Food insecurity, hunger, stress, and homelessness among young adults.

BACKGROUND: Compared to the effects of stress on hunger, the temporal effect of hunger on stress levels is less understood, especially in the context of everyday lives of vulnerable populations with unstable access to food. OBJECTIVE: Our objective was to examine the effects of food insecurity and momentary hunger on momentary stress and stress variability in a sample of currently and formerly homeless young adults. METHOD: We used a 7-day ecological momentary assessment study querying affect, hunger, and risky behaviors. A mixed-effects location scale model was used to examine the effects of hunger on mean levels and within- and between-subjects variability of stress with 100 currently homeless and 69 formerly homeless young adults ages 18-29 in Los Angeles County, California. RESULTS: When individuals experienced greater-than-average hunger, they then experienced greater stress variability at the next prompt, showing the impact of hunger on stress at the momentary level. Those with higher average levels of stress, regardless of hunger, became substantially more stressed when becoming hungry compared to their generally less stressed counterparts. CONCLUSIONS: The study shows the extent to which food insecurity results in erratic stress among vulnerable populations and how high levels of hunger may lead to a more inconsistent stress response. Findings reinforce the need for more mental health services and food programs for young adults who have experienced homelessness. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Feasibility and Acceptability of Ecological Momentary Assessment With Young Adults Who Are Currently or Were Formerly Homeless: Mixed Methods Study.

BACKGROUND: Ecological momentary assessment (EMA) has been used with young people experiencing homelessness to gather information on contexts associated with homelessness and risk behavior in real time and has proven feasible in this population. However, the extent to which EMA may affect the attitudes or behaviors of young adults who are currently or were formerly homeless and are residing in supportive housing has not been well investigated. OBJECTIVE: This study aims to describe the feedback regarding EMA study participation from young adults who are currently or were formerly homeless and examine the reactivity to EMA participation and compliance. METHODS: This mixed methods study used cross-sectional data collected before and after EMA, intensive longitudinal data from a 7-day EMA prompting period, and focus groups of young adults who are currently or were formerly homeless in Los Angeles, California, between 2017 and 2019. RESULTS: Qualitative data confirmed the quantitative findings. Differences in the experience of EMA between young adults who are currently or were formerly homeless were found to be related to stress or anxiety, interference with daily life, difficulty charging, behavior change, and honesty in responses. Anxiety and depression symptomatology decreased from before to after EMA; however, compliance was not significantly associated with this decrease. CONCLUSIONS: The results point to special considerations when administering EMA to young adults who are currently or were formerly homeless. EMA appears to be slightly more burdensome for young adults who are currently homeless than for those residing in supportive housing, which are nuances to consider in the study design. The lack of a relationship between study compliance and symptomatology suggests low levels of reactivity.

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.

Housing interventions for emerging adults experiencing homelessness: A scoping review.

INTRODUCTION: This review aims to identify and synthesize literature focused on housing interventions for young adults experiencing homelessness. METHODS: Following a five-stage approach to scoping reviews, a computerized search was conducted between February 4-8, 2019 to include peer-reviewed articles from a total of eight electronic databases: PsychINFO, Google Scholar, PubMed, Web of Science, Social Work Abstracts, Cochrane, Clinicaltrials.gov, and CINAHL. The search was limited to include literature published between January 1, 1987 and December 31, 2018. Search parameters included three domains: homelessness, housing intervention, and age. RESULTS: Of the initial 7,344 sources identified, 29 articles met the search criteria and were included in the final sample. Housing models discussed in the reviewed literature include Permanent Supportive Housing, Transitional and Independent Housing and Living Programs, the Foyer model, Housing First, and general Supportive Housing. Housing models were discussed in the context of outcome domains including quality of life, education, employment, housing tenure, cost of intervention, systems and service use, HIV, and social network and relationships. DISCUSSION: Housing interventions for young adults experiencing homelessness remains a relatively new intervention to combat homelessness among younger demographics. While the evidence base continues to grow, there remains a need for quality research to generate empirical evidence in this area, though studies included in this review showed promise for the development of best housing practices with this population.

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.

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.

Practice Facilitation in Integrated Behavioral Health and Primary Care Settings: a Scoping Review.

Little is known about the contributions of practice facilitators in settings aiming to deliver integrated behavioral health and primary care. This scoping review identifies peer-reviewed articles that describe efforts to deliver integrated behavioral health care with the support of practice facilitators. Five databases were systematically searched to identify empirical and conceptual papers. Fourteen articles met the following inclusion criteria: (1) empirical studies evaluating the effectiveness of practice facilitation (n = 4), (2) study protocols that will test the effectiveness of practice facilitation (n = 2), (3) studies that included practice facilitators as part of a larger intervention without evaluating their effectiveness (n = 5), and (4) conceptual manuscripts endorsing practice facilitation for integrated care (n = 3). Practice facilitators can potentially support health systems in delivering integrated behavioral health care, but future research is needed to understand their necessary qualifications, the effectiveness of practice facilitation these efforts, and what study outcomes are appropriate for evaluating whether practice facilitation has been effective.

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.

Surveying Tenants of Permanent Supportive Housing in Skid Row about COVID-19.

Permanent supportive housing (PSH) enrolls highly vulnerable homeless adults who experience early onset of geriatric conditions and require in-home support. Thus, there is potentially a high risk for COVID-19 within PSH, which may require tenants to take protective measures. This study reports on survey results collected from 532 PSH tenants in Los Angeles, California during the 4th week of March in 2020. Results show that nearly all tenants were aware of COVID-19, and 65% considered it to be a very serious health threat. The latter characteristic was a strong predictor of taking protective measures (i.e., handwashing and social distancing). Tenants in units with shared bathroom facilities had lower odds of social distancing than those in studio apartments. Tenants with mental health diagnoses had lower odds of consistent handwashing. Lack of access to food, hygiene items, and medication delivery were commonly reported barriers to sheltering in place.

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.

Longitudinal effects of permanent supportive housing on insomnia for homeless adults.

OBJECTIVES: To examine the longitudinal change in insomnia as adults transition from homelessness to permanent supportive housing (PSH) and whether additional factors may moderate this relationship. METHODS: Standardized interviews were conducted with 331 homeless participants in Los Angeles prior to moving into PSH. Outcomes were measured 3, 6, and 12 months after move-in. Insomnia was assessed using the Sleep Condition Indicator, which is a 2-item validated short-form inventory that is intended to be used in clinical settings as a brief screening instrument for insomnia. Mixed-effects models were used to examine insomnia across all 4 measurement points and to test for interactions between time and covariates. RESULTS: Participants were on average approximately 55 years old and had spent an average of 5.6 years homeless in their lifetime, with approximately 70% identifying as male. Sixty-two percent of the sample screened positive for insomnia disorder at baseline. There was a significantly reduced likelihood of insomnia at each measurement period compared to baseline, but no differences were found between 3, 6, and 12 months. Mental health symptoms, physical health comorbidities, tobacco consumption, and female gender were associated with an increased likelihood of insomnia. CONCLUSION: Findings indicate a significant decrease in insomnia after moving into PSH, regardless of time spent homeless.

Investigating Health Risk Environments in Housing Programs for Young Adults: Protocol for a Geographically Explicit Ecological Momentary Assessment Study.

BACKGROUND: Young adults who experience homelessness are exposed to environments that contribute to risk behavior. However, few studies have examined how access to housing may affect the health risk behaviors of young adults experiencing homelessness. OBJECTIVE: This paper describes the Log My Life study that uses an innovative, mixed-methods approach based on geographically explicit ecological momentary assessment (EMA) through cell phone technology to understand the risk environment of young adults who have either enrolled in housing programs or are currently homeless. METHODS: For the quantitative arm, study participants age 18-27 respond to momentary surveys via a smartphone app that collects geospatial information repeatedly during a 1-week period. Both EMAs (up to 8 per day) and daily diaries are prompted to explore within-day and daily variations in emotional affect, context, and health risk behavior, while also capturing infrequent risk behaviors such as sex in exchange for goods or services. For the qualitative arm, a purposive subsample of participants who indicated engaging in risky behaviors are asked to complete an in-depth qualitative interview using an interactive, personalized geospatial map rendering of EMA responses. RESULTS: Recruitment began in June of 2017. To date, 170 participants enrolled in the study. Compliance with EMA and daily diary surveys was generally high. In-depth qualitative follow-ups have been conducted with 15 participants. We expect to recruit 50 additional participants and complete analyses by September of 2019. CONCLUSIONS: Mixing the quantitative and qualitative arms in this study will provide a more complete understanding of differences in risk environments between homeless and housed young adults. Furthermore, this approach can improve recall bias and enhance ecological validity. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/12112.

What's next? A grounded theory of the relationship between ontological security, mental health, social relationships, and identity formation for young adults in supportive housing.

This qualitative study of 29 young adults (aged 18-25) living in permanent supportive housing (PSH) resulted in a grounded theory that shows how PSH generally provides a sense of ontological security for young adults-much like for older adults-who are also experiencing significant developmental change processes. Simply stated, ontological security refers to a concept of well-being in the world that is rooted in a sense of order in one's social and material environment. Thematic analyses indicated that the presence of markers of ontological security (for example, constancy, routine, control) positively affected participants' mental health and well-being, which helped with positive identity construction. An increase in ontological security also related to residents' social environment and participants' ability to improve on social relationships, which supported improved mental health and sense of self. Most young adults in this study regarded living in PSH as "a chance to start my life" and considered the question of "What's next?" within a normative developmental trajectory. Counterexamples that demarcate the limits of these thematic findings are included in the grounded theory model, including some experiences of social isolation and struggles with mental health associated with less positive orientations toward "what's next."