prevalence of condomless sex remains high (63%) at 12-months. Combined with a precipitous drop in HIV prevention programming exposure (from 56% at baseline to 23% at 12-months), only two-thirds of those sexually active reporting a past year HIV test at 12-months post-housing, and rare use of PrEP, these findings suggest a need for additional attention to promotion of sexual health behaviors and HIV prevention within PSH.

The Role of Mental Health and Substance Use in Homeless Adults' Tobacco Use and Cessation Attempts.

Objective: Although tobacco use is prevalent among adults experiencing homelessness, research deficits exist regarding the mental health, substance use, and demographic correlates of tobacco use behaviors in this population. This study examined whether correlates of tobacco use among housed adults identified by the Center for Disease Control (CDC) were significant correlates of tobacco use and cessation attempts among a sample of homeless adults. Methods: Participants (N = 421) were adults experiencing homelessness entering permanent supportive housing programs in Los Angeles. Multivariate logistic regression determined associations of lifetime mental health diagnoses, recent substance use, demographic characteristics, and lifetime literal homelessness with daily tobacco use and cessation attempts. Results: Lifetime diagnoses of schizophrenia, posttraumatic stress disorder, depression, bipolar disorder, and illicit substance use were associated with increased odds of daily tobacco use. A lifetime diagnosis of depression was associated with an increased likelihood of a past 3-month tobacco cessation attempt, while illicit substance use was associated with a lower likelihood of a cessation attempt. Conclusions: Findings suggest that demographic and clinical characteristics associated with tobacco use differ among this sample of homeless adults and those identified by the CDC among housed adults. Mental health conditions and substance use appear to be the primary correlates of tobacco use among adults experiencing homelessness and may be critical in efforts aimed at improving cessation.

Mental health change in the transition to permanent supportive housing: The role of housing and social networks.

AIMS: Permanent Supportive Housing (PSH) may improve homeless adults' mental health via housing stabilization and/or improved relational factors, however, the role of housing and social networks on PSH residents' mental health change is minimally understood. METHODS: Interviews were conducted with a baseline sample of adults experiencing homelessness ( N = 421), across their initial year in PSH (3-months, 6-months, and 12-months). Generalized linear mixed models assessed changes in positive past-month psychiatric disability screenings (Modified-Colorado Symptom Index [MCSI]) and probable posttraumatic stress disorder (PC-PTSD) in controlled models, and between and within-subject effects of time-varying social network correlates on mental health changes. RESULTS: Compared with baseline, positive MCSI screens continuously decreased over time (56%, 54%, and 50%) while PC-PTSD screens declined initially (40%) with marginal decreases at remaining follow-ups (39% and 38%). These differences remained significant in controlled models. Gaining a romantic partner was associated with a longitudinal increase in a positive MCSI screening. Between subjects, emotional health counselors and conflicting network members were associated with an increased likelihood in positive screenings, while doctors and case managers were protective. CONCLUSION: Housing may facilitate positive changes in PSH residents' mental health, yet positive screenings remain high. Social network interventions that increase residents' positive interpersonal exchanges and prosocial relationships are warranted.

But Everyone is Doing It (Sort of)! Perceived Sexual Risks in the Social Environment and the Impact on Homeless Youth Engagement in Concurrent Sexual Relationships.

Although homeless youth are likely to engage in concurrent sexual relationships and doing so can accelerate HIV transmission, the issue of sexual concurrency (i.e., having sexual partnerships that overlap in time) has received scarce attention in this vulnerable population. The literature that exists tends to focus on individuals' characteristics that may be associated with concurrency and overlooks the influence of their social environment. Informed by the risk amplification and abatement model (RAAM), this study explored the association between pro-social and problematic social network connections, and sexual concurrency among homeless youth using drop-in center services (N = 841). Nearly 37% of youth engaged in concurrency. Partially consistent with the RAAM, regression analyses showed that affiliation with more problematic ties (i.e., having more network members who practice concurrency and unprotected sex) was associated with greater sexual concurrency. Programs addressing HIV risk among homeless youth in drop-in centers should consider the role youths' network composition may play in concurrency.