Colette L. Auerswald

Youth homelessness in San Francisco: A life cycle approach

HIV risk behaviors and seroprevalence are particularly high among street youth. Though many programs have been designed to serve them, street youth have low rates of service utilization. The aim of this street-based, ethnographic project was to study the social and cultural context of street life in this population. Data were collected by participant observation, exploratory interviews and semi-structured interviews. Twenty street youth (15-23 years old; six female), recruited from street sites in San Francisco, participated in the interviews. Field notes and transcriptions were analyzed using an inductive technique for model building. This analysis yielded a proposed model of the life cycle of youth homelessness. In the first on the street stage, youth face an intense psychological feeling of outsiderness, and an urgency to meet basic needs. These stresses either lead to an escape from street life or to a process of acculturation to the street. Initiation to the street is facilitated by street mentors, who provide youth with survival skills. In the stasis stage, youth reach a tenuous equilibrium in which they can meet their basic needs. A strong street ethic allows youth to rationalize significant conflicts and frequent physical suffering. Youth in stasis are repeatedly thrown into disequilibrium, crises that frequently cause them to come into greater contact with mainstream society. After repeated episodes of disequilibrium, some youth extricate themselves from street life, finding a new identity in mainstream society. Otherwise, youth return to the street, in an episode of recidivism. The life cycle model suggests that street youth who are most open to intervention are those who are in transitional states, i.e., those who have just arrived on the street or those who are in crisis (disequilibrium). If this model is validated in a larger population of youth, programs that are aimed at these two stages in the life cycle could potentially effectively complement existing programs, which are usually focused on youth in stasis.

Fidelity Management African-American Adolescents' Attempts to Control the Sexual Behavior of their Partners

This qualitative study examined how adolescents conceptualize sexual behavior. Open-ended interviews about sex were conducted with a sample of 21 male and 18 female African- American adolescents. Topics related to health risk virtually never emerged in their responses. The topic of partner infidelity and concerns about control of infidelity, on the other hand, were mentioned extensively. Informants described a cycle in which commitment to a partner often leads to suspicion of infidelity and jealousy. The jealous partner then performs acts of surveillance which can lead either to reassurance or to discovery of infidelity. The article concludes by discussing the degree of uniqueness of fidelity management to African- American adolescents and possible relevance to design of AIDS risk-reduction interventions.

Does partner selection contribute to sex differences in sexually transmitted infection rates among African American adolescents in San Francisco

Introduction: Little is known regarding whether partner characteristics explain sex differences in sexually transmitted infection (STI) rates in nonclinic-based, school-aged African American youth. Materials and Methods: A random digit dial household sample of 14- to 19-year-old youth in San Francisco reported the total number, age, race, and perceived history of incarceration, gang membership, and level of sexual activity of their partners. Youth were tested for gonorrhea and chlamydia. Results: Female participants were more likely than male participants to have a partner who was older or had been incarcerated and less likely to have a non-African American partner. Controlling for partner number, females odds ratio (OR) for having an STI was 1.39 (95% confidence interval [CI] = 0.98–1.98; P = 0.07). Controlling for partner incarceration and number of partners, the borderline sex difference was eliminated (OR = 1.07; 95% CI = 0.70–1.63). Conclusion: Sex differences in STI rates among African American adolescents may be determined more by the risk of the partner than the risk of the individual.

The Health Status of Street Children and Youth in Low- and Middle-Income Countries: A Systematic Review of the Literature

The health of the tens of millions of street children globally is understudied. We undertook a systematic review of the existing quantitative literature regarding the health status of street children and youth in low- and middle-income countries to summarize available knowledge, identify underexplored areas of research, and inform the future research agenda regarding the health of this population. A total of 108 articles met our inclusion criteria. Demographic data and structural factors associated with street life are summarized. Although data in specific regions or diseases are sparse, the literature review illustrates that youths survival behaviors and the exposures associated with poor shelter have resulted in disproportionate morbidity in the areas of infectious illness, psychiatric disease, reproductive health, and perhaps to a lesser extent, growth. Vast areas of health that may disproportionately affect street children in childhood or later on as adults have not been investigated, including chronic diseases and cognitive deficits. Studies of specific diseases or conditions vary considerably by region. Strengths and limitations of the literature are discussed and principles for future research in this area are proposed.

Concurrent partnerships among adolescents in a Latino community: the Mission District of San Francisco, California.

Objectives: Latino adolescents in the United States are disproportionately affected by sexually transmitted infections, yet knowledge of their sexual networks, particularly concurrent sex partners, is limited. Goal: The goal of this study was to describe the prevalence, patterns, and correlates of sexual concurrency among adolescents in an urban neighborhood. Study Design: The authors conducted cross-sectional analyses of 368 sexually active youth recruited from public venues within a predominantly Latino neighborhood in San Francisco, California. Results: During the prior 6 months, 20% of sexually experienced youth had concurrent partnerships, but this was more likely among males (27%) as females (12%) (odds ratio = 2.6; 95% confidence interval = 1.5–4.5). Sexually transmitted infection prevalence was too low to examine its association with concurrency. Factors that increased the likelihood of concurrency among males included: immigrant generation and being below grade level; and among females: older age and use of illegal substances. Conclusions: Ample opportunities to transmit sexually transmitted infections through concurrency were present, yet very few adolescents were infected, perhaps owing to adequate condom use within a neighborhood with low sexually transmitted infection prevalence.

Qualitative assessment of venues for purposive sampling of hard-to-reach youth. An illustration in a Latino community.

Background Latino youth suffer disproportionately from unintended pregnancy and sexually transmitted infections (STIs), but studies of the social context of their sexual behaviors are lacking. Goal Our qualitative assessment of recruitment venues in a Latino neighborhood had 3 objectives: to identify venues where youth at risk of unintended pregnancy and STIs could be found; to describe different youth “crowds”; and to investigate how and where youth meet their sex partners. Study Design We conducted ethnographic interviews with 62 youth recruited primarily from street sites. Mapping of venues was conducted with Map-Info. Results Youth crowds included the Regulars, gang-related crowds, street-economy affiliated crowds, and female crowds. Maps demonstrated the dominance of the venues in the Mission by gang members. Street sites are important venues for meeting sexual partners. Conclusion The qualitative assessment produced insights and hypotheses that can contribute to the planning of research, outreach, testing, and interventions with Latino youth.

“It is all about the fear of being discriminated [against]…the person suffering from HIV will not be accepted”: a qualitative study exploring the reasons for loss to follow-up among HIV-positive youth in Kisumu, Kenya

BackgroundYouth represent 40% of all new HIV infections in the world, 80% of which live in sub-Saharan Africa. Youth living with HIV (YLWH) are more likely to become lost to follow-up (LTFU) from care compared to all other age groups. This study explored the reasons for LTFU among YLWH in Kenya.MethodsData was collected from: (1) Focus group Discussions (n = 18) with community health workers who work with LTFU youth. (2) Semi-structured interviews (n = 27) with HIV + youth (15–21 years old) that had not received HIV care for at least four months. (3) Semi-structured interviews (n = 10) with educators selected from schools attended by LTFU interview participants. Transcripts were coded and analyzed employing grounded theory.ResultsHIV-related stigma was the overarching factor that led to LTFU among HIV + youth. Stigma operated on multiple levels to influence LTFU, including in the home/family, at school, and at the clinic. In all three settings, participants’ fear of stigma due to disclosure of their HIV status contributed to LTFU. Likewise, in the three settings, the dependent relationships between youth and the key adult figures in their lives were also adversely impacted by stigma and resultant lack of disclosure. Thus, at all three settings stigma influenced fear of disclosure, which in turn impacted negatively on dependent relationships with adults on whom they rely (i.e. parents, teachers and clinicians) leading to LTFU.ConclusionsInterventions focusing on reduction of stigma, increasing safe disclosure of HIV status, and improved dependent relationships may improve retention in care of YLWH.

Identifying Counseling Needs of Nulliparous Adolescent Intrauterine Contraceptive Users: A Qualitative Approach

PURPOSE To describe the intrauterine contraception (IUC) adoption process among nulliparous adolescents and to identify the role of the medical provider in this trajectory. METHODS We conducted semistructured interviews with a clinic-based sample of 20 nulliparous adolescents (aged 15-24 years) with a history of IUC use. Interviews were analyzed using modified grounded theory and cross-case analysis to reveal a process model for IUC adoption, with a focus on the role of the medical provider. RESULTS The model includes the following stages: first awareness, initial reaction, information gathering, adoption, and adjustment and reassessment. It is influenced by personal preferences and experiences, friends, family, sexual partner(s), and medical providers. Interactions with medical providers that study participants found helpful in navigating the adoption process included the use of visuals; tailored counseling to address specific contraceptive needs; assurance that IUC discontinuation was an option; information on a wide range of side effects; medical provider self-disclosure regarding use of IUC; and addressing and validating concerns, both before and after IUC insertion. CONCLUSIONS Nulliparous adolescents in this study described a complex IUC adoption process in which the medical provider plays a substantial supportive role. Findings from this study may be used to counsel and support future nulliparous adolescents regarding IUC use.

Gender Differences in Sexual Risk and Sexually Transmitted Infections Correlate With Gender Differences in Social Networks Among San Francisco Homeless Youth

PURPOSE To explore whether gender differences in sexual risk and sexually transmitted infections (STIs) among homeless youth may be explained in part by gender differences in their social networks. METHODS Our sample includes 258 youth (64% male) recruited in San Francisco from street venues and transitional programs. Participants completed an audio computer-administered self-interview survey regarding their housing status and risk behaviors and an interviewer-administered survey regarding their social networks, and were tested for STIs (chlamydia and gonorrhea). We examined relationships between sexual risk and STI rates and social network characteristics by gender. RESULTS Condom use was lower in young women than in young men, whereas young women were more likely to have an injection drug user (IDU) sex partner and to be diagnosed with an STI. Homeless young men were more likely to have stably housed contacts and same-sex friendships in their social networks than were young women. Stably housed network contacts were associated with increased condom use and decreased STI prevalence in young men. Same-sex friends were associated with increased condom use in young women. No young woman with a family member in her network had an IDU sex partner. Having a network member who had been recently incarcerated was associated with having an IDU sex partner for young women. CONCLUSIONS Homeless young womens networks may place them at greater risk for STIs than young men. Increasing mainstream contacts and same-gender friendships may protect all homeless youth from STIs. Interventions addressing homeless young womens social networks may decrease their gender-disparate STI risk.

Examining differences in types and location of recruitment venues for young males and females from urban neighborhoods: findings from a multi-site HIV prevention study.

Finding and accessing members of youth subpopulations, such as young men who have sex with men (YMSM) of color or young females of color, for behavioral or disease surveillance or study recruitment, pose particular challenges. Venue-based sampling strategies—which hinge on where individuals congregate or “hang out” rather than where they live—appear to be effective alternatives. Methods used to identify venues focus on engaging members of social networks to learn where targeted populations congregate. However, it is not always clear if and how these methods differ according to gender, whether the youth accessed at a venue are actually from neighborhoods in which the venues are found, and whether the location of venues relative to neighborhoods of residence is different for young men and young women. This study illustrates the gender differences in venue type and venue location where eligible youth study participants from high-risk neighborhoods could be accessed for HIV research across 15 research sites (sites). The findings indicate that the study’s method led to identifying venues where one quarter or more of the youth were eligible study participants and from the high-risk neighborhoods. Sites targeting young women of color had a higher proportion of eligible study participants who were also from the high-risk neighborhoods than sites targeting YMSM. Clubs were most commonly identified by sites targeting YMSM as recruitment venues, whereas neighborhood-based service or commercial centers were more common venues for young women of color. This study reveals how venue-based recruitment strategies can be tailored and resources maximized by understanding the key differences in the types of venues preferred by males and females and by recognizing that female-preferred venues are more likely to be closer to home.