@Article{info:doi/10.2196/53488,
author="Deng, Tianjie
and Urbaczewski, Andrew
and Lee, Jin Young
and Barman-Adhikari, Anamika
and Dewri, Rinku",
title="Identifying Marijuana Use Behaviors Among Youth Experiencing Homelessness Using a Machine Learning--Based Framework: Development and Evaluation Study",
journal="JMIR AI",
year="2024",
month="Oct",
day="17",
volume="3",
pages="e53488",
keywords="machine learning",
keywords="youth experiencing homelessness",
keywords="natural language processing",
keywords="infodemiology",
keywords="social good",
keywords="digital intervention",
abstract="Background: Youth experiencing homelessness face substance use problems disproportionately compared to other youth. A study found that 69\% of youth experiencing homelessness meet the criteria for dependence on at least 1 substance, compared to 1.8\% for all US adolescents. In addition, they experience major structural and social inequalities, which further undermine their ability to receive the care they need. Objective: The goal of this study was to develop a machine learning--based framework that uses the social media content (posts and interactions) of youth experiencing homelessness to predict their substance use behaviors (ie, the probability of using marijuana). With this framework, social workers and care providers can identify and reach out to youth experiencing homelessness who are at a higher risk of substance use. Methods: We recruited 133 young people experiencing homelessness at a nonprofit organization located in a city in the western United States. After obtaining their consent, we collected the participants' social media conversations for the past year before they were recruited, and we asked the participants to complete a survey on their demographic information, health conditions, sexual behaviors, and substance use behaviors. Building on the social sharing of emotions theory and social support theory, we identified important features that can potentially predict substance use. Then, we used natural language processing techniques to extract such features from social media conversations and reactions and built a series of machine learning models to predict participants' marijuana use. Results: We evaluated our models based on their predictive performance as well as their conformity with measures of fairness. Without predictive features from survey information, which may introduce sex and racial biases, our machine learning models can reach an area under the curve of 0.72 and an accuracy of 0.81 using only social media data when predicting marijuana use. We also evaluated the false-positive rate for each sex and age segment. Conclusions: We showed that textual interactions among youth experiencing homelessness and their friends on social media can serve as a powerful resource to predict their substance use. The framework we developed allows care providers to allocate resources efficiently to youth experiencing homelessness in the greatest need while costing minimal overhead. It can be extended to analyze and predict other health-related behaviors and conditions observed in this vulnerable community. ",
doi="10.2196/53488",
url="https://ai.jmir.org/2024/1/e53488"
}


@Article{info:doi/10.2196/45309,
author="Ilyas, Yousaf
and Hassanbeigi Daryani, Shahrzad
and Kiriella, Dona
and Pachwicewicz, Paul
and Boley, A. Randy
and Reyes, M. Karen
and Smith, L. Dale
and Zalta, K. Alyson
and Schueller, M. Stephen
and Karnik, S. Niranjan
and Stiles-Shields, Colleen",
title="Geolocation Patterns, Wi-Fi Connectivity Rates, and Psychiatric Symptoms Among Urban Homeless Youth: Mixed Methods Study Using Self-report and Smartphone Data",
journal="JMIR Form Res",
year="2023",
month="Apr",
day="18",
volume="7",
pages="e45309",
keywords="mHealth",
keywords="mobile health",
keywords="smartphones",
keywords="geolocation",
keywords="Wi-Fi",
keywords="youth experiencing homelessness",
keywords="mobile phone",
keywords="homelessness",
keywords="youth",
abstract="Background: Despite significant research done on youth experiencing homelessness, few studies have examined movement patterns and digital habits in this population. Examining these digital behaviors may provide useful data to design new digital health intervention models for youth experiencing homelessness. Specifically, passive data collection (data collected without extra steps for a user) may provide insights into lived experience and user needs without putting an additional burden on youth experiencing homelessness to inform digital health intervention design. Objective: The objective of this study was to explore patterns of mobile phone Wi-Fi usage and GPS location movement among youth experiencing homelessness. Additionally, we further examined the relationship between usage and location as correlated with depression and posttraumatic stress disorder (PTSD) symptoms. Methods: A total of 35 adolescent and young adult participants were recruited from the general community of youth experiencing homelessness for a mobile intervention study that included installing a sensor data acquisition app (Purple Robot) for up to 6 months. Of these participants, 19 had sufficient passive data to conduct analyses. At baseline, participants completed self-reported measures for depression (Patient Health Questionnaire-9 [PHQ-9]) and PTSD (PTSD Checklist for DSM-5 [PCL-5]). Behavioral features were developed and extracted from phone location and usage data. Results: Almost all participants (18/19, 95\%) used private networks for most of their noncellular connectivity. Greater Wi-Fi usage was associated with a higher PCL-5 score (P=.006). Greater location entropy, representing the amount of variability in time spent across identified clusters, was also associated with higher severity in both PCL-5 (P=.007) and PHQ-9 (P=.045) scores. Conclusions: Location and Wi-Fi usage both demonstrated associations with PTSD symptoms, while only location was associated with depression symptom severity. While further research needs to be conducted to establish the consistency of these findings, they suggest that the digital patterns of youth experiencing homelessness offer insights that could be used to tailor digital interventions. ",
doi="10.2196/45309",
url="https://formative.jmir.org/2023/1/e45309",
url="http://www.ncbi.nlm.nih.gov/pubmed/37071457"
}


@Article{info:doi/10.2196/26704,
author="Santa Maria, Diane
and Padhye, Nikhil
and Businelle, Michael
and Yang, Yijiong
and Jones, Jennifer
and Sims, Alexis
and Lightfoot, Marguerita",
title="Efficacy of a Just-in-Time Adaptive Intervention to Promote HIV Risk Reduction Behaviors Among Young Adults Experiencing Homelessness: Pilot Randomized Controlled Trial",
journal="J Med Internet Res",
year="2021",
month="Jul",
day="6",
volume="23",
number="7",
pages="e26704",
keywords="youth",
keywords="homelessness",
keywords="HIV",
keywords="prevention",
keywords="just-in-time adaptive interventions",
keywords="mHealth",
keywords="ecological momentary assessments",
keywords="drug use",
keywords="stress",
keywords="intervention",
keywords="smartphone",
keywords="mobile phone",
keywords="drug",
keywords="efficacy",
keywords="pilot",
keywords="feasibility",
keywords="predictor",
keywords="risk",
keywords="behavior",
abstract="Background: People experiencing homelessness have higher rates of HIV than those who are stably housed. Mental health needs, substance use problems, and issues unique to homelessness such as lack of shelter and transiency need to be considered with regard to HIV prevention. To date, HIV prevention interventions for young adults experiencing homelessness have not specifically addressed modifiable real-time factors such as stress, sexual or drug use urge, or substance use, or been delivered at the time of heightened risk. Real-time, personalized HIV prevention messages may reduce HIV risk behaviors. Objective: This pilot study tested the initial efficacy of an innovative, smartphone-based, just-in-time adaptive intervention that assessed predictors of HIV risk behaviors in real time and automatically provided behavioral feedback and goal attainment information. Methods: A randomized attention control design was used among young adults experiencing homelessness, aged 18-25 years, recruited from shelters and drop-in centers in May 2019. Participants were randomized to either a control or an intervention group. The intervention (called MY-RID [Motivating Youth to Reduce Infection and Disconnection]) consisted of brief messages delivered via smartphone over 6 weeks in response to preidentified predictors that were assessed using ecological momentary assessments. Bayesian hierarchical regression models were used to assess intervention effects on sexual activity, drug use, alcohol use, and their corresponding urges. Results: Participants (N=97) were predominantly youth (mean age 21.2, SD 2.1 years) who identified as heterosexual (n=51, 52\%), male (n=56, 57\%), and African American (n=56, 57\%). Reports of sexual activity, drug use, alcohol use, stress, and all urges (ie, sexual, drug, alcohol) reduced over time in both groups. Daily drug use reduced by a factor of 13.8 times over 6 weeks in the intervention group relative to the control group (Multimedia Appendix 4). Lower urges for sex were found in the intervention group relative to the control group over the duration of the study. Finally, there was a statistically significant reduction in reports of feeling stressed the day before between the intervention and control conditions (P=.03). Conclusions: Findings indicate promising intervention effects on drug use, stress, and urges for sex in a hard-to-reach, high-risk population. The MY-RID intervention should be further tested in a larger randomized controlled trial to further investigate its efficacy and impact on sexual risk behaviors. Trial Registration: ClinicalTrials.gov NCT03911024; https://clinicaltrials.gov/ct2/show/NCT03911024 ",
doi="10.2196/26704",
url="https://www.jmir.org/2021/7/e26704",
url="http://www.ncbi.nlm.nih.gov/pubmed/34255679"
}


@Article{info:doi/10.2196/21638,
author="Acorda, Darlene
and Businelle, Michael
and Santa Maria, Diane",
title="Perceived Impacts, Acceptability, and Recommendations for Ecological Momentary Assessment Among Youth Experiencing Homelessness: Qualitative Study",
journal="JMIR Form Res",
year="2021",
month="Apr",
day="6",
volume="5",
number="4",
pages="e21638",
keywords="youth experiencing homelessness",
keywords="ecological momentary assessment",
keywords="mobile apps",
keywords="behavior change",
abstract="Background: The use of ecological momentary assessment (EMA) to study youth experiencing homelessness (YEH) behaviors is an emerging area of research. Despite high rates of participation and potential clinical utility, few studies have investigated the acceptability and recommendations for EMA from the YEH perspective. Objective: This study aimed to describe the perceived benefits, usability, acceptability, and barriers to the use of EMA from the homeless youth perspective. Methods: YEH were recruited from a larger EMA study. Semistructured exit interviews were performed using an interview guide that focused on the YEH experience with the EMA app, and included perceived barriers and recommendations for future studies. Data analyses used an inductive approach with thematic analysis to identify major themes and subthemes. Results: A total of 18 YEH aged 19-24 years participated in individual and group exit interviews. The EMA was highly acceptable to YEH and they found the app and EMA surveys easy to navigate. Perceived benefits included increased behavioral and emotional awareness with some YEH reporting a decrease in their high-risk behaviors as a result of participation. Another significant perceived benefit was the ability to use the phones for social support and make connections to family, friends, and potential employers. Barriers were primarily survey and technology related. Survey-related barriers included the redundancy of questions, the lack of customizable responses, and the timing of survey prompts. Technology-related barriers included the ``freezing'' of the app, battery charge, and connectivity issues. Recommendations for future studies included the need to provide real-time mental health support for symptomatic youth, to create individually customized questions, and to test the use of personalized motivational messages that respond to the EMA data in real time. Conclusions: YEH are highly receptive to the use of EMA in studies. Further studies are warranted to understand the impact of EMA on YEH behaviors. Incorporating the YEH perspective into the design and implementation of EMA studies may help minimize barriers, increase acceptability, and improve participation rates in this hard-to-reach, disconnected population. ",
doi="10.2196/21638",
url="https://formative.jmir.org/2021/4/e21638",
url="http://www.ncbi.nlm.nih.gov/pubmed/33821805"
}


@Article{info:doi/10.2196/23989,
author="Linnemayr, Sebastian
and Zutshi, Rushil
and Shadel, William
and Pedersen, Eric
and DeYoreo, Maria
and Tucker, Joan",
title="Text Messaging Intervention for Young Smokers Experiencing Homelessness: Lessons Learned From a Randomized Controlled Trial",
journal="JMIR Mhealth Uhealth",
year="2021",
month="Apr",
day="1",
volume="9",
number="4",
pages="e23989",
keywords="smokers",
keywords="quitting",
keywords="text messaging",
keywords="homeless",
keywords="young adults",
keywords="cessation resources",
keywords="peer support",
keywords="smoking rate",
keywords="smartphone",
abstract="Background: Smoking rates are significantly higher among young people experiencing homelessness than in the general population. Despite a willingness to quit, homeless youth have little success in doing so on their own, and existing cessation resources tailored to this population are lacking. Homeless youth generally enjoy the camaraderie and peer support that group-based programs offer, but continuous in-person support during a quit attempt can be prohibitively expensive. Objective: This study aimed to assess the feasibility and acceptability of an automated text messaging intervention (TMI) as an adjunct to group-based cessation counseling and provision of nicotine patches to help homeless youth quit smoking. This paper outlines the lessons learned from the implementation of the TMI intervention. Methods: Homeless youth smokers aged 18 to 25 years who were interested in quitting (n=77) were recruited from drop-in centers serving homeless youth in the Los Angeles area. In this pilot randomized controlled trial, all participants received a group-based cessation counseling session and nicotine patches, with 52\% (40/77) randomly assigned to receive 6 weeks of text messages to provide additional support for their quit attempt. Participants received text messages on their own phone rather than receiving a study-issued phone for the TMI. We analyzed baseline and follow-up survey data as well as back-end data from the messaging platform to gauge the acceptability and feasibility of the TMI among the 40 participants who received it. Results: Participants had widespread (smart)phone ownership---16.4\% (36/219) were ineligible for study participation because they did not have a phone that could receive text messages. Participants experienced interruptions in their phone use (eg, 44\% [16/36] changed phone numbers during the follow-up period) but reported being able to receive the majority of messages. These survey results were corroborated by back-end data (from the program used to administer the TMI) showing a message delivery rate of about 95\%. Participant feedback points to the importance of carefully crafting text messages, which led to high (typically above 70\%) approval of most text messaging components of the intervention. Qualitative feedback indicated that participants enjoyed the group counseling session that preceded the TMI and suggested including more such group elements into the intervention. Conclusions: The TMI was well accepted and feasible to support smoking cessation among homeless youth. Given high rates of smartphone ownership, the next generation of phone-based smoking cessation interventions for this population should consider using approaches beyond text messages and focus on finding ways to develop effective approaches to include group interaction using remote implementation. Given overall resource constraints and in particular the exigencies of the currently ongoing COVID-19 epidemic, phone-based interventions are a promising approach to support homeless youth, a population urgently in need of effective smoking cessation interventions. Trial Registration: ClinicalTrials.gov NCT03874585; https://clinicaltrials.gov/ct2/show/NCT03874585 International Registered Report Identifier (IRRID): RR2-10.1186/s13722-020-00187-6 ",
doi="10.2196/23989",
url="https://mhealth.jmir.org/2021/4/e23989",
url="http://www.ncbi.nlm.nih.gov/pubmed/33792551"
}


@Article{info:doi/10.2196/18244,
author="Chavez, Johnson Laura
and Kelleher, Kelly
and Slesnick, Natasha
and Holowacz, Eugene
and Luthy, Ellison
and Moore, Laura
and Ford, Jodi",
title="Virtual Reality Meditation Among Youth Experiencing Homelessness: Pilot Randomized Controlled Trial of Feasibility",
journal="JMIR Ment Health",
year="2020",
month="Sep",
day="24",
volume="7",
number="9",
pages="e18244",
keywords="virtual reality",
keywords="meditation",
keywords="homelessness",
keywords="stress",
abstract="Background: Homelessness among youth is devastating, with high rates of substance use disorders and mental health comorbidity. Mindfulness-based interventions that include meditation and mindfulness skills training reduce stress and symptoms of anxiety or depression. However, engaging high-risk youth in interventions is challenging. Virtual reality is a more flexible platform for delivering meditation and may be appealing to youth. Objective: The study objectives were to evaluate the feasibility of delivering virtual reality meditation and of collecting outcome measures, including anxiety and physiologic stress. Methods: A sample of 30 youth experiencing homelessness was enrolled in the study. Youth were randomized to receive 10 minutes of one of three interventions: (1) virtual reality meditation, (2) audio meditation (through a web-based platform), or (3) virtual reality imagery of historical pictures and text. Subjects who consented to the study attended two research visits. The first visit collected survey measures of demographics, mental health, and substance use, and oriented subjects to the intervention platforms. The second visit (1-3 days later) delivered the intervention and collected pre and post outcome measures of anxiety and physiologic stress (salivary cortisol). Changes in anxiety and cortisol at the second visit were compared across groups using a linear regression model in which the primary analysis compared virtual reality meditation to audio meditation and secondary analyses compared virtual reality meditation to virtual reality imagery. Results: Anxiety scores decreased in all groups, with a larger reduction among the virtual reality meditation group (difference=10.8) compared to the web-based meditation or virtual reality images groups (difference=5.8 and 5.0, respectively). After controlling for baseline values, there were no significant group differences in changes in anxiety scores or cortisol levels. In comparing virtual reality meditation and audio meditation, the effect size for anxiety was moderate (Cohen d=0.58) while the effect size for cortisol was small (Cohen d=0.08). Conclusions: Preliminary results suggest that virtual reality meditation has a moderate benefit for anxiety but not physiologic stress. Future research is needed to confirm these results in a larger sample and to investigate whether the effects are sustained or increase with repeated use of virtual reality mediation. Virtual reality meditation appears feasible to deliver among homeless youth and merits further study. Trial Registration: ClinicalTrials.gov NCT04004520; https://clinicaltrials.gov/ct2/show/NCT04004520 ",
doi="10.2196/18244",
url="http://mental.jmir.org/2020/9/e18244/",
url="http://www.ncbi.nlm.nih.gov/pubmed/32969834"
}


@Article{info:doi/10.2196/14833,
author="Jennings Mayo-Wilson, Larissa
and Glass, E. Nancy
and Labrique, Alain
and Davoust, Melissa
and Ssewamala, M. Fred
and Linnemayr, Sebastian
and Johnson, W. Matthew",
title="Feasibility of Assessing Economic and Sexual Risk Behaviors Using Text Message Surveys in African-American Young Adults Experiencing Homelessness and Unemployment: Single-Group Study",
journal="JMIR Form Res",
year="2020",
month="Jul",
day="17",
volume="4",
number="7",
pages="e14833",
keywords="HIV",
keywords="sexual risk behaviors",
keywords="homelessness",
keywords="text messages",
keywords="young adults",
keywords="economic",
keywords="mobile phones",
abstract="Background: Text messages offer the potential to better evaluate HIV behavioral interventions using repeated longitudinal measures at a lower cost and research burden. However, they have been underused in US minority settings. Objective: This study aims to examine the feasibility of assessing economic and sexual risk behaviors using text message surveys. Methods: We conducted a single-group study with 17 African-American young adults, aged 18-24 years, who were economically disadvantaged and reported prior unprotected sex. Participants received a text message survey once each week for 5 weeks. The survey contained 14 questions with yes-no and numeric responses on sexual risk behaviors (ie, condomless sex, sex while high or drunk, and sex exchange) and economic behaviors (ie, income, employment, and money spent on HIV services or products). Feasibility measures were the number of participants who responded to the survey in a given week, the number of questions to which a participant responded in each survey, and the number of hours spent from sending a survey to participants to receiving their response in a given week. One discussion group was used to obtain feedback. Results: Overall, 65\% (n=11/17) of the participants responded to at least one text message survey compared with 35\% (n=6/17) of the participants who did not respond. The majority (n=7/11, 64\%) of the responders were women. The majority (n=4/6, 67\%) of nonresponders were men. An average of 7.6 participants (69\%) responded in a given week. Response rates among ever responders ranged from 64\% to 82\% across the study period. The mean number of questions answered each week was 12.6 (SD 2.7; 90\% of all questions), ranging from 72\% to 100\%. An average of 6.4 participants (84\%) answered all 14 text message questions in a given week, ranging from 57\% to 100\%. Participants responded approximately 8.7 hours (SD 10.3) after receiving the survey. Participants were more likely to answer questions related to employment, condomless sex, and discussions with sex partners. Nonresponse or skip was more often used for questions at the end of the survey relating to sex exchange and money spent on HIV prevention services or products. Strengths of the text message survey were convenience, readability, short completion time, having repeated measures over time, and having incentives. Conclusions: Longitudinal text message surveys may be a valuable tool for assessing HIV-related economic and sexual risk behaviors. Trial Registration: ClinicalTrials.gov NCT03237871; https://clinicaltrials.gov/ct2/show/NCT03237871 ",
doi="10.2196/14833",
url="https://formative.jmir.org/2020/7/e14833",
url="http://www.ncbi.nlm.nih.gov/pubmed/32706656"
}


@Article{info:doi/10.2196/15557,
author="Thulien, S. Naomi
and Kozloff, Nicole
and McCay, Elizabeth
and Nisenbaum, Rosane
and Wang, Andrea
and Hwang, W. Stephen",
title="Evaluating the Effects of a Rent Subsidy and Mentoring Intervention for Youth Transitioning Out of Homelessness: Protocol for a Mixed Methods, Community-Based Pilot Randomized Controlled Trial",
journal="JMIR Res Protoc",
year="2019",
month="Dec",
day="20",
volume="8",
number="12",
pages="e15557",
keywords="homeless youth",
keywords="community integration",
keywords="qualitative research",
keywords="randomized controlled trial",
keywords="housing",
keywords="mentorship",
abstract="Background: Although the risk factors associated with young people entering and becoming entrenched in street life have been thoroughly investigated, peer-reviewed evidence is scarce to nonexistent for rigorous interventions targeting social integration outcomes for young people who have experienced homelessness. From the limited research that has been done, emerging evidence signals that, although structural supports such as subsidized housing and social service providers are important, these resources alone are insufficient to help young people integrate into the mainstream society. Objective: The overarching aim of this study is to assess whether and how rent subsidies and mentorship influence social integration outcomes for formerly homeless young people living in market rent housing in 3 Canadian cities. The primary outcome measures for this study are community integration (psychological and physical) and self-esteem at 18 months. Secondary outcomes include social connectedness, hope, and academic and vocational participation at 18 months. Exploratory outcomes include income, perceived housing quality, engulfment, psychiatric symptoms, and participant perspectives of intervention barriers and facilitators. Methods: This is a convergent mixed methods, open-label, 2-arm parallel randomized controlled trial (RCT) with 1:1 allocation embedded within a community-based participatory action research (CBPAR) framework. The intervention will provide 24 young people (aged 16-26 years), who have transitioned out of homelessness and into market rent housing within the past year, with rent subsidies for 24 months. Half of the young people will also be randomly assigned an adult mentor who has been recruited and screened by 1 of our 3 community partners. Data collection will occur every 6 months, and participants will be followed for 30 months. Results: Ethical approval for this study has been obtained from the Providence, St Joseph's, and St Michael's Healthcare Research Ethics Board (number 18-251). Enrollment took place from April 2019 to September 2019. Preliminary analysis of the baseline quantitative and qualitative data is underway. Conclusions: This pilot RCT will be the first to test the impact of economic and social support on meaningful social integration for formerly homeless young people living in market rent housing. We believe that the mixed methods design will illuminate important contextual factors that must be considered if the intervention is to be scaled up and replicated elsewhere. Importantly, the CBPAR framework will incorporate the perspectives of the community, including formerly homeless young people, who are in the best position to determine what might work best in the context of their lives. Trial Registration: Clinicaltrials.gov NCT03779204; https://clinicaltrials.gov/ct2/show/NCT03779204. International Registered Report Identifier (IRRID): DERR1-10.2196/15557 ",
doi="10.2196/15557",
url="https://www.researchprotocols.org/2019/12/e15557",
url="http://www.ncbi.nlm.nih.gov/pubmed/31859688"
}


@Article{info:doi/10.2196/15144,
author="Glover, C. Angela
and Schueller, M. Stephen
and Winiarski, A. Dominika
and Smith, L. Dale
and Karnik, S. Niranjan
and Zalta, K. Alyson",
title="Automated Mobile Phone--Based Mental Health Resource for Homeless Youth: Pilot Study Assessing Feasibility and Acceptability",
journal="JMIR Ment Health",
year="2019",
month="Oct",
day="11",
volume="6",
number="10",
pages="e15144",
keywords="mental health",
keywords="young adult",
keywords="homelessness",
keywords="telemedicine",
keywords="treatment",
keywords="mHealth",
keywords="mobile phone",
abstract="Background: Youth experiencing housing instability have higher rates of mental health problems than their housed peers. Few studies have evaluated technological resources for homeless youth to determine how to effectively engage and reach them. Objective: The primary aims of this pilot study were to establish the feasibility (as measured by phone retention rates) and acceptability (ie, participant ratings of resources) of delivering automated mental health resources via smartphone technology. Methods: Youth aged 16 to 25 years (N=100) were recruited through homeless shelter agencies in the Chicago metropolitan area. Eligible participants completed a baseline assessment and received a smartphone with a 3-month data plan. The phone was preloaded with several apps designed to promote mental health wellness and provide real-time resources. One app specifically designed for this study, Pocket Helper 2.0, sent participants daily surveys and tips via push notification. The tips focused on coping and motivation, and the surveys assessed mood. This app also included an automated self-help system with brief cognitive behavioral interventions (5-10 min) and access to several interactive mobile tools, including a crisis text line, a telephone hotline, a crowd-based emotional support tool, and an app providing up-to-date information on social service and mental health resources for homeless youth in Chicago. Participants completed assessments at 3 and 6 months. Results: Some individuals (23\%, 23/100) experienced problems with the phones (eg, theft, loss, and technological issues) throughout the study. Participant retention at the midpoint was moderate, with 48\% (48/100) of youth responding to the 3-month surveys. At 6 months, only 19\% (19/100) of the total sample responded to the end point survey. Overall, 63\% (30/48) to 68\% (13/19) of respondents at both time points reported benefiting from the intervention; however, participant usage and satisfaction varied with the different features. At both time points, participants reported receiving the most benefit from the daily tips and daily surveys. Daily tips that were most preferred by participants involved motivational tips related to overcoming struggles and making progress in life. Aside from the tips and surveys, the most used features were the app providing up-to-date resources and the automated self-help system. Interactive features, including the telephone hotline and crowd-based emotional support tool, were the least used features and were rated as the least beneficial. Conclusions: Automated mental health interventions seem to be an acceptable way to engage homeless youth in mental health support. The participants preferred fully automated features and brief interventions over features requiring interaction with others or more engagement. Future research should explore ways to retain homeless youth in interventions and evaluate the clinical impact of automated technology-based interventions for improving mental health. Trial Registration: ClinicalTrials.gov NCT03776422; https://clinicaltrials.gov/ct2/show/NCT03776422 ",
doi="10.2196/15144",
url="http://mental.jmir.org/2019/10/e15144/",
url="http://www.ncbi.nlm.nih.gov/pubmed/31605516"
}


@Article{info:doi/10.2196/11165,
author="Swendeman, Dallas
and Arnold, Mayfield Elizabeth
and Harris, Danielle
and Fournier, Jasmine
and Comulada, Scott W.
and Reback, Cathy
and Koussa, Maryann
and Ocasio, Manuel
and Lee, Sung-Jae
and Kozina, Leslie
and Fern{\'a}ndez, Isabel Maria
and Rotheram, Jane Mary
and ",
title="Text-Messaging, Online Peer Support Group, and Coaching Strategies to Optimize the HIV Prevention Continuum for Youth: Protocol for a Randomized Controlled Trial",
journal="JMIR Res Protoc",
year="2019",
month="Aug",
day="09",
volume="8",
number="8",
pages="e11165",
keywords="adolescents",
keywords="HIV/AIDS",
keywords="mHealth",
keywords="homelessness",
keywords="MSM",
keywords="transgender",
keywords="prevention",
abstract="Background: America's increasing HIV epidemic among youth suggests the need to identify novel strategies to leverage services and settings where youth at high risk (YAHR) for HIV can be engaged in prevention. Scalable, efficacious, and cost-effective strategies are needed, which support youth during developmental transitions when risks arise. Evidence-based behavioral interventions (EBIs) have typically relied on time-limited, scripted, and manualized protocols that were often delivered with low fidelity and lacked evidence for effectiveness. Objective: This study aims to examine efficacy, implementation, and cost-effectiveness of easily mountable and adaptable, technology-based behavioral interventions in the context of an enhanced standard of care and study assessments that implement the guidelines of Centers for Disease Control and Prevention (CDC) for routine, repeat HIV, and sexually transmitted infection (STI) testing for high-risk youth. Methods: Youth aged between 12 and 24 years (n=1500) are being recruited from community-based organizations and clinics serving gay, bisexual, and transgender youth, homeless youth, and postincarcerated youth, with eligibility algorithms weighting African American and Latino youth to reflect disparities in HIV incidence. At baseline and 4-month intervals over 24 months (12 months for lower-risk youth), interviewers monitor uptake of HIV prevention continuum steps (linkage to health care, use of pre- or postexposure prophylaxis, condoms, and prevention services) and secondary outcomes of substance use, mental health, and housing security. Assessments include rapid diagnostic tests for HIV, STIs, drugs, and alcohol. The study is powered to detect modest intervention effects among gay or bisexual male and transgender youth with 70\% retention. Youth are randomized to 4 conditions: (1) enhanced standard of care of automated text-messaging and monitoring (AMM) and repeat HIV/STI testing assessment procedures (n=690); (2) online group peer support via private social media plus AMM (n=270); (3) coaching that is strengths-based, youth-centered, unscripted, based on common practice elements of EBI, available over 24 months, and delivered by near-peer paraprofessionals via text, phone, and in-person, plus AMM (n=270); and (4) online group peer support plus coaching and AMM (n=270). Results: The project was funded in September 2016 and enrollment began in May 2017. Enrollment will be completed between June and August 2019. Data analysis is currently underway, and the first results are expected to be submitted for publication in 2019. Conclusions: This hybrid implementation-effectiveness study examines alternative models for implementing the CDC guidelines for routine HIV/STI testing for YAHR of acquiring HIV and for delivering evidence-based behavioral intervention content in modular elements instead of scripted manuals and available over 24 months of follow-up, while also monitoring implementation, costs, and effectiveness. The greatest impacts are expected for coaching, whereas online group peer support is expected to have lower impact but may be more cost-effective. Trial Registration: ClinicalTrials.gov NCT03134833; https://clinicaltrials.gov/ct2/show/NCT03134833 (Archived by WebCite at http://www.webcitation.org/76el0Viw9) International Registered Report Identifier (IRRID): DERR1-10.2196/11165 ",
doi="10.2196/11165",
url="https://www.researchprotocols.org/2019/8/e11165/",
url="http://www.ncbi.nlm.nih.gov/pubmed/31400109"
}


@Article{info:doi/10.2196/12347,
author="Schueller, M. Stephen
and Glover, C. Angela
and Rufa, K. Anne
and Dowdle, L. Claire
and Gross, D. Gregory
and Karnik, S. Niranjan
and Zalta, K. Alyson",
title="A Mobile Phone--Based Intervention to Improve Mental Health Among Homeless Young Adults: Pilot Feasibility Trial",
journal="JMIR Mhealth Uhealth",
year="2019",
month="Jul",
day="02",
volume="7",
number="7",
pages="e12347",
keywords="mental health",
keywords="homelessness",
keywords="telemedicine",
keywords="treatment",
abstract="Background: Youth homelessness is a substantial issue, and many youths experiencing homelessness have mental health issues as both a cause and consequence of homelessness. These youths face many barriers to receiving traditional mental health services, and as a result, only a few youths experiencing homelessness receive any form of mental health care. Objective: This project aimed to develop and determine the feasibility and acceptability of engaging young adults (ie, individuals aged 18-24 years) experiencing homelessness in a remotely delivered mental health intervention. This intervention provided brief emotional support and coping skills, drawing from cognitive behavioral principles as an introduction into psychosocial support. The intervention was piloted in a homeless shelter network. Methods: A total of 35 young adults experiencing homelessness participated in a single-arm feasibility pilot trial. Participants received a mobile phone, a service and data plan, and 1 month of support from a coach consisting of up to 3 brief phone sessions, text messaging, and mobile mental health apps. We evaluated feasibility by looking at completion of sessions as well as the overall program and acceptability with satisfaction ratings. We also collected clinical symptoms at baseline and the end of the 1-month support period. We used validity items to identify participants who might be responding inappropriately and thus only report satisfaction ratings and clinical outcomes from valid responses. Results: Most participants (20/35, 57\%) completed all 3 of their phone sessions, with an average of 2.09 sessions (SD 1.22) completed by each participant. Participants sent an average of 15.06 text messages (SD 12.62) and received an average of 19.34 messages (SD 12.70). We found higher rates of satisfaction among the participants with valid responses, with 100\% (23/23) of such participants indicating that they would recommend participation to someone else and 52\% (12/23) reporting that they were very or extremely satisfied with their participation. We found very little change from pre- to posttreatment on measures of depression (d=0.27), post-traumatic stress disorder (d=0.17), and emotion regulation (d=0.10). Conclusions: This study demonstrated that it was feasible to engage homeless young adults in mental health services in this technology-based intervention with high rates of satisfaction. We did not find changes in clinical outcomes; however, we had a small sample size and a brief intervention. Technology might be an important avenue to reach young adults experiencing homelessness, but additional work could explore proper interventions to deliver with such a platform. Trial Registration: ClinicalTrials.gov NCT03620682; https://clinicaltrials.gov/ct2/show/NCT03620682 ",
doi="10.2196/12347",
url="https://mhealth.jmir.org/2019/7/e12347/",
url="http://www.ncbi.nlm.nih.gov/pubmed/31267980"
}


@Article{info:doi/10.2196/jmir.9306,
author="VonHoltz, Houdek Lauren A.
and Frasso, Rosemary
and Golinkoff, M. Jesse
and Lozano, J. Alicia
and Hanlon, Alexandra
and Dowshen, Nadia",
title="Internet and Social Media Access Among Youth Experiencing Homelessness: Mixed-Methods Study",
journal="J Med Internet Res",
year="2018",
month="May",
day="22",
volume="20",
number="5",
pages="e184",
keywords="adolescent",
keywords="homeless youth",
keywords="internet",
keywords="social media",
keywords="smartphone",
keywords="health",
abstract="Background: Youth experiencing homelessness are at a risk for a variety of adverse outcomes. Given the widespread use of the internet and social media, these new technologies may be used to address their needs and for outreach purposes. However, little is known about how this group uses these resources. Objective: This study investigated how homeless adolescents use these technologies for general and health-related purposes, whether the scope of their use changes with housing status, and their interest in a website dedicated to youth experiencing homelessness. Methods: A convenience sample of youth aged 18 to 21 years was recruited from a youth-specific homeless shelter. All participants completed a 47-item survey, with 10 individuals completing a semistructured interview. Descriptive statistics, exact testing, logistic regression, and generalized estimating equation modeling was performed for quantitative data analysis. Interviews were transcribed verbatim, and NVivo 10 (QSR International) was employed to facilitate double coding and thematic analysis. Results: A total of 87 participants completed the survey with a mean age of 19.4 (SD 1.1) years. While experiencing homelessness, 56\% (49/87) accessed the internet at least once a day, with 86\% (75/87) accessing once a week. Access to a smartphone was associated with a 3.03 greater odds of accessing the internet and was the most frequently used device (66\% of participants, 57/87). While experiencing homelessness, subjects reported a 68\% decreased odds in internet access frequency (odds ratio [OR] 0.32, P<.001), 75\% decreased odds in spending greater amounts of time on the internet (OR 0.25, P<.001), and an 87\% decreased odds of social media use (OR 0.13, P=.01). Ten participants completed the semistructured interview. Several themes were identified, including (1) changes in internet behaviors while experiencing homelessness, (2) health status as a major concern and reason for Internet use, and (3) interest in a website dedicated to youth experiencing homelessness. While experiencing homelessness, participants indicated their behaviors were more goal-oriented and less focused on leisure or entertainment activities. Conclusions: While homeless youth experience changes in the frequency, amount of time, and specific uses of the internet and social media, study participants were able to access the internet regularly. The internet was used to search health-related topics. Given the importance of smartphones in accessing the internet, mobile-optimized websites may be an effective method for reaching this group. ",
doi="10.2196/jmir.9306",
url="http://www.jmir.org/2018/5/e184/",
url="http://www.ncbi.nlm.nih.gov/pubmed/29789281"
}


@Article{info:doi/10.2196/publichealth.9020,
author="Santa Maria, Diane
and Padhye, Nikhil
and Yang, Yijiong
and Gallardo, Kathryn
and Businelle, Michael",
title="Predicting Sexual Behaviors Among Homeless Young Adults: Ecological Momentary Assessment Study",
journal="JMIR Public Health Surveill",
year="2018",
month="Apr",
day="10",
volume="4",
number="2",
pages="e39",
keywords="homeless youth",
keywords="sexual behaviors",
keywords="ecological momentary assessment",
abstract="Background: Homeless youth continue to be disproportionately affected by HIV compared with their housed peers, with prevalence rates as high as 13\%. Yet, HIV prevention in this high-risk population has been only marginally effective. Objective: The aim of this study was to use ecological momentary assessments to examine real-time factors to determine the predictors of sexual activity among homeless youth. Methods: Youth experiencing homelessness aged between 18 and 24 years were recruited from a drop-in center in Houston, Texas, between August 2015 and May 2016. All the participants received a study-issued mobile phone that prompted brief ecological momentary assessments (EMAs) 5 times a day for 21 days. EMA items assessed near real-time sexual behaviors, cognitions, stress, affect, environmental factors, and environmental circumstances. Results: Participants (N=66) were predominantly male (41/66, 64\%) and black (43/66, 66\%) with a median age of 20 years. The mean number of EMAs completed by each participant was 45 out of 105 possible observations. During the study, 70\% (46/66) of participants were sexually active and reported condomless sex in 102 of the 137 cases of sexual intercourse (74.5\%). In total, 82\% (38/46) of the youth who reported having sex during the 3 weeks of data collection also reported engaging in high-risk sexual activities, including having condomless sex (24/46, 53\%), having multiple sexual partners on the same day (12/46, 26\%), trading sex (7/46, 16\%), and sharing needles while injecting drugs (1/46, 3\%). Of those, 71\% (27/38) were engaged in multiple sexual risk behaviors. The predictive model was based on observations from 66 subjects who reported 137 cases of sexual intercourse over 811 days; sexual orientation, race, mental health, drug use, and sexual urge were included as predictors in the parsimonious generalized linear mixed model selected on the basis of the Akaike information criterion. The estimated odds ratios (ORs) were notable for same-day drug use (OR 8.80, 95\% CI 4.48-17.31; P<.001) and sexual urge (OR 4.23, 95\% CI 1.60-11.28; P=.004). The performance of the risk estimator was satisfactory, as indicated by the value of 0.834 for the area under the receiver operating characteristic curve. Conclusions: Real-time EMA data can be used to predict sexual intercourse among a sample of high-risk, predominately unsheltered homeless youth. Sexual urge and drug use accounts for increased odds of engaging in sexual activity on any given day. Interventions targeting sexual urge and drug use may help predict sexual activity among a population at high risk of HIV. ",
doi="10.2196/publichealth.9020",
url="http://publichealth.jmir.org/2018/2/e39/",
url="http://www.ncbi.nlm.nih.gov/pubmed/29636318"
}


@Article{info:doi/10.2196/pediatrics.9037,
author="Leonard, R. Noelle
and Casarjian, Bethany
and Fletcher, R. Richard
and Prata, Cathleen
and Sherpa, Dawa
and Kelemen, Anna
and Rajan, Sonali
and Salaam, Rasheeda
and Cleland, M. Charles
and Gwadz, Viorst Marya",
title="Theoretically-Based Emotion Regulation Strategies Using a Mobile App and Wearable Sensor Among Homeless Adolescent Mothers: Acceptability and Feasibility Study",
journal="JMIR Pediatr Parent",
year="2018",
month="Mar",
day="01",
volume="1",
number="1",
pages="e1",
keywords="electrodermal response",
keywords="adolescence",
keywords="mothers",
keywords="emotion",
keywords="parenting",
abstract="Background: Many adolescent mothers are parenting young children under highly stressful conditions as they are managing first-time parenthood, poverty, lack of housing, school and work, and challenging peer and familial relationships. Mobile health (mHealth) technology has the potential to intervene at various points in the emotion regulation process of adolescent mothers to provide them support for more adaptive emotional and behavioral regulation in the course of their daily life. Objective: The goal of this study was to examine the acceptability, feasibility, use patterns, and mechanisms by which a mobile technology used as an adjunct to in-person, provider-delivered sessions fostered adolescent mothers' adaptive emotion regulation strategies under real-life conditions. Methods: Participants (N=49) were enrolled in the intervention condition of a larger pilot study of homeless adolescent mothers living in group-based shelters. The mHealth technology, Calm Mom, consisted of a mobile app and a wrist-worn sensorband for the ambulatory measurement and alerting of increased electrodermal activity (EDA), a physiological measurement of stress. We examined logs of mobile app activity and conducted semistructured qualitative interviews with a subsample (N=10) of participants. Qualitative data analysis was guided by the theoretical frames of the intervention and a technology acceptance model and included an analysis of emerging themes and concepts. Results: Overall, participants indicated that one or more of the elements of Calm Mom supported their ability to effectively regulate their emotions in the course of their daily life in ways that were consonant with the intervention's theoretical model. For many adolescent mothers, the app became an integral tool for managing stress. Due to technical challenges, fewer participants received sensorband alerts; however, those who received alerts reported high levels of acceptability as the technology helped them to identify their emotions and supported them in engaging in more adaptive behaviors during real-life stressful situations with their children, peers, and family members. Conclusions: Calm Mom is a promising technology for providing theoretically driven behavioral intervention strategies during real-life stressful moments among a highly vulnerable population. Future research efforts will involve addressing technology challenges and refining tailoring algorithms for implementation in larger-scale studies. ",
doi="10.2196/pediatrics.9037",
url="http://pediatrics.jmir.org/2018/1/e1/",
url="http://www.ncbi.nlm.nih.gov/pubmed/30637376"
}


@Article{info:doi/10.2196/mhealth.5168,
author="Sheoran, Bhupendra
and Silva, Lynn Cara
and Lykens, Elliot James
and Gamedze, Londiwe
and Williams, Samantha
and Ford, VanNess Jessie
and Habel, A. Melissa",
title="YTH StreetConnect: Development and Usability of a Mobile App for Homeless and Unstably Housed Youth",
journal="JMIR Mhealth Uhealth",
year="2016",
month="Jul",
day="14",
volume="4",
number="3",
pages="e82",
keywords="mHealth",
keywords="homelessness",
keywords="youth",
keywords="STD",
keywords="sexually transmitted diseases",
keywords="mobile app",
abstract="Background: Homeless and unstably housed (H/UH) youth are disproportionately affected by sexual health issues, including human immunodeficiency virus/sexually transmitted diseases, teen pregnancy, and dating violence, and are at a higher risk for poor mental health and underutilization of services. Research suggests that linking health care to H/UH adolescents might help improve their continuity of care, with most preferring to access health care information via the Internet. YTH StreetConnect is a dual-purpose mobile app that helps H/UH youth access health and vital services in Santa Clara County, CA, USA. We developed YTH StreetConnect PRO in parallel with the youth app as a companion tablet app for providers who serve H/UH youth. Objective: The objective of our study was to develop a mobile app to support H/UH youth and their providers in accessing health and vital resources, and to conduct usability and feasibility testing of the app among H/UH youth and technical consultants with local expertise in serving H/UH youth. Methods: Formative research included a literature review on H/UH youths' mobile phone and Internet usage. In January 2015, we conducted interviews with medical and service providers of H/UH youth. Usability and feasibility testing were done with target audiences. Additionally, we conducted focus groups with youth regarding the app's youth friendliness, accessibility, and usefulness. Results: H/UH youth and their providers noted the app's functionality, youth friendliness, and resources. Usability testing proposed improvements to the app, including visual updates to the user interface, map icons, new underrepresented resource categories, and the addition of a peer rating system. Limitations included a small sample size among H/UH youth and providers and a single site for the study (Santa Clara County, CA), making the findings ungeneralizable to the US population. Conclusions: YTH StreetConnect is a promising way to increase service utilization, provide referral access, and share resources among H/UH youth and providers. Input from H/UH youth and providers offers insights on how to improve future models of YTH StreetConnect and similar programs that assist H/UH youth. ",
doi="10.2196/mhealth.5168",
url="http://mhealth.jmir.org/2016/3/e82/",
url="http://www.ncbi.nlm.nih.gov/pubmed/27417882"
}