Adeline Nyamathi

Relative contributions of parent substance use and childhood maltreatment to chronic homelessness, depression, and substance abuse problems among homeless women: mediating roles of self-esteem and abuse in adulthood ☆

OBJECTIVE This study, using latent variable methodology, explores simultaneously the relative effects of childhood abuse and early parental substance abuse on later chronic homelessness, depression, and substance abuse problems in a sample of homeless women. We also examine whether self-esteem and recent violence can serve as mediators between the childhood predictors and the dysfunctional outcomes. METHOD The sample consists of 581 homeless women residing in shelters or sober living centers in Los Angeles (54% African-American, 23% Latina, 22% White, mean age=33.5 years). Multiple-indicator latent variables served as predictors and outcomes in structural models. Childhood abuse was indicated by sexual, physical, and verbal abuse. RESULTS Childhood abuse directly predicted later physical abuse, chronic homelessness, depression, and less self-esteem. Parent substance use directly predicted later substance use problems among the women. Recent physical abuse predicted chronic homelessness, depression, and substance use problems. Greater self-esteem predicted less depression and fewer substance use problems. Childhood abuse also had significant indirect effects on depression, chronic homelessness, and drug and alcohol problems mediated through later physical abuse and self-esteem. CONCLUSIONS Although there was a strong relationship between childhood abuse and parent drug use, childhood abuse was the more pervasive and devastating predictor of dysfunctional outcomes. Childhood abuse predicted a wider range of problems including lower self-esteem, more victimization, more depression, and chronic homelessness, and indirectly predicted drug and alcohol problems. The mediating roles of recent physical abuse and self-esteem suggest salient leverage points for change through empowerment training and self-esteem enhancement in homeless women.

AIDS-related knowledge, perceptions, and behaviors among impoverished minority women.

OBJECTIVES The aims of this study were to (1) describe AIDS-related knowledge, perceptions, and risky behaviors of impoverished African-American and high- and low-acculturated Latina women; (2) delineate relationships involving high-risk behaviors; and (3) determine whether risky behaviors differ by race and levels of acculturation. METHODS Survey instruments were administered to 1173 impoverished women of color residing in homeless shelters and drug recovery programs. RESULTS Differences based on ethnicity and level of acculturation were found in AIDS-related knowledge, perceived risk of acquiring AIDS, and risky behaviors. Low-acculturated Latinas reported low perceived risk and were least likely to engage in illegal drug use and sexual activity with multiple partners. Intravenous drug use was most prevalent among high-acculturated Latinas, whereas nonintravenous drug use and high-risk sexual activity was most prevalent among African-American women. CONCLUSIONS The data indicate the need for culturally sensitive AIDS prevention programs for women that deal with general issues of drug use and unprotected sex, and that include separate sessions for women of different ethnic backgrounds and acculturation levels to address specialized areas of concern.

Risk factors for hepatitis C virus infection among homeless adults

OBJECTIVE: To describe the prevalence of hepatitis C virus (HCV) infection in a sample of homeless and impoverished adults and examine risk factors for HCV infection in the overall sample and as a function of injection drug use.DESIGN: Assays were conducted on stored sera. Socio-demographic characteristics and risky sexual activity were measured by content-specific items. Substance use was measured by a structured questionnaire. HCV antibodies were tested by enzyme-linked immunosorbent assay; a confirmatory level was defined by recombinant immunoblot assay.SETTINGS: Shelters (N=36) and outdoor locations in Los Angeles.PARTICIPANTS: Eight hundred eighty-four homeless women and/or partners or friends.RESULTS: Among this sample of 884 homeless and impoverished adults, 22% were found to be HCV infected. Lifetime injection drug users (IDUs) (cocaine, crack, and methamphetamine) and recent daily users of crack were more likely than nonusers or less-frequent users of these drugs to be HCV-infected. Similar results were found for those who had been hospitalized for a mental health problem. Among non-injection drug users and persons in the total sample, those who reported lifetime alcohol abuse were more likely than those who did not to be HCV infected. Controlling for socio-demographic characteristics, multiple logistic regression analyses revealed IDUs have over 25 times greater odds of having HCV infection than non-IDUs. HCV infection was also predicted by older age, having started living on one’s own before the age of 18, and recent chronic alcohol use. Males and recent crack users had about one and a half times greater odds of HCV infection when compared to females and non-chronic crack users.CONCLUSIONS: Targeted outreach for homeless women and their partners, including HCV testing coupled with referrals to HCV and substance abuse treatments, may be helpful.

Sheltered Versus Nonsheltered Homeless Women: Differences in Health, Behavior, Victimization, and Utilization of Care

OBJECTIVE: To contrast sociodemographic characteristics, physical and mental health status, substance use, sexual behaviors, victimization, and utilization of health services between homeless women residing in sheltered and nonsheltered environments.DESIGN: Cross-sectional survey. A structured scale was used to measure mental health status. Physical health status, substance use, sexual behavior, history of adult victimization, and health services utilization were measured by content-specific items.SETTING: Shelters (N=47) and outdoor locations in Los Angeles.PARTICIPANTS: One thousand fifty-one homeless women.RESULTS: Homeless women living on the streets were more likely than sheltered women to be white and longer-term homeless. Controlling for sociodemographic characteristics, multiple logistic regression analyses revealed that unsheltered women had over 3 times greater odds of fair or poor physical health, and over 12 times greater odds of poor mental health than sheltered homeless women. They were also more likely than sheltered women to report using alcohol or noninjection drugs, to have multiple sexual partners, and to have a history of physical assault. About half of the overall sample reported utilization of a variety of health services; however, unsheltered homeless women were less likely to utilize all of the health services that were assessed, including drug treatment.CONCLUSIONS: There is a critical need for aggressive outreach programs that provide mental health services and substance abuse treatment for homeless women on the streets. Comprehensive services that also include medical care, family planning, violence prevention, and behavioral risk reduction may be particularly valuable for homeless women, especially those living in unsheltered environments.

PSYCHOSOCIAL PREDICTORS OF AIDS RISK BEHAVIOR AND DRUG-USE BEHAVIOR IN HOMELESS AND DRUG-ADDICTED WOMEN OF COLOR

The present study examined a causal model consisting of personal and social resources, threat appraisal processes, coping styles, and barriers to risk reduction as predictors of general AIDS risk and specific drug use behaviors among homeless African American (N = 714) and Latina (N = 691) women. The model, which was based on a stress and coping framework, supported many of the hypothesized relationships. Active coping was associated with fewer general AIDS risk behaviors for both groups and less specific drug use behavior among African American women. Specific drug use behavior was predicted by high threat appraisal and avoidant coping for both groups. Ethnic differences and implications for intervention are discussed.

Gender differences in relationships among stress, coping, and health risk behaviors in impoverished, minority populations

Abstract In this study, we examined gender differences among impoverished minority females (n = 205; 87% African-American, 13% Latina) and males (n = 203; 89% African-American, 11% Latino) in associations among latent variables representing stress, self-esteem, avoidant and active coping strategies, and health outcomes of depression, escapist drug use, and sexual risk behaviors. Among both men and women, drug use and depression were positively related to each other. A large and significant relationship between stress and sexual risk behaviors among women was not evidenced for men. In multiple group latent means comparison models, the women reported significantly more stress, depression, and avoidant coping styles than the men. In predictive path models, an avoidant coping style predicted escapist drug use among men whereas greater stress predicted escapist drug use among women. Greater stress, and lower self-esteem predicted depression in both groups. Greater stress and less active coping predicted more sexual risk behaviors for women. No predictor construct in this model significantly predicted more sexual risk behavior among the men. Gender-specific leverage points for AIDS-risk reduction interventions are discussed.

Type of social support among homeless women: its impact on psychosocial resources, health and health behaviors, and use of health services.

BACKGROUND Information about whether specific types of support are associated with poor psychosocial profiles, health behaviors, and positive use of medical care is critical for identifying homeless women at highest risk for negative outcomes. OBJECTIVES This study aimed to examine the impact that various levels of support from substance users and nonusers have on homeless womens psychosocial profiles, health and health behaviors, and use of health services. METHODS This cross-sectional survey used a sample of 1,302 sheltered homeless women. Using controls for potential confounders, outcomes were compared across four mutually exclusive subgroups of women reporting support from substance users only (n = 58), substance nonusers only (n = 439), both users and nonusers (n = 136), and no one (n = 669). Structured and psychometrically sound instruments measured social support, substance use, self-esteem, coping, and psychological symptoms. Additional instruments measured sociodemographic characteristics, sexual risk behavior, health status, and use of health services. RESULTS As compared with those who have little or no support, women whose support included substance nonusers reported better psychosocial profiles and somewhat greater use of health services. Support from substance nonusers only was associated with better health behaviors and greater use of health services. Support from substance users only was essentially equivalent to not having support. CONCLUSION Modifying the social networks of homeless women appears to be associated with improved mental health outcomes, less risky health behaviors, and greater use of health services.

Project CHARM: an HIV prevention program for adolescent mothers.

Effects were examined of a human immunodeficiency virus (HIV) prevention program for adolescent mothers offered in pregnant minor and parenting programs in Los Angeles County. The sample included young women (N = 497) of predominantly poor, Latina backgrounds who had complete data from baseline to the one-year follow-up. The treatment group demonstrated statistically significant improvements in AIDS knowledge and intentions to use condoms, and fewer sex partners at the six-month follow-up as compared to the control group. Findings related to the effects of the intervention on theoretical variables provide some support for selected concepts from Social Cognitive Theory and the Theory of Reasoned Action.

Personal, cognitive, behavioral, and demographic predictors of HIV testing and STDs in homeless women.

Using a multiracial sample of 621 homeless women, we tested a latent variable causal model of personal, cognitive, behavioral, and demographic predictors of two coping mediators and the outcome variables of HIV testing and return for test results and a recent STD infection. HIV testing and return were predicted by more social support, greater AIDS knowledge, greater perceived risk for AIDS, and more problem-focused coping strategies. Recent STDs were predicted by more AIDS knowledge, emotion-focused coping strategies, and risky sexual behavior and one measured variable, crack cocaine use. Emotion-focused coping strategies were predicted by drug use, less self-esteem, more social support, and greater perceived risk for AIDS. Hispanics reported less emotion-focused coping strategies than African-Americans. Predictors of problem-focused coping strategies included less drug use, more self-esteem, more social support, more AIDS knowledge, and less risky sexual behavior. African-Americans reported less problem-focused coping strategies than Latinas. Indirect effects on the outcomes mediated through coping styles are also reported. Theoretical and practical implications of results for community outreach are discussed.

HIV-risk behaviors and mental health characteristics among homeless or drug-recovering women and their closest sources of social support.

This article describes risky drug and sexual behavior and mental health characteristics in a sample of 240 homeless or drug-recovering women and their most immediate sources of social support. Women and their closest support sources both reported a great deal of recent noninjection drug use (56% and 52%, respectively) and lesser, though similar amounts of recent injection drug use (12% and 14%, respectively). More than one third of both groups reported a history of sexually transmitted disease and sexual activity with multiple partners. Fifty-one percent of the women and 31% of their support sources had Center for Epidemiological Studies Depression Scale (CES-D) scores of 27 or greater, suggesting a high level of depressive disorders in both samples. Similarly, 76% of the women and 59% of their support sources had psychological well-being scores below a standard clinical cutoff point. These data suggest that homeless and impoverished women turn to individuals who are themselves at high risk for emotional distress and risky behaviors as their main sources of support.