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Network Approaches to Substance Use and HIV/Hepatitis C Risk among Homeless Youth and Adult Women in the United States: A Review



During the United States economic recession of 2008–2011, the number of homeless and unstably housed people in the United States increased considerably. Homeless adult women and unaccompanied homeless youth make up the most marginal segments of this population. Because homeless individuals are a hard to reach population, research into these marginal groups has traditionally been a challenge for researchers interested in substance abuse and mental health. Network analysis techniques and research strategies offer means for dealing with traditional challenges such as missing sampling frames, variation in definitions of homelessness and study inclusion criteria, and enumeration/population estimation procedures. This review focuses on the need for, and recent steps toward, solutions to these problems that involve network science strategies for data collection and analysis. Research from a range of fields is reviewed and organized according to a new stress process framework aimed at understanding how homeless status interacts with issues related to substance abuse and mental health. Three types of network innovation are discussed: network scale-up methods, a network ecology approach to social resources, and the integration of network variables into the proposed stress process model of homeless substance abuse and mental health. By employing network methods and integrating these methods into existing models, research on homeless and unstably housed women and unaccompanied young people can address existing research challenges and promote more effective intervention and care programs.
Health, 2016, 8, 1143-1165
ISSN Online: 1949-5005
ISSN Print: 1949-4998
DOI: 10.4236/health.2016.812119 August 26, 2016
Network Approaches to Substance Use
and HIV/Hepatitis C Risk among Homeless
Youth and Adult Women in the United States:
A Review
Kirk Dombrowski1, Kelley Sittner2, Devan Crawford3, Melissa Welch-Lazoritz3, Patrick Habecker1,
Bilal Khan1
1Department of Sociology, University of Nebraska-Lincoln, Lincoln, USA
2Department of Sociology, Oklahoma State University, Stillwater, USA
3REACH Lab, University of Nebraska-Lincoln, Lincoln, USA
During the United States economic recession of 2008-
2011, the number of homeless
and unstably housed people in the United States increased considerably. Homeless
adult women and unaccompanied homeless youth make up the most marginal se
ments of this population. Because homeless individuals are a hard to reach popul
tion, research into these marginal groups has traditionally been a challenge for r
searchers interested in substance abuse and mental health. Network analysis tec
niques and research strategies offer means for dealing with traditional challenges
such as missing sampling frames, variation in definitions of homelessness and study
inclusion criteria, and enumeration/po
pulation estimation procedures. This review
focuses on the need for, and recent steps toward, solutions to these problems that
involve network science strategies for data collection and analysis. Research from a
range of fields is reviewed and organized according to a new stress process fram
work aimed at understanding how homeless status interacts with issues related to
substance abuse and mental health.
Three types of network innovation are discussed:
network scale-up methods, a network ecology approach t
o social resources, and the
integration of network variables into the proposed stress process model of homeless
substance abuse and mental health. By employing network methods and integrating
these methods into existing models, research on homeless and uns
tably housed
women and unaccompanied young people can address existing research challenges
and promote more effective intervention and care programs.
How to cite this paper:
Dombrowski, K.
, K., Crawford, D., Welch-
., Habecker, P. and Khan, B. (2016) Ne
Approaches to Sub
stance Use and HIV/
Hepatitis C Risk among Homeless Youth
and Adult Women in the United States: A
, 1143-1165.
July 20, 2016
August 23, 2016
August 26, 2016
Copyright © 201
6 by authors and
Research Publishing Inc.
This work is licensed under the Creative
Commons Attribution International
License (CC BY
Open Access
K. Dombrowski et al.
Network Science, Homeless Women, Homeless Youth, Stress Process Models,
Network Ecology, Racial/Ethnic Health Disparities
1. Introduction
During the United States economic recession of 2008-2011, poverty levels increased
substantially, as did the number of “doubled-up” households, foreclosures, those on
welfare and homeless adults and children [1]. In addition to economic consequences,
the recession also had negative effects on people’s health and mental health, some of
which have been documented in national and regional sources [1] [2]. A handful of
studies have examined the extent to which the economic consequences suffered during
the Great Recession led to alcohol problems. For example, according to Burgard, alco-
hol consumption increased as did binge drinking and alcohol dependence [1]. Little
specific attention, however, has been given to the substance use and mental health
needs of homeless populations and those made homeless by the economic downturn.
Homeless and unstably housed youth [HUHY] make up one of the most vulnerable
populations in the U.S. They often are victims of caretaker physical and sexual abuse
[3]-[5], family disorganization [3] [6], sexual exploitation [7]-[9], hunger [10] [11], and
physical and sexual assault when on the streets [3] [12] [13]. Sexual behaviors, drug use,
and subsistence behaviors make them among the most susceptible to sexually transmit-
ted infections (STIs) such as HIV/AIDS [14]-[17] and hepatitis [18]-[20], most HUHY
lack conventional social support and adult mentorship [21] [22]. These combined risk
factors take an enormous psychological and developmental toll. Over time, conventional
opportunities diminish and the consequences of street life accumulate. This “cumula-
tive continuity” [23] can result in a lifetime of marginality characterized by antisocial
behaviors [24]-[26], involvement in the criminal justice system [27]-[29], drug abuse
and dependency [30] [31], economic disadvantage [32], health problems [33], and adult
psychiatric disorders [13]. Although there have been numerous studies of homeless
youth, there has never been a comprehensive national study of the spectrum of HUHY
that comprise this complex subpopulation.
Similarly, homeless adult [HA] women remain a significantly understudied popula-
tion. Perhaps because women make up a lower percentage of homeless adults, studies of
HA women are relatively scarce in comparison to both general studies of HA and stu-
dies of male HA. What few studies exist of specifically female HA are characterized by
small sample sizes and restricted to a single location in predominantly large coastal ci-
ties. There are few regional or longitudinal studies of HA women in the United States.
Of the few studies of female HA, a significant number focus only on specific subpopu-
lations of HA women (
., HIV+ samples, in-treatment/clinical samples). Although HA
women are one of the fastest growing segments of the homeless population in the
United States [34], they remain an understudied group [35]. What findings exist suggest
K. Dombrowski et al.
HA women are an extremely vulnerable population, demonstrating comparable or
higher rates of substance use and mental health needs as HA men. Similar results are
obtained when HA women are compared to housed women [36] [37]. The few well-
designed, large sample studies that included subsamples of homeless women are now
more than a decade old [38] and existing studies do not include the entire spectrum of
homeless women. Research to address this problem at regional levels and across a large
US region is needed to characterize this rapidly changing population.
2. Network Approaches to Homeless Population Estimation
Among the more important questions confronting policy makers concerned with hard-
to-reach and hidden populations is the size of the population itself [39] [40]. Though
fluid and often dependent on definitions of homelessness, such data are nevertheless
critical to effective programing and budgeting at the national and local levels [41]-[43].
Unfortunately, as Lee
et al.
point out, hard-to-reach populations are, by definition,
equally hard-to-enumerate [44] (see also Marpsat and Razafindrastsima [45]).
Understanding the size and distribution of the full spectrum of HUHY and HA
women housing needs is critical. The most recent estimates of the number HUHY
range from 380,000 [46] to 1,500,000 [44]. The wide range of estimates is caused by
differences in the definition of homelessness: different housing statuses [sheltered and
unsheltered], idiosyncratic estimation designs, differing age criteria, and/or a focus on
specific identity groups [47] [48]. Moreover, many of these estimates fail to recognize
that homelessness is not a steady state [49]. HUHY are constantly shifting between
short-term housing, shelters, living in institutional settings [50] (e.g., foster care and
serial fosterage, group homes, and post-incarceration settings), and episodes of street
homelessness. The link between the housing statuses of young people [51] and differ-
ences in sexual identity [52], gender [53], employment [54], drug use [55]-[57], mental
health [13], criminal justice involvement [28] [58], victimization [59], and family sup-
port [6] are well recognized. Yet each of these axes provides unique challenges to pro-
grams aimed at reducing harm, risk, and victimization among the population. Only by
knowing the extent and needs of each of these groups can we hope to sufficiently ad-
dress the risk of the population as a whole. This is particularly true for HIV/HepC pol-
icy, as the social conditions of HUHY present barriers to testing, awareness building,
and outreach, while those involved remain at substantial risk [15] [60]-[62]. Taken
singly, these problems represent significant program challenges; together they represent
a crisis for an entire population.
Beyond housing status, there is consensus that HUHY tend to cluster by identity
and/or subsistence strategies, [63], further fracturing service delivery and outreach.
Much of the current research, however, focuses on a single identity cluster (e.g., LGBT,
travelers, sexually exploited children, gangs), leaving the relationships between these
clusters largely unknown. Movement between clusters and the transfer of risk behaviors
from one to another are also clear, resulting in a situation best described as a “total risk
network” [64] [65]. Identity specific research, in combination with small, non-repres-
K. Dombrowski et al.
entative samples (e.g., a single shelter, or clients of a single program), neglects the web
of connections between risk groups. This results in a loss of critical epidemiological in-
formation and misleading estimates of the proportions and characteristics of HUHY by
identity, which can exacerbate service shortages and result in less than optimum service
delivery plans.
For all these reasons, reaching the full spectrum of HUHY is crucial, and delays in
doing so are costly in both personal and social terms. There is plentiful evidence that
the number and length of homeless episodes are central factors in risk for victimization
and stress [66]. There is also evidence that the consequences for mental health, sub-
stance abuse, and physical health are amplified by time on the streets and repeated vic-
timization [67] [68]. All of these factors are associated with elevated levels of HIV/
HepC exposure, creating a feedback loop where behavioral risk is amplified at each
successive episode of housing loss.
In the 1990s, “point-in-time” estimation [48] [69] and “plant/capture” correction
procedures [70] were developed as advances over conventional homeless census tech-
niques [71]-[73] and both were used in a number of US cities [47] [74] [75] (recently,
see Bezerra
et al.
[76]). Yet both point-in-time and plant/capture are dependent on the
existence of total census operations for their effectiveness. The use of social network
techniques for population estimation from more limited samples represents a new di-
rection in counting hard-to-enumerate groups [77]-[80].
The most notable of the new network techniques is referred to as the “network
scale-up method” (NSUM). This method has been used in research on hard-to-enu-
merate populations, including HIV prevalence for out of treatment populations and
numbers of injection drug users [81]-[84]. Though questions have been raised in com-
parative trials about discrepancies between NSUM and other estimation methods [85],
the concept of network-based sampling has secured an important place among those
who do research with hard-to-enumerate populations, including the considerable at-
tention gained by respondent driven sampling (RDS) techniques [86]-[89]. More re-
cently, researchers in New York have combined ideas drawn from network scale-up
methods and conventional capture/recapture techniques. These techniques were used
in two prior NIJ funded studies to estimate the number of commercially sexually ex-
ploited children [90] and methamphetamine users [91]. In more recent work, these
techniques were expanded to include confidence intervals and error estimation [80].
Such work holds promise for use in other locations.
3. Peer and Network Influences on HIV Risk among Homeless and
Unstably Housed Youth
As Ennett
et al.
noted more than a decade ago [92], peer networks among young people
clearly demonstrate both risk-enhancing and risk-decreasing properties that influence
substance abuse and unsafe sexual behavior. More recently, researchers have framed
this question as the issue of prosocial versus problematic peers, and tied it directly to
HIV incidence among homeless adolescents. Rice
et al.
’s [93] study of young people in
K. Dombrowski et al.
unstable housing in Los Angeles found that the number of prosocial peers had demon-
strable effects on the likelihood of HIV risk over time, building on earlier work that
showed the effect of these same factors on drug choice/use [94] (see also Bousman [95]
for similar results for homeless youth from San Diego, and similar network findings by
et al.
[96]). Ferguson found that for highly mobile or “transient” homeless youth,
being dependent on peers, as opposed to family, was closely associated with participa-
tion in street-survival behaviors, including survival sex [97] (see Tyler [98] and Um
[99] for drug use and overall risk).
Elsewhere [100], some of these same data were used to show that peer network
composition for homeless adolescents changed over time, away from “prosocial” peers
and toward those network connections that increased HIV risk. The latter is important,
as it shows a changing trajectory of HIV risk that is activated through network me-
chanisms, which in turn corresponds directly to time spent on the street. Indeed, it is
possible that one central and often ignored mechanism for the cumulative effect of
“time on the street” can be found in the changing composition of individual social
networks. Evidence for this is emerging. Working in Los Angeles, Martino
et al.
found that rates of risk for HIV were higher among “traveler” youth who demonstrate
long-term and long-distance migration patterns. Here, differences in risk correlated
with differences in social network composition, as over time HUHY moved away from
“conventional individuals and institutions” and toward others like themselves [102].
Others have examined the link between drug use and sex-based risk among HUHY
[103] [104]. In work by Weber
et al
. [105], sexual risk among homeless youth was
found to be influenced by the combination of partnership choices and drug use (both in
kind and frequency), highlighting a theme that recurs in later research: sexual risk and
risk of substance abuse are closely interrelated [65] [106] [107]. These findings echo
results of research by Dombrowski
et al
. for non-street-based users of methampheta-
mine in New York City [91], as well as for adolescents engaged in commercial sex work
[90]. Here, peer and network influences on sexual risk are important considerations.
Among 249 respondents, 46% of girls, 44% of boys, and 68% of transgendered youth
said that they were recruited into the commercial sex economy by “friends”, rather than
by potential customers, market facilitators (pimps/“boyfriends”) or family members (p.
46). The report notes:
CSEC [commercially sexually exploited children] peer groups were not only vital to
youth’s entry into the market, but also to their ability to engage the market and their
decision to remain in “the life. Some of their networks were quite extensive, and over
one quarter of the teens (27%) claimed to know 20 or more CSEC youth, an additional
20% of the youth said that they knew between 10 and 20 other CSEC youth…There was
a widespread ethos among CSEC youth of helping each other out, even if they did not
know each other very well, and this orientation extended into the market and beyond…
“We recommend customers to one another and help each other out. ‘Cause we all in
the same predicament, so why not…if I could look out, I’m gonna look out” (p. 59).
Homelessness played a critical role in motivating participation. The majority of study
K. Dombrowski et al.
participants were living in an unstable situation: 32% of the sample for this study de-
scribed their situation as “living in the street” with an additional 44% of girls saying
they lived “outside a family home” [90].
With the recognition that network peers influence risk has come the realization that
peer and network influences may also affect service delivery and positive social support
[108] [109]. Recent work by Rice
et al
. and Chew Ng
et al
. emphasize the potential of
network ties to increase shelter use [110] and reduce substance use [111]. As these au-
thors note, social ties can be used to facilitate peer-based interventions, yet to do so, we
must know more about the overall network structures that link homeless and unstably
housed young people to one another [112]. This includes ties within and across identity
groups, subsistence clusters, and across the full range of housing situations. Such data
are rare in a single network study. Full network topologies (network sociograms that go
beyond ego networks to display the full set of connections among a group) are nearly
non-existent among HUHY. Nor do we know much about the connections between
clusters, or the structure of the relationship between HUHY and their non-homeless
To make matters worse, most studies of homeless youth have not provided adequate
comparison groups among those marginally housed and those currently experiencing
an episode of homelessness who may be co-participants in many of the same activities
or behaviors. As noted above, the relationship between HIV/HepC risk (via drug use
and commercial/exchange sex) and the range of housing statuses remains murky; while
it may be well known in some places [113] [114], it is largely unknown in others.
4. Stress Processes among HA Women
Both stress and substance abuse/dependence disorders (SAD) are disproportionately
high among homeless adult populations. Available evidence indicates that homeless
adults experience significantly more stressors than other populations, including low-
income housed adults [115]. In part, this is attributable to contemporaneous stressors:
the fact that homelessness itself is stressful, whether due to the events of becoming
homeless or to the enduring, chronic strains associated with being on the street. Yet
homelessness itself is frequently the result of prior stressors, such as childhood abuse,
unemployment, intimate partner violence, and past homelessness.
Homeless women encounter more stressors and strains on average than housed
women. They are more likely to be victims of violence [116] and sexual assault [117],
more likely to have a current and lifetime mental disorder, and to be unemployed or
under employed. A large proportion of HA women may be accompanied by children,
yet other HA women do not have physical custody of their children [118] [119]. Both
circumstances may operate as significant sources of stress. HA women, by virtue of be-
ing homeless and being negatively regarded by the public, may experience discrimina-
tion when seeking services or in their daily lives [120]. Their gender may also place
them at risk for discrimination in wage discrepancies and employment [121].
The same bi-directional causality can be seen in the area of substance use/abuse
K. Dombrowski et al.
among homeless adults. In general, substance use is one response to stress [122] [123],
and has also been found to exacerbate stress [124]. Among HA women, rates of sub-
stance use disorders vary between 30% and 55% [125], and rates of binge drinking and
hard drug use are also quite high [126]. Chronic or ongoing stressors increase or ex-
acerbate existing substance use problems. In Tucker
et al
.’s study [116] comparing
sheltered and housed women in Los Angeles, those living in a shelter were more likely
to have experienced violence, which propelled them into homelessness, and were more
likely to report an increase in alcohol/drug use in response to the violence. Further-
more, the presence of mental disorder may generate additional mental health problems
and stressful experiences [127] [128], and thereby affect the development or persistence
of SAD.
These factors can be captured under a single model that combines a classic stress
process model [129] [130] with Whitbeck
et al.
’s risk amplification model [67] to con-
sider both the bi-directional nature of the stress-substance use relationship and the
buffering role of social network supports and access, as shown in Figure 1. The model
links 5 core concepts in a complex model of directed and bi-directed causality. Here the
major elements identified by prior researchers of homeless adults and HA women are
represented as boxes: Prior Stressors, Contemporaneous Stressors, Substance Abuse
and Dependence, Social Support and Exchange Networks, and a range of Homeless
Outcomes that are at once contemporaneous stressors, and the behaviors/strategies
most often linked to the perpetuation of homelessness (reliance on sex work survival
strategies, CJS involvement, deviant subsistence strategies, and related outcomes).
These 5 core concepts are related by a series of causal and bi-directional links (A
through I) that predict homeless outcomes.
Thus, for example, it could be that HA women who engage in higher levels of sub-
stance use and/or have substance abuse and dependence disorders often experience
more stressors (path B), whose manifestation is perpetuated by their substance abuse/
Figure 1. A stress process model for substance abuse and mental health among
homeless populations.
Race/ethnicity and
gender differences Prior Stressors
Social Networks of
Support and Access
Substance Abuse &
Sex work
Deviant subsistence strategies
Risky sexual behaviors
CJS involvement
K. Dombrowski et al.
dependence (path A). These together can perpetuate homeless outcomes (paths H and
I; such as missed counseling appointments) that later contribute to failed efforts to exit
homelessness though failures of program compliance. Examples of such simultaneous
cause/effect/cause relationships are well documented in the literature: for example, be-
ing under the influence of drugs or alcohol places homeless people on the street at
higher risk of being victimized [131], which in turn acts as a stressor for mental health
issues, which can in turn trigger continued reliance on substance use.
This model also takes into account the role of prior stressors. Women’s experiences
prior to becoming homeless, including during childhood, are often predictive of both
later homelessness and SAD (path C). Stressors in childhood such as child maltreat-
ment have been associated with risk for adult alcohol use disorders [132]. Compared to
housed women, rates of childhood abuse and neglect are higher in samples of HA
women [133]-[135]. It is estimated that 19% to 63% of the homeless women in prior
studies had been abused or neglected as children [136] [137]. In adulthood, rates of in-
timate partner violence are also considerably higher among HA women than housed
women [35] [116] [138]. Additionally, homeless adults are more likely to have family
histories of homelessness or housing instability [139]. These prior stressors have direct
effects on current stressors, contributing to their proliferation [140], as well as on cur-
rent substance use problems (path C). For instance, childhood abuse is positively asso-
ciated with later mental health problems among homeless youth [141]. Furthermore,
prior stressors may be associated with SAD via their effects on current stressors.
Among HA women, childhood abuse has been associated with chronic homelessness
and substance use problems in part because of its effect on later physical abuse [30].
5. Network Approaches to a Stress Process Model of HA Women,
as a Means to Address Racial/Ethnic Disparities
Research on the topic of homeless women and substance use/abuse is timely given re-
cent economic changes that have increased the homeless population in suburban and
rural areas. Nationally, between 2007 and 2010, the number of homeless families is es-
timated to have increased by 20% and the number of those families using shelters in-
creased by 57% [142]. A recent report by the National Coalition for the Homeless indi-
cates that the subprime mortgage crisis especially affected lower-income families and
single parent families [143]. Often these families are female-headed households
showing that gender differences extend beyond individual vulnerabilities to impact
homeless children as well [144]. Many of the affected households continue to live in
unstable housing situations, indicating that for those on the bottom, the housing crisis
is not over. For individuals having gone through the process of home loss and foreclo-
sure, the health repercussions are just now being understood [145]-[147].
Apparent ethnic/racial differences among HA women may mask more salient social
differences related to broad political economic changes, particularly in the aftermath of
the social transformations that have taken place in the last several years. No current or
previous study has examined how racial/ethnic outcomes may be related to differing
K. Dombrowski et al.
levels of social capital and social network access in a rapidly changing rural political
economy. Shelter populations in mid-size Central US cities now contain women from
longstanding, historically urban African American populations, newly arrived white
women displaced by changes in agricultural economies, Hispanic women who have
immigrated more recently to work in the emerging rural economy, and Native Ameri-
can women who move between reservation and urban margins. Together, they repre-
sent a significant departure from past populations. Such personal historical differences
necessarily provide different levels of social support that significantly impact both the
ability to transcend homeless and deal with substance use/abuse issues.
In the Central US, the housing crisis may have both masked and accelerated ongoing
rural social changes [148] [149]. Much of this transformation has been tied to changes
in the meat packing industry that have attracted considerable migration from Central
America [150]-[152]. Yet other deep structural changes have emerged recently as well,
including differences in gendered employment [153]-[155], uneven and short-lived
patterns of return migration [156] [157], differential impact of age [158] and education
[159] on migration, and related general patterns of rural economic well-being [160]-
[162]. One possible explanation is that these changes lie behind surface statistics docu-
menting racial/ethnic health disparities among homeless women in the region. While
little specific research has focused on this topic in the region, racial and ethnic health
disparities among homeless women are well known [163]-[165].
In this view, racial and ethnic differences in homeless trajectories (and their related
health outcomes) would be seen as closely related to differences in the social networks
of support and influence, which themselves are products of markedly distinct roles that
women of different ethnic and racial groups play in the emerging rural economy of the
Central US. For white women in the region, rural economic decline has, for some,
meant a descent into poverty and resulting strained family ties, internal migration, and
new forms of welfare dependency. In contrast, Hispanic migrant women, many of
whom lack legal documentation, can draw on little support when domestic or economic
changes overwhelm personal resources. African American women in the region are
primarily urban, and many are able to retain social networks despite tenuous economic
status (in contrast, for example, to migrant Hispanic women). And Native American
women often move in and out of social networks as conditions in home reservation
communities prompt circular patterns of migration into and out of regional urban
In each case, individual social networks reflect these historical differences, and are
reflected in individual histories of housing instability and homelessness. If different
groups, seemingly identifiable by racial or ethnic background, draw on very different
networks of support, then their differential paths out of homelessness would likely be
very different. To the extent that homelessness itself is a recognized vector for both
substance abuse and health deterioration, the ability to tailor programs to specific needs
(toward and from desired and undesired influences) represents an important step for-
ward in our ability to meet the needs of what, on the surface, may seem a uniformly
K. Dombrowski et al.
needy population.
Network considerations can be added as mediators and moderators of the new stress
process model shown in Figure 1. Considerable evidence exists for this approach. Prior
research has found that negative social supports and coping strategies promote drug
use or drug problems, whereas positive coping and social support reduce those same
problems [34]. Throughout the US, HA women have been found to lack strong positive
social support systems [133] [166], which are integral to obtaining and maintaining
stable housing. Social networks remain an important and understudied aspect of
homeless women’s experience, that may have direct effects (path F) as well as moderat-
ing and mediating effects on stress exposure and substance use (paths D and E). First,
these networks can reduce or ameliorate stressors associated with being homeless by
providing important avenues of emotional and instrumental support (path D). Second,
a key factor in preventing and recovering from SAD is having access to effective social
support networks (path E). Conversely, some social networks may facilitate or exacer-
bate both the stressors associated with homelessness and SAD if antisocial, abusive, or
substance using peers and family members constitute a woman’s social network. Third,
social networks serve as a key moderator of the stress/SAD association (path F), whe-
reby women who experience stressors associated with being homeless may be more
likely to reduce substance use or seek treatment if they have supportive networks,
compared to women with more stressors but weak social supports. Finally, social net-
works themselves may be influenced by the SAD of women, including the composition
of the network (
., selecting substance using network members) as well as by damag-
ing relationships with prosocial members (path G). These networks then may be an
important mediator in the substance use-to-stress association.
At stake in such a network-enabled model is the ability to better predict homeless
outcomes. Being homeless often necessitates adaptive behaviors as survival mechan-
isms, including sex work and deviant subsistence strategies (path H). SAD may also fa-
cilitate negative behaviors associated with abuse/addiction, such as risky sexual beha-
viors and deviant subsistence strategies (path I). In a study of homeless young people in
four cities, being unemployed and having drug problems increased the odds of engag-
ing in risky survival strategies [97]. Furthermore, both homelessness and SAD are asso-
ciated with involvement in the criminal justice system, as many of the behaviors asso-
ciated with them place homeless women at risk for arrest and imprisonment. It is esti-
mated that 20% to 52% of women who have been homeless also have a history of crim-
inal justice system involvement [38] [167] [168].
Contextualizing this entire model is the larger question of ethnic/racial differences in
homeless outcomes (dashed circle). These differences may appear in any of the rela-
tionships in the model. For instance, distributions of stress and adversity may be high-
est among African Americans [122], which may partially account of the disproportio-
nately higher numbers of African American homeless women in the cities we will
study. Substance abuse and dependence also varies by racial/ethnic status, with higher
rates among American Indian and white women and lower rates among African Amer-
ican women in general population studies [169]. Negative outcomes such as CJS in-
K. Dombrowski et al.
volvement may also be higher for racial/ethnic minority women, compared to white
women. Importantly, it is very likely that access to supportive social networks will also
differ across racial/ethnic groups [170], which also impacts both homelessness and
SAD. In sum, race/ethnicity is an important determinate of both homeless experiences
and SAD.
There are clear payoffs from defining network actors and ties more broadly: chiefly,
in this model people are not only seen as sources of resources, they are also seen as
sources of resource competition [171]. Given the limited resources available to HA
women, individuals in the same vicinity, doing the same things, are potential competi-
tors for the same goods and services. For example, a street corner cannot support a
large number of people pan-handling in the same location. In this view, subsistence and
other survival strategies, like shelter beds, exist in a finite ecology of limited resources
[171]-[173]. This competition is directly related to both flows of resources and sources
of stress for HA women (see, for example, the link between scarcity and stress by Ensel
and Lin [174]). In short, by thinking in terms of competition, and not just resources,
researchers can test specific hypotheses about behavior, substance use, and mental
health changes. Future research should examine these networks at multiple instances to
see how patterns of exchange and network ties evolve over time [175]-[177] and how
stress and competitive pressure affects mental health outcomes and behaviors over time
[178]. At a macro level, we should consider how the entire system of exchange changes
over time, as well as how the connections between organizations (defined by serving the
same population) evolve over time.
6. Network Approaches to a Stress Process Model of HA Women,
as a Means to Address Racial/Ethnic Disparities
This review argues that network techniques can play an important role in understand-
ing substance abuse and HIV/hepatitis risk among two segments of the US homeless
population: homeless adult women and homeless and unstably housed youth. In the
last three decades, the use of network techniques has grown significantly public health
research. We have discussed evidence that supports the greater use of network data
collection and analysis in three areas: 1) population enumeration of the homeless and
unstably housed, especially homeless youth (using combined network scale-up and
capture-recapture methods), 2) a sociometric approach to homeless adult resource use
and competition (using a network ecology approach), and 3) the integration of network
factors into existing stress process models aimed at understanding substance abuse and
mental health interactions (using a network-enhanced stress process model shown
above). Together these elements hold out promise for greater integration of existing re-
search findings, which in turn can help intervention planners to more successfully meet
the needs of a group that has grown in both size and complexity over the last decade.
This work was supported by the NIH National Institute on Drug Abuse of the National
K. Dombrowski et al.
Institutes of Health (grant number R01DA037117) and the NIH National Institute for
General Medical Sciences (grant number R01GM118427). The content is solely the re-
sponsibility of the authors and does not necessarily represent the official views of the
National Institutes of Health.
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... Other findings draw specific attention to the fact that homeless experience is shaped along gender lines [19][20][21]. Homeless females are often driven to homelessness and runaway decisions for very different reasons than their male counterparts [22]. The experience on the street is also lived differently for women compared to men. ...
... Scholars have noted differences between research and clinical diagnostic routines [35] for BPD that can also complicate field diagnoses. Further, disentangling the relationships between impulsivity, abandonment, other previous diagnoses, and substance abuse in a non-clinical setting is difficult [21]. Given these issues, we follow the lead of researchers that have focused on BPD symptoms when diagnosis is not available or applicable [36]. ...
Full-text available
Engaging in survival sex and mental illness are overrepresented within homeless populations. This article assesses the relationship between symptoms of borderline personality disorder (BPD) and engaging in survival sex among homeless women. One hundred and fifty-eight homeless women completed surveys on self-reported BPD symptomology and sexual history. Bivariate and multivariate analyses conducted in this study provided insights into the association of experiencing BPD symptoms and engaging in survival sex. Results indicate that some symptoms of BPD are robustly correlated with engaging in survival sex among homeless adult women. Implications for service agencies and others working with at-risk female populations are discussed.
... Given the inherent housing instability of PEH, the notable lack of access to healthcare and associated risk behaviors, such as IDU and successful HCV treatment interventions, are challenging for this population (Department of Health and Human Services [DHHS], 2017). Increasingly, the intersectionality of the abovementioned conditions and other important factors (i.e., social, cognitive, structural, and financial, etc.) describes the complex interplay of facilitators and barriers to treatment experienced in each sociodemographic (Dombrowski et al., 2016;Ho et al., 2015;Werb et al., 2016). ...
... While recent research has explored therapeutic relationships between homeless individuals and healthcare providers (Moore-Nadler et al., 2020), the need for culturally sensitive treatment studies is important to understand, explain, and tailor to the complex sociocultural factors that create the conditions for both low participation and low HCV completion rates among PEH with curative HCV interventions (Hanlon et al., 2018;Lambert et al., 2019;Surey et al., 2019). Addressing the sociocultural factors from within a PEH community context is foundational to any HCV intervention among homeless adults (Dombrowski et al., 2016). ...
Despite the availability of cure for hepatitis C virus (HCV), people experiencing homelessness (PEH) are challenged with initiating and completing HCV treatment. The design of culturally sensitive HCV treatment programs is lacking. The objective was to employ community-based participatory research methods to understand perceptions of HCV-positive PEH, and providers, on the design and delivery of a culturally sensitive, nurse-led community health worker (RN/CHW) HCV initiation and completion program. Four focus group sessions were conducted with HCV-positive PEH (n = 30) as well as homeless service providers (HSP; n = 7) in Skid Row, Los Angeles. An iterative, thematic approach provided the themes of essentials of successful participant engagement and retention: Role of nurse-Led CHW in promoting: (a) tangible and emotional support; (b) cognitive and behavioral support; and (c) financial and structural resources. The goal of this study is to provide the groundwork for future research of HCV program design to support HCV cure among homeless populations.
... The existing research on VH supports that youth from lowincome, vulnerable backgrounds are at the greatest risk of infection, yet prevention research and programming is minimal. Those studies that are available on VH knowledge have focused largely on homeless [14] and injecting drug using US youth [15]. Unfortunately, prevention intervention efforts for VH, specifically catered to youth, are infrequent. ...
Full-text available
Racial-ethnic minority youth between the ages of 13 and 24 in the USA are disproportionately impacted by HIV. Low HIV knowledge and psychological antecedents such as low perception of risk and low sexual negotiation skills have all been associated with HIV risk behaviors; however, the role of ethnic identity on these factors is unclear in the literature. Ethnic identity, which is a critical part of identity development among racial-ethnic minority youth, has been found to be a protective factor in risk-taking behaviors. However, limited research is available on the role of ethnic identity in HIV prevention research among youth. For this study, data were collected as part of a larger HIV prevention education program using a sample of 564 students of color (Meanage = 16.30, standard deviation [SD] = 1.26; 67.4% Hispanic, 29.5% Black) from an underserved northeastern US urban community. We examined whether ethnic identity moderated the relationship between psychological antecedents (e.g., perception of risk and sexual negotiation skills), gender, and viral hepatitis knowledge on HIV knowledge. Findings revealed that ethnic identity significantly moderated the relationship between psychological antecedent variables and HIV knowledge by strengthening these associations as ethnic identity increased. Female adolescents were also more likely to have higher levels of HIV knowledge than males. Findings provide support for cultural and gender-specific prevention programs for racial-ethnic minority youth that seek to reduce HIV risk behaviors by increasing ethnic identity, particularly in under-resourced communities.
... However, VH knowledge and awareness research is limited in the U.S. The existing research on VH risk supports that youth from low-income, vulnerable backgrounds are at the greatest risk of infection; yet, prevention research and programming is minimal. Those studies that are available on VH knowledge have focused largely on homeless [21,22] and injecting drug using U.S. youth [23][24][25][26][27]. While these are highly critical populations, there is a need for research examining VH risk and knowledge among lowincome ethnic minority youth, in general. ...
Full-text available
Viral hepatitis (VH) knowledge among youth is understudied in the United States. There has been a rise in VH cases in the U.S. in the wake of the opioid epidemic. Innovative approaches to preventing the infection are needed especially in urban communities. This study presents preliminary findings from a community-based HIV/AIDS, substance abuse, and VH prevention education intervention for ethnic minority youth in a northeastern urban community. We aimed to evaluate VH knowledge and factors associated with knowledge. Participants in the study completed a baseline survey followed by an exit survey measuring VH knowledge after the intervention. The survey was completed by 691 individuals. Logistic regression analyses were conducted and indicated that there was a significant increase (82.3%) in VH knowledge among youth who participated in the intervention. The development and implementation of VH knowledge interventions can be crucial in alleviating the rise of VH infections in the U.S.
... The majority of studies published on homeless young adults focus on substance abuse and mental health (3,4,6,19). Studies that have addressed the physical and functional health of homeless adolescents and young adults have largely been conducted outside of the United States (14,22). ...
Full-text available
Proper musculoskeletal health is dependent on the efficient inner workings of muscles, tendons, ligaments, joints, and bones. The homeless experience can be physically debilitating to these tissues and anatomical structures. This feasibility study aims to explore how to answer the overarching question: do the lived experiences of homeless young adults negatively affect their musculoskeletal health? Questionnaires were distributed to assess the demographic characteristics, physical activity, health behaviors, and sleep patterns of 40 homeless young adults and 45 university students in Los Angeles County. Participants also completed supervised stretch tests to assess musculoskeletal flexibility. Findings indicate that homeless young adults were less flexible in all four stretch assessments compared to university students. Noteworthy differences were noted with the sit and reach (p=0.050), butterfly (p=0.036), right shoulder (p=0.005), and left trunk twist tests (p=0.041). Analyses of physical activity levels and sleep location within the homeless subgroup suggest a deleterious impact on flexibility. Flexibility assessments are a low cost and sensitive method for measuring degree of musculoskeletal dysfunction of homeless young adults. Preliminary data suggests that the musculoskeletal health of this subgroup is adversely affected by their lived experience. Health services such as yoga or Pilates, in addition to existing case management and mental health services at homeless drop-in centers, may reduce the likelihood of long-term physical disability.
Black and Latina women are disproportionately impacted by HIV/AIDS. Despite existing research linking social networks and HIV risk among men who have sex with men (MSM) and other high-risk populations, little research has examined how ethnic/racial minority women's social networks shape HIV prevention and intervention targets. Using interviews with a sample of 165 predominantly Black and Latina-identifying women from a small city in the Western U.S., this research examines the relationship between egocentric network characteristics and HIV knowledge, attitudes, and testing history. Results reveal that network characteristics play a significant role in shaping HIV-related knowledge, prejudice, and testing intention but not HIV testing history. Individual-level factors like homelessness and perceptions of testing barriers are more salient for explaining testing behaviors than network characteristics. Intervention efforts to improve knowledge and reduce prejudice among Black and Latina women may benefit from mobilizing network ties.
Background. Homeless individuals are at high risk of contracting the Hepatitis C virus (HCV) given that many use intravenous drugs or have a prison history, common risk factors for the disease. Although there is no vaccine, it is curable. Methods. This cross-sectional study surveyed residents (n=120) of five homeless shelters in Connecticut to understand their screening willingness and knowledge about HCV. Results. Those who tested previously (OR=0.46, 95% CI 0.23-0.90) and those who had never spent time in prison (OR=0.39, 95% CI 0.15-0.98) were less willing to be screened. Most did not recognize HCV symptoms and risk factors. Conclusions. The study revealed that 12.5% of those surveyed have HCV and 60% had been to prison. Although 67.8% indicated HCV knowledge, the mean grade on the quiz was 48.6%. Discussion. 92.5% had been to a doctor within the past year, yet HCV and screening do not appear to have been discussed.
This report is an examination of a theoretical model of risk amplification within a sample of 255 homeless and runaway adolescents. The young people were interviewed on the streets and in shelters in urban centers of four Midwestern states. Separate models were examined for males (n = 102) and females (n = 153). Results indicated that street experiences such as affiliation with deviant peers, deviant subsistence strategies, risky sexual behaviors, and drug and/or alcohol use amplified the effects of early family abuse on victimization and depressive symptoms for young women. These street adaptations significantly increased the likelihood of serious victimization over and above the effects of early family history for both young men and women. Similarly, street behaviors and experiences increased the likelihood of depressive symptoms for young women over the effects of early family abuse, but not for young men. The risk‐amplification model from the life course theoretical perspective is discussed as an example of the cumulative continuity of maladaptive behaviors.
Homeless women experience extensive health risks including physical and sexual victimization. Few studies that have gathered information on homeless persons have reported results separately for women or have compared them directly with men. Research that both investigates antecedents of victimization among homeless women and compares them to those for men is necessary to determine whether prevention efforts must be different for each group. We investigated potential antecedents of recent (past 30 days) physical and sexual victimization in a probability sample of 394 homeless women and compared findings to those for 1159 homeless men. As hypothesized, mental disorder, substance dependence, and engaging in economic survival strategies significantly predicted victimization among homeless women. With few dissimilarities, these characteristics also predicted victimization among homeless men. Although differences in the needs and experiences of homeless women and men must be recognized, both women and men require assistance to establish and maintain safe residences, treatment of any substance use and mental disorder, and alternatives to economic survival strategies that place them at risk for victimization.
Objective: This study sought to investigate the rates and correlates of homelessness, especially mental illness, among adult jail inmates. Methods: Data from a national survey of jail inmates (N=6,953) were used to compare the proportion of jail inmates who had been homeless in the previous year with the proportion of persons in the general population who had been homeless in the previous year, after standardization to the age, race and ethnicity, and gender distribution of the jail sample. Logistic regression was then used to examine the extent to which homelessness among jail inmates was associated with factors such as symptoms or treatment of mental illness, previous criminal justice involvement, specific recent crimes, and demographic characteristics. Results: Inmates who had been homeless (that is, those who reported an episode of homelessness anytime in the year before incarceration) made up 15.3% of the U.S. jail population, or 7.5 to 11.3 times the standardized estimate of 1.36% to 2.03% in the general U.S. adult population. In comparison with other inmates, those who had been homeless were more likely to be currently incarcerated for a property crime, but they were also more likely to have past criminal justice system involvement for both nonviolent and violent offenses, to have mental health and substance abuse problems, to be less educated, and to be unemployed. Conclusions: Recent homelessness was 7.5 to 11.3 times more common among jail inmates than in the general population. Homelessness and incarceration appear to increase the risk of each other, and these factors seem to be mediated by mental illness and substance abuse, as well as by disadvantageous sociodemographic characteristics.
Respondent-driven sampling (RDS) is an approach to sampling design and analysis which utilizes the networks of social relationships that connect members of the target population, using chain-referral. RDS sampling will typically oversample participants with many acquaintances. Naïve estimators, such as the sample average, will thus be biased towards the state of the most highly connected individuals. Current methodology cannot estimate population size from RDS, and promotes inverse probability weighted estimators for population parameters such as HIV prevalence. We propose to use the timing of recruitment, typically collected and discarded, in order to estimate the population size via a counting process model. Once population size and degree frequencies are made available, prevalence can be debiased in a post-stratified framework. We adapt methods developed for inference in epidemiology and software reliability to estimate the population size, degree counts and frequencies. A fundamental advantage of our approach is that it makes the assumptions of the sampling design explicit. This enables verification of the assumptions, maximum likelihood estimation, extension with covariates, and model selection. We develop large-sample theory, proving consistency and asymptotic normality. We further compare our estimators to other estimators in the RDS literature, through simulation and real-world data. In both cases, we find our estimators to outperform current methods. The likelihood problem in the model we present is separable, and thus efficiently solvable. We implement these estimators in an accompanying R package, chords, available on CRAN.
Evaluating the representativeness of homeless samples is important for generalizing research findings on the homeless and designing interventions targeting their health needs. The present study contrasts homeless and domiciled free-clinic users (216 homeless [132 men, 84 women], 212 domiciled [102 men, 110 women]) and 531 community homeless persons (388 men, 143 women) on latent variables representing substance use, mental and physical health, appearance, life satisfaction, and health services utilization (HSU). Homeless clinic patients equalled the community sample in substance abuse and psychological problems but exceeded the sample in HSU and cleanliness. Homeless clinic users reported more substance abuse, poorer health, greater mental illness and mental HSU, less cleanliness, and lower life satisfaction than domiciled patients. Relationships among the variables are reported, and implications concerning health needs among the homeless are discussed
Americans have started to recognize interpersonal violence as a major health care issue. Increasingly, clinicians are beginning to recognize both the high rate of victimization among extremely poor women and its health consequences. However, most clinical responses focus on the immediate effects of child abuse, partner abuse, and rape. The long-term medical and mental health consequences and the relationship between early victimization and adult problems are still largely ignored. This article focuses on medical and mental health needs of extremely poor women survivors of interpersonal violence. It begins by documenting the extent and nature of violence against low-income women. Special attention is focused on the long-term sequelae of childhood abuse and on identifying and managing complex trauma responses in these women. The article concludes by discussing obstacles to care and the necessity of advocating for increased resources to respond to women living in extreme poverty.