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.

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.

Examining the health status of homeless adults entering permanent supportive housing.

Background: Permanent supportive housing (PSH) has been recognized as an effective intervention and the national policy for addressing chronic homelessness in the United States. Due to an aging cohort of homeless adults and prioritizing those who are most vulnerable for housing, the health status of those entering PSH is likely worse than those previously reported in the literature. Methods: This report examined the self-reported health and health conditions of a sample of 421 homeless adults entering PSH between 2014 and 2016. The average age of our sample was 54 years old. Results: Overall, 90% reported two or more chronic conditions (either physical or mental), 68% reported at least two chronic physical health conditions and 56% indicated at least two chronic mental health conditions. Describing their health status, 57% reported fair, poor or very poor health. Conclusions: These findings suggest that access to housing will not easily remedy the well-documented premature mortality among chronically homeless adults.

Provider perceptions on HIV risk and prevention services within permanent supportive housing.

Permanent supportive housing (PSH) is an evidence-based solution to homelessness for persons experiencing chronic or long-term homelessness and one or more physical or behavioral health problems. Health services through PSH typically focus on physical and behavioral health. With the exception of programs specifically designed for persons living with HIV/AIDS, little attention has focused on services through PSH to prevent transmission of HIV or other sexually transmitted infections (STIs), yet sexual risk behavior continues after homeless persons move into PSH. The purpose of this study was to investigate how PSH providers approach HIV prevention and the challenges they perceive surrounding HIV prevention in PSH. Results serve as a critical first step toward addressing the acceptability and feasibility of providing HIV/STI prevention services to PSH residents. As part of a longitudinal mixed methods study examining HIV risk and prevention behavior among homeless unaccompanied adults moving into PSH in Los Angeles, we conducted eleven focus groups with a total of 60 frontline staff across 10 PSH agencies. Thirty-three percent of focus group participants were African American, 32% were Hispanic, and 55% were women. Results suggest that provider awareness and knowledge of PrEP is very limited, and provision of formal HIV prevention programing for residents is perceived as challenging. Informal, ad hoc conversations with residents about sexual risk and HIV prevention do occur when providers have rapport with clients and perceive risk. There are significant gaps in HIV prevention services through PSH but also opportunities to enhance providers' efforts to promote the health of residents through prevention.

Risk behavior and access to HIV/AIDS prevention services in a community sample of homeless persons entering permanent supportive housing.

Homeless persons suffer disproportionately high rates of HIV infection, and moving into permanent supportive housing (PSH) can provide a stable base from which to access needed prevention services. However, little is known about HIV risk or prevention behavior during this critical time of transition. The current study investigated STI and HIV risk and prevention behavior and recent use of prevention and treatment services (i.e., education, testing, medication) among homeless persons preparing to move into PSH. Data come from interviews with 421 homeless adults before they moved into PSH. Thirty-seven percent of the respondents were sexually active; of those, 75.7% reported unprotected sex. Nearly two-thirds (64%) reported past year HIV testing and 40% reported testing for another STI. Fewer than one-third (31%) of respondents reported receiving posttest counseling at their last HIV test. HIV seropositivity was self-reported by 10%. Among those persons who were HIV-positive, 57.1% reported less than 100% antiretroviral (ARV) adherence. Among HIV-negative respondents, less than 1% had been prescribed preexposure prophylaxis (PrEP). Less than half (46.4%) of the sample reported any HIV prevention education in the past year. This population of homeless adults about to move into PSH report high rates of HIV risk behavior, but low rates of HIV prevention education and very little PrEP utilization. Further, low rates of ARV adherence among HIV-positive respondents indicate significant risk for HIV transmission and acquisition. Entering PSH is a period of transition for homeless persons when integrated care is critically important to ensure positive health outcomes, but these data suggest that PrEP and other HIV prevention services are poorly accessed among this population. As such, multipronged services that integrate PrEP and other HIV prevention services are needed to prevent transmission and acquisition of HIV in this high-risk, vulnerable population and ensure the health and wellbeing of PSH residents.

Violence, Trauma, Mental Health, and Substance Use Among Homeless Youth Juggalos.

Insane Clown Posse is a musical duo whose fans are known as Juggalos. Many homeless youths (HY) identify as Juggalos, most likely because the group's music embraces poverty and being an outsider in mainstream society. Juggalos are stereotyped as being violent, undereducated, poor, racist, crime-committing youth, and in 2011 the FBI officially labeled Juggalos as a gang. However, little is known about the intersection of HY and Juggalos. A convenience sample of Los Angeles-area, drop-in service-seeking HY completed a self-administered questionnaire (N = 495). In the sample, 15 % of HY identified as Juggalos. Juggalo-identifying youth were more likely to have experienced childhood trauma, including physical and sexual abuse and witnessing community violence. Multivariable models revealed that identifying as a Juggalo was associated with increased odds of recent methamphetamine use, ecstasy use, chronic marijuana use, and prescription drug misuse. Juggalos were also more likely to experience suicidal ideation, attempt suicide, recently engage in interpersonal violence, become injured during a fight, and have unprotected sex. In conclusion, Juggalos constitute a unique subpopulation of HY. Implications for Juggalo-specific trauma-informed services, rather than punitive, are discussed as well as the potential for future research regarding resiliency associated with Juggalo identification.

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.

Are Parental Relationships Always Protective? A Social Network Analysis of Black, Latino, and White Homeless Youth and Sexual Risk-Taking Behaviors.

Black and Latino homeless youth are at high risk of HIV, and yet no HIV prevention interventions have been specifically designed for these groups. Given the success of parent-child intervention programs for housed Black and Latino youth, this study examined parental relationships that could be leveraged for future HIV prevention efforts targeting minority homeless youth, specifically the associations among presence of parents in social networks, parental influence, and parental support. A convenience sample of Black, Latino, and White homeless youth (N = 754) was recruited from three drop-in centers in Los Angeles. Participants completed a computerized, self-administered questionnaire and an interviewer-led personal social network interview. Multivariate logistic regression models assessed the association between parental relationships and sexual risk behaviors. Forty-five percent (n = 338) of youth identified a parent in their network. Having at least one parent in their network was significantly associated with decreased odds of using a condom for Black and White youth. Black youth were almost four times more likely to report being tested for HIV if they spoke to their parents about sex, whereas Latino youth were 91 % less likely to report being tested for HIV if they talked with their parents about sex. Black youth who identified a parent as a positive influence (i.e., promoting condom use or discouraging multiple partners) were almost four times more likely to have used a condom during their last sexual encounter. Parent-child HIV prevention interventions targeting homeless youth would benefit from culturally tailored adaptations.

Cyberbullying perpetration and victimization among middle-school students.

OBJECTIVES: We examined correlations between gender, race, sexual identity, and technology use, and patterns of cyberbullying experiences and behaviors among middle-school students. METHODS: We collected a probability sample of 1285 students alongside the 2012 Youth Risk Behavior Survey in Los Angeles Unified School District middle schools. We used logistic regressions to assess the correlates of being a cyberbully perpetrator, victim, and perpetrator-victim (i.e., bidirectional cyberbullying behavior). RESULTS: In this sample, 6.6% reported being a cyberbully victim, 5.0% reported being a perpetrator, and 4.3% reported being a perpetrator-victim. Cyberbullying behavior frequently occurred on Facebook or via text messaging. Cyberbully perpetrators, victims, and perpetrators-victims all were more likely to report using the Internet for at least 3 hours per day. Sexual-minority students and students who texted at least 50 times per day were more likely to report cyberbullying victimization. Girls were more likely to report being perpetrators-victims. CONCLUSIONS: Cyberbullying interventions should account for gender and sexual identity, as well as the possible benefits of educational interventions for intensive Internet users and frequent texters.

Cell phone internet access, online sexual solicitation, partner seeking, and sexual risk behavior among adolescents.

Online partner seeking is associated with sexual risk behavior among young adults (specifically men who have sex with men), but this association has yet to be explored among a probability sample of adolescents. Moreover, cell phone internet access and sexual risk taking online and offline have not been explored. A probability sample (N = 1,831) of Los Angeles Unified School District high school students was collected in 2011. Logistic regression models assessed relationships between specific sexual risk behaviors (online sexual solicitation, seeking partners online, sex with internet-met partners, condom use) and frequency of internet use, internet access points, and demographics. Students with cell phone internet access were more likely to report being solicited online for sex, being sexually active, and having sex with an internet-met partner. Bisexual-identifying students reported higher rates of being approached online for sex, being sexually active, and not using condoms at last sex. Gay, lesbian, and questioning (GLQ) students were more likely to report online partner seeking and unprotected sex at last sex with an internet-met partner. Additionally, having sex with an internet-met partner was associated with being male, online sexual solicitation, and online partner seeking. Internet- and school-based sexual health programs should incorporate safety messages regarding online sexual solicitation, seeking sex partners online, and engaging in safer sex practices with all partners. Programs must target adolescents of all sexual identities, as adolescents may not yet be "out," and bisexual and GLQ adolescents are more likely to engage in risky sex behaviors.

Pet ownership among homeless youth: associations with mental health, service utilization and housing status.

As many as 25 % of homeless persons have pets. To our knowledge, pet ownership has not been studied quantitatively with homeless youth. This study examined pet ownership among 398 homeless youth utilizing two Los Angeles drop-in centers. Twenty-three percent of homeless youth had a pet. The majority of pet owners reported that their pets kept them company and made them feel loved; nearly half reported that their pets made it more difficult to stay in a shelter. Pet owners reported fewer symptoms of depression and loneliness than their non-pet owning peers. Pet ownership was associated with decreased utilization of housing and job-finding services, and decreased likelihood of currently staying in a shelter. These findings elucidate many of the positive benefits of pet ownership for homeless youth, but importantly highlight that pet ownership may negatively impact housing options. Housing and other services must be sensitive to the needs of homeless youth with pets.

Acceptability of smartphone application-based HIV prevention among young men who have sex with men.

Young men who have sex with men (YMSM) are increasingly using mobile smartphone applications ("apps"), such as Grindr, to meet sex partners. A probability sample of 195 Grindr-using YMSM in Southern California were administered an anonymous online survey to assess patterns of and motivations for Grindr use in order to inform development and tailoring of smartphone-based HIV prevention for YMSM. The number one reason for using Grindr (29 %) was to meet "hook ups." Among those participants who used both Grindr and online dating sites, a statistically significantly greater percentage used online dating sites for "hook ups" (42 %) compared to Grindr (30 %). Seventy percent of YMSM expressed a willingness to participate in a smartphone app-based HIV prevention program. Development and testing of smartphone apps for HIV prevention delivery has the potential to engage YMSM in HIV prevention programming, which can be tailored based on use patterns and motivations for use.

Associations of unprotected anal intercourse with Grindr-met partners among Grindr-using young men who have sex with men in Los Angeles.

Grindr, a geosocial smartphone application, is a networking medium for men who have sex with men. Although three quarters of young men who have sex with men (YMSM) Grindr users report having sex with a Grindr-met partner, the correlates of risky sexual behavior with Grindr-met partners are unknown. A randomly selected sample of 18- to 24-year-old, Grindr-using YMSM completed an anonymous online questionnaire assessing patterns of Grindr use and sexual behavior with their last Grindr-met partners. Of the 146 YMSM who reported having sex with Grindr-met partners, 20% had unprotected anal intercourse (UAI) at last sex with their Grindr-met partner. In the multivariable model, YMSM who used Grindr for at least one year showed naked chest/abs in their profile photo, and reported more past month Grindr-met partners were more likely to report UAI. These findings suggest that familiarity with the app was associated with YMSM's UAI with Grindr-met partners. Moreover, sexualized profile photos (i.e., naked chest/abs) may be associated with sexual risk-taking behaviors. HIV prevention interventions delivered or linked through such apps should target individuals who are longer/frequent users and who present sexualized profiles.

Social Network Change after Moving into Permanent Supportive Housing: Who Stays and Who Goes?

Social relationships are important among persons experiencing homelessness, but there is little research on changes in social networks among persons moving into permanent supportive housing (PSH). Using data collected as part of a longitudinal study of 405 adults (aged 39+) moving into PSH, this study describes network upheaval during this critical time of transition. Interviews conducted prior to and after three months of living in PSH assessed individual-level characteristics (demographics, homelessness history, health and mental health) and included a social network component that assessed network size and composition (demographics, relationship type, social support); interviewers utilized network member characteristics to assess whether network members were new or sustained between baseline and 3 months post-housing. Multilevel logistic regression models assessed what characteristics of network members were associated with being newly-gained or persisting in networks 3 months after moving into PSH. We found that only one-third of social networks were retained during the transition to PSH, and that veterans, African Americans and other persons of racial/ethnic minorities, and those living in scattered-site housing were more likely to experience network disruption. Relatives, romantic partners, and service providers were most likely to be retained after move-in. Some network change was moderated by tie strength, including the retention of street-met persons. Implications are discussed.

A text messaging-based intervention to increase physical activity among persons living in permanent supportive housing: Feasibility and acceptability findings from a pilot study.

OBJECTIVE: Persons who have experienced homelessness and are living in permanent supportive housing experience high rates of health and mental health problems. Given that physical activity is associated with improved health outcomes and persons with homelessness histories report high rates of cell phone use, phone-based interventions to increase physical activity may be effective for improving health and wellbeing among persons in permanent supportive housing. METHODS: To understand the acceptability and feasibility of a cell phone-based physical activity intervention in this population, this 6-week pilot study enrolled 13 persons living in permanent supportive housing. Participants were eligible if they had completed their final, 12-month follow-up interview in a larger, longitudinal study of persons moving into permanent supportive housing in the Los Angeles area, spoke English, and reported comorbid chronic physical and mental health conditions. For the study duration, participants wore a pedometer, received multiple weekly motivational text messages on set days (at times selected by the participant), and responded via text to weekly depression screeners and requests to report their weekly step totals, as recorded by their pedometers. Follow-up interviews asked open-ended questions about study participation and satisfaction. RESULTS: Participants were 53 years old on average, most were female (54%), and most were African-American (62%). Changes to people's physical activity levels were limited, but participants reported increased quality of life during the intervention period. Interviews revealed that the intervention was well received and enjoyable for participants. CONCLUSIONS: The efficacy of utilizing cell phones to improve health and wellbeing among adults living in permanent supportive housing requires further research, but these pilot findings suggest that such interventions are feasible and acceptable.

Moving Beyond Housing: Service Implications for Veterans Entering Permanent Supportive Housing.

As a result of efforts to end homelessness among U.S. veterans, more former service members are entering permanent supportive housing (PSH). While PSH has been successfully used to house homeless veterans, more research is needed about services beyond housing placement and retention. This study uses the Gelberg-Andersen behavioral model for vulnerable populations to determine associations between predisposing, enabling, and need characteristics and recent service use (i.e., services to satisfy basic needs, occupational development, financial, healthcare, mental health) among unaccompanied homeless veterans (N=126) entering PSH in Los Angeles. Among the significant findings, as indicated using univariable logistic regression models, were veterans who had incarceration histories were more likely to utilize basic needs services, compared to those without incarceration histories. Veterans who received an honorable discharge were more likely to utilize occupational development services, compared to veterans with other discharge statuses. Veterans who had a case manager were more likely to utilize mental health services than those without a case manager, while those who received social security were less likely to utilize mental health services compared to veterans who did not receive social security. Veterans who met criteria for a psychological disability and veterans who met criteria for probable PTSD were more likely to use basic needs services and mental health services than veterans who fell below these thresholds. Clinical implications for social workers including "equal access to services," "enhancing economic stability," "providing safe and affordable housing with trauma-informed services," and "training service social workers to deliver well-informed linkages and services" are discussed.

Availability of comprehensive services in permanent supportive housing in Los Angeles.

Studies have often described a specific model or models of permanent supportive housing (PSH), yet few studies have systematically examined what services are typically offered to PSH tenants in any given service system and how those services are offered. Using telephone surveys from 23 PSH agency supervisors and qualitative data collected from 11 focus groups with 60 frontline providers and 17 individual interviews with supervisors from a subset of surveyed agencies-all of which were completed between July 2014 and December 2015-the goal of this study is to better understand what services are being offered in PSH organisations located in Los Angeles and what barriers frontline providers face in delivering these services. Survey findings using statistical frequencies suggest the existence of robust support services for a high-needs population and that single-site providers may offer more services than scatter-site providers. Qualitative thematic analysis of interview and focus group transcripts suggests services may be less comprehensive than they appear. If PSH is to be regarded as an intervention capable of more than "just" ending homelessness, further consideration of the provision of supportive services is needed.

Differences in Health and Social Support between Homeless Men and Women Entering Permanent Supportive Housing.

BACKGROUND: Permanent supportive housing (PSH) is the leading intervention to end chronic homelessness. Little is known, however, about gender differences, including potential disparities in physical and mental health and social support, that might inform services available through PSH. METHODS: This study included 421 homeless adults, at least 39 years old, English- or Spanish-speaking, who were moving into PSH through 26 different agencies in the Los Angeles area. RESULTS: Compared with men entering PSH, homeless women (28% of the sample) were younger (p < .01), less likely to have achieved at least a high school education (p < .05), and had lower incomes (p < .01). Women had more chronic physical health conditions (p < .01), were more likely to have any chronic mental health condition (odds ratio, 2.5; p < .01), and had more chronic mental health conditions than men (p < .01). Women had more relatives in their social networks (Coefficient, 0.79, p < .01) and more relatives who provided support (coefficient, 0.38; p < .05), but also more relatives with whom they had conflict (coefficient, 0.19; p < .01). Additionally, women were less likely to have caseworkers (coefficient, -0.59; p < .001) or physical and mental health care providers in their networks (coefficient, -0.23 [p < .01]; coefficient, -0.37 [p < .001], respectively). However, after correcting for multiple testing, three outcomes lost significance: number of chronic physical health conditions, number of relatives who provided any support, and number of relatives with whom there was conflict. CONCLUSIONS: There is evidence of gender differences in mental health and social support among homeless adults moving into PSH. PSH cannot be a one-size-fits-all approach. Supportive services within housing should be tailored based on gender and other individual needs.

No Digital Divide? Technology Use among Homeless Adults.

Homeless adults experience increased risk of negative health outcomes, and technology-based interventions may provide an opportunity for improving health in this population. However, little is known about homeless adults' technology access and use. Utilizing data from a study of 421 homeless adults moving into PSH, this paper presents descriptive technology findings, and compares results to age-matched general population data. The vast majority (94%) currently owned a cell phone, although there was considerable past 3-month turnover in phones (56%) and phone numbers (55%). More than half currently owned a smartphone, and 86% of those used Android operating systems. Most (85%) used a cell phone daily, 76% used text messaging, and 51% accessed the Internet on their cell phone. One-third reported no past 3-month Internet use. These findings suggest that digital technology may be a feasible means of disseminating health and wellness programs to this at-risk population, though important caveats are discussed.