A pilot randomized controlled trial of CAPABLE in permanent supportive housing for formerly homeless adults.

BACKGROUND: CAPABLE is a time-limited, evidence-based intervention that helps older adults live independently. It has not been previously tested for use among formerly homeless adults in permanent supportive housing (PSH) who experience accelerated aging that can jeopardize their ability to live independently and age in place. METHODS: A pilot randomized controlled trial with PSH tenants with an average age of 63 years old was conducted to examine the impact of CAPABLE on basic and instrumental activities of daily living (ADL) (and other function-related parameters). Twenty-seven PSH tenants received the intervention and 30 PSH tenants were assigned to a waitlist control group. RESULTS: Those who received the intervention showed improvements in five of seven health outcomes with small to medium effect sizes (Cohen's d = 0.20-0.47). When compared to the control group, the intervention group showed significantly greater improvements in two health outcomes-namely, reduction in limitations in instrumental ADL (p = 0.03) and depression (p = 0.01)-and greater effect sizes (d = 0.17-0.61). CONCLUSIONS: CAPABLE is an evidence-based practice that can be successfully implemented in PSH to improve outcomes in a population that experiences significant health disparities and premature decline. Further investigation with a larger sample is warranted.

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).

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.

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.

The application of GIS in homelessness research and service delivery: A qualitative systematic review.

GIS is increasingly popular in the study of complex social issues, such as homelessness. This study aims to assess how GIS has been leveraged and applied to homelessness research and service delivery. Systematic searching of sixteen databases was completed between January and March of 2021 using the terms "homeless" and "Geospatial Information Systems (GIS)." A final sample of 19 sources were identified from a total of 1719 identified sources. Through quantitative and qualitative methods, the included sources examined 1) static location characteristics associated with homelessness, and 2) mobility of homeless persons.

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.

Burden, Belonging, and Homelessness: Disclosure and Social Network Differences among LGBTQ Youth Recruited from a Suicide Crisis Service Provider.

Among LGBTQ youth, suicidality and homelessness occur at heightened rates. Using the Interpersonal Theory of Suicide (ITS), this study seeks to explore the associations of having a parent, family member, friend, or romantic partner in one's social network and not being "out" to specific network members (lack of disclosure) with ITS constructs (perceived burdensomeness and thwarted belonging), considering homelessness history. Data include 462 youth aged 12-24 who contacted an LGBTQ youth-focused suicide crisis provider from 2015 to 2017. Disclosure status and network composition differed by homelessness experience. Homeless youth were more likely to disclose to their parents and less likely to disclose to other family members. Youth who had not disclosed to their parents reported higher perceived burdensomeness and thwarted belonging whereas having more family members and peers in one's network was associated with lower scores on ITS constructs. Implications for prevention approaches with youth who may be at increased risk for suicide are discussed.

Service utilisation changes in the transition to permanent supportive housing: The role of the housing environment and case management.

This study examines whether routine, low-cost service use changes in the transition from homelessness to permanent supportive housing (PSH) and explores whether housing model, neighbourhood and level of case management engagement affect utilisation of routine services. Data come from a prospective longitudinal study of adults experiencing homelessness who entered PSH in Los Angeles between 2014 and 2016 and participated in four interviews: pre-housing (i.e., while experiencing homelessness), and 3, 6 and 12 months after move-in. Mixed effects logistic regression assessed the effects of demographics, case management, housing model and neighbourhood location on service utilisation at each time point across five domains: basic needs, financial, educational, mental health and physical health. Longitudinal unmet need for services and onsite service use contextualised findings. Service utilisation significantly decreased at each time point in the domains of basic needs, financial and mental health. Neighbourhood was significantly associated with basic needs and mental health service use, while housing model was associated with financial service utilisation. Case management was associated with all service use outcomes with all relationships demonstrating more case management visits was associated with greater odds of routine service utilisation. Unmet service needs were consistent over time. Onsite service utilisation was low across all residents. Results indicate that routine service use declines with length of tenancy while unmet need for services remain prevalent. Case management appears to be critical in facilitating routine service use, while the housing environment should be considered to ensure residents have accessible and proximal routine care.

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.

Factors associated with condom and contraceptive use among currently and formerly homeless young adults: Does housing matter?

BACKGROUND: Young adults that experience homelessness (YAEH) are at heightened risk of unplanned pregnancy and contracting STIs, including HIV than their housed counterparts. It is unclear how exiting homelessness into Supportive Housing (SH), the most prominent intervention in homelessness, may shape sexual risk-taking. OBJECTIVE: The goal of this study is to explore associations of condom and contraception use with particular interest in the role of partner type (i.e., casual and/or serious) and housing status. METHODS: This study includes 143 sexually active YAEH (ages 18-27) who reported engaging in vaginal sex during the past three months: 67 "unhoused" (i.e., street-based, couch-surfers, or staying in emergency shelter), and 76 "housed" from SH programs. Multiple logistic regression examined the relationship of housing status and partner type with condom and contraceptive use. RESULTS: Being a parent was associated with higher odds of contraceptive use regardless of housing status, while partner type (i.e., serious or casual partner) was differently associated with condom use by housing status. DISCUSSION: Despite documented differences in condom-using behaviors by housing status, findings revealed similar patterns in contraceptive use between the two groups, indicating a possible need for enhanced and targeted service planning for YAEH, particularly among those transitioning to and residing in SH, regarding contraceptive use and prevention.

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.

Construct, concurrent, and real-world predictive validity of the Difficulties in Emotion Regulation (DERS-18) among young adults with history of homelessness.

Skills in emotional regulation are vitally important for enabling homeless young adults to navigate the complex and chaotic settings associated with homelessness. The current study seeks to test the construct, concurrent, and predictive validity of the Difficulties in Emotional Regulation Scale (DERS-18) in a sample of formerly and currently homeless young adults. Data come from a study of HIV risk among young adults who have experienced homelessness, including both those currently experiencing homelessness (n = 99) and in permanent housing (n = 120), collected between 2017 and 2019 in Los Angeles, CA. Structural Equation Modeling was used to complete Confirmatory Factor Analysis and Path Models focused on the relationship between mental health symptomatology and emotional regulation. Linear regression models tested the link between affective intensity and instability and the DERS-18. Model fit indices pointed to the five-factor solution of the DERS-18, excluding the Awareness subscale. Clinical scores of anxiety, depression, and PTSD were found to have a significant, positive correlation with DERS. Both intensity and instability of negative affect were associated with greater difficulty in emotional regulation, while the increased intensity of positive affect was associated with increased skills in emotional regulation. This study addressed several gaps in both homelessness and emotional regulation literature. The DERS-18 was found to have construct, concurrent, and predictive validity in our sample. Future work should consider the use of the DERS-18 to assess skills in emotional regulation, understand outcomes, and better tailor interventions for young adults who have experienced homelessness. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

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.

Exchange and Survival Sex, Dating Apps, Gender Identity, and Sexual Orientation Among Homeless Youth in Los Angeles.

We estimated the association between gender and sexual identities, and engagement in exchange and survival sex and seeking these partners via dating apps or websites, within a sample of homeless youth. In 2017, 253 homeless youth were interviewed from three different drop-in centers in Los Angeles. Multivariable regression analyses assessed associations between gender/sexual identity, and exchange and survival sex, adjusting for demographic characteristics. Sexual minority (43.6%) and gender minority (12.1%) youth reported elevated rates of exchange sex compared to cisgender heterosexual youth. Twenty-three percent of youth who engaged in survival or exchange sex used dating apps or websites to find partners. Exchange sex was associated with having recent HIV positive sex partners. Reporting an HIV positive partner and a relatively high number of sexual partners were significant predictors of engaging in survival sex. Programs and interventions for homeless youth should address engagement with technology and exchange and survival sex, and should respond to the unique needs of sexual and gender minority homeless youth.

Understanding Wait Times in Rapid Re-Housing Among Homeless Youth: A Competing Risk Survival Analysis.

Approximately 3.5 million youth experience homelessness in the United States. Assisting youth to exit homelessness as quickly as possible through various housing venues aims to prevent adverse health impacts that prolonged homeless experiences may have on youth. Rapid re-housing (RRH) is a recent, short-term, less costly housing option than permanent supportive housing that provides temporary housing supports and services to counter homelessness. Although previous literature indicates that youth are likely to achieve stable homelessness exits via RRH, the duration of wait times for youth and potential disparities in RRH waiting periods remain unclear. We used administrative data from 16 communities across the United States (N = 10,920) to gain a greater understanding about RRH wait times among homeless youth. In addition, we adopted a competing risk survival analysis to investigate potential disparities (i.e., race and ethnicity, gender, rurality, sexual orientation, and previous homelessness condition) in RRH wait times while taking into consideration the presence of other homelessness exit options (e.g., permanent supportive housing). Study results indicate that RRH is a common homelessness exit for homeless youth and is prioritized for youth assessed as mid-vulnerability, per commonly accepted assessment measures of youth vulnerability. However, youth who received RRH waited, on average, 131 days following their housing eligibility assessment. Furthermore, being a minor (i.e., 17 years old or younger), experiencing homelessness in rural communities, and lower engagement in homeless services (e.g., emergency shelters and transitional living programs) were all associated with lower probability of exiting into RRH over time, taking into account the possibility of other competing homelessness exits. Expansion of the short-term housing supports offered through RRH may be a promising strategy to counter homelessness among youth in a timely manner. However, such an expansion should also address the potential disparities underlying youths' wait time to receive RRH in order to reduce prolonged homelessness experiences within this vulnerable population.

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."