Addressing Health Disparities of Vulnerable Underserved Youth: - - PDF document

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UCLA Semel Institute for Neuroscience and Human Behavior

Addressing Health Disparities of Vulnerable Underserved Youth:

Discovering challenges and strategies in intervention research Susana A. Lopez, Ph.D. & Sung‐Jae Lee, Ph.D. University of California Los Angeles

UCLA Nathanson Family Resilience Center STAR Seminar September 18, 2019

Overview

Key Considerations of Equity and Justice for Youth At‐Risk in Los Angeles County Homelessness and Juvenile Justice‐Involvement among Adolescents (US Los Angeles County, California (LA)) Challenges and Strategies for Conducting Family‐Based Intervention Research in Juvenile Justice Settings: EXPORT/STRIVE: Mixed Methods Study of Family‐Based Intervention for Juvenile‐Justice Involved Youth Integrated Community Based Recruitment Strategy to Identify Youth at Risk or Living with HIV and Strategies to Maximize Engagement and Retention of Youth at Risk or Living with HIV: Adolescent Medicine Trials Network (ATN) CARES

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STATISTICS

Adolescents (10 to 19 years ) and young adults (20 to 24 years) make up 21 percent of the population of the United States. Adolescents are becoming more and racially and ethnically diverse – rapid increases in the numbers of Latinx and Asian American youth. Healthy People 2020 (National Institutes of Health (NIH):

• Growing ethnic diversity requires cultural responsiveness to health care needs.
• Increased focus on the use of positive youth development interventions for preventing adolescent

health risk behaviors.

Adolescents in the US: Statistics +

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Objectives

To give context to the structure in which mental health risk is produced for at‐risk youth, we

• ffer three critical points for

consideration:

1) Rising housing insecurity within Los Angeles County has made affordable housing particularly inaccessible to black, brown, and poor communities. 2) High youth unemployment and increases in low‐wage labor have left youth with declining rates of economic power. 3) Criminalization of homelessness has disproportionately placed those unhoused at greater risk of arrest, incarceration, and death. Points are particularly applicable for health equity and social justice centered research utilizing frameworks that are more “ecosocial” and “syndemic” in nature.

Image Source: https://iaphs.org/syndemics‐population‐health‐qa‐anthropologist‐emily‐mendenhall/

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UCLA Semel Institute for Neuroscience and Human Behavior “In part, the spike in youth homelessness can be attributed to better counting. However, a bigger reason is that young people simply can’t afford to live in LA, according to Bill Bedrossian of Covenant House California, a youth homeless services agency. “Where they used to be able to live on the margins and bunk up with friends and split the rent, now it’s just so high, that, even in that case, if they’re not making significantly more than minimum wage, they’re not able to live,” said Bedrossian. Service providers in Los Angeles say that, more and more, homeless youth are coming from impoverished families who don’t have the resources to help, even if they want to. This was the case for Leo Serrano, an 18‐year‐old community college student, who found help at Jovenes Inc., an organization in Boyle Heights that serves homeless youth. Serrano, whose parents live in Mexico, was staying at his grandmother’s house, but when she faced eviction for having too many people under one roof, he was forced out.

Excerpt from article found here: http://curious.kcrw.com/2017/07/why‐are‐ there‐6000‐homeless‐youth‐in‐la

Characteristics of Homeless Youth (2013 LAHSA

Greater LA Homeless Count)

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Characteristics of Homeless Youth (2013 LAHSA

Greater LA Homeless Count)

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Income Inequality in Los Angeles County

Source (graph on left): Community Health Assessment 2015, Los Angeles County Department of Public Health Source (statistic on right): Los Angeles County Department of Public Health, City and Community Health Profiles: Percentage of Residents Living Below 100% and 200% of the Federal Poverty Level (FPL). June 2018.

38%

• f Los Angeles

County Residents live 200% below the Federal Poverty Line

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Youth Employment in Los Angeles County

UCLA Semel Institute for Neuroscience and Human Behavior Source: http://milliondollarhoods.org/wp‐content/uploads/2017/10/MDHHouselessReport‐3.pdf

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UCLA Semel Institute for Neuroscience and Human Behavior Source: http://milliondollarhoods.org/wp‐content/uploads/2017/10/MDHHouselessReport‐3.pdf UCLA Semel Institute for Neuroscience and Human Behavior

“For almost five decades the overall policy response has been neglectful at best, but the policies pursued over the past year seem deliberately designed to remove basic protections from the poorest, punish those who are not in employment and make even basic health care into a privilege to be earned rather than a right of citizenship.”

Report of the Special Rapporteur on extreme poverty and human rights in the United States of America

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Susana A. Lopez, PhD., Eraka Bath, M.D., Bita Amani, PhD., MHS, Scott Comulada, DrPH, MPH, Jessica Jackson, MS., Alex Klomhaus, MS., Angela Young‐Brinn, M.B.A.and Norweeta Milburn, PhD

Challenges and Strategies for Conducting Family‐Based Intervention Research in Juvenile Justice Settings: Family Conflict: Happens in All Families

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“It might be said that family conflict causes youth homelessness.” (Mallett et al., 2009) “Severe family conflict is the most common reason for a young person to be homeless.” (Bardine,

National Network for Youth)

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Family Reunification is “New‐ish”

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“Gaining parents’ trust, working with – not against – parents (Urban Institute, 2016).” Study Intervention

Slesnick et al. (2005, 2009) Ecologically‐based family therapy (EBFT) 15 – 16 sessions (50 minutes) Slesnick et al. (2009) Functional family therapy (FFT) 16 sessions (50 minutes) Milburn et al. (2012) Behavioral family intervention (STRIVE) 5 sessions (60 – 90 minutes)

Family‐Based Interventions

References = 15,995 References = 12 Family‐based interventions = 3

Have two to nine times greater effect sizes compared to individual‐based interventions (Kumpfer, Alvarado, & Whiteside, 2003).

Project EXPORT/STRIVE: Randomized Control Trial (RCT) with juvenile justice involved youth and their Parents/Guardians

Family Strengths Problem Solving Conflict Negotiation Role Clarification

Affirmation (Tokens) Emotional Regulation (Feeling Thermometer, FTD) Problem Solving (SMART) Negotiation Situation Analysis (Reframing, Role Playing) Support System

Intervention Core Elements and Tools

Family‐Based Intervention (5 Sessions) Built Upon:

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Re‐Entry Juvenile Justice‐Involved Youth and Homeless Youth

Racial/Ethnic Minority Mental/Physical Health Problems Risk for HIV and other STI Substance Use

Characteristics

• f the Families

in Project STRIVE (N = 254)

Adolescents (n = 127) 74% Female 16.79 mean age 54% Latinx American 37% African American 16% White American 95% Heterosexual Parents/Guardians (n = 127) 83% female 45.17 mean age 50% Latinx American 43% African American 12% White American 54% Unemployed

• Adolescents with a “homeless experience”: n = 28
• Adolescents without a “homeless experience”: n = 99

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Identify Barriers unique to juvenile justice youth entering the community with probationary terms after release and discusses planful and innovative Strategies. Goal is to reduce disparities in JJ‐ involved youth and reduce recidivism

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Challenge

Solutions

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Challenge Solutions

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Challenge Solutions

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UCLA Semel Institute for Neuroscience and Human Behavior

UCLA Semel Institute for Neuroscience and Human Behavior

Challenge Solutions

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UCLA Semel Institute for Neuroscience and Human Behavior Not Interested 20% No Time 21% Moved 6% Detained 6% Could not be Reached 45% Did not want to answer 2%

Exit Interview Results

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Integrated Community‐Based Recruitment Strategy to Identify Youth at Risk or Living with HIV and Strategies to Maximize Engagement and Retention of Youth at Risk or Living with HIV: ATN CARES*

Sung‐Jae Lee, Ph.D. & Maryann Koussa, M.P.H.

*This work was funded by the Adolescent Medicine Trials Network (ATN) for HIV/AIDS Interventions from NICHD (NIH grant U19HD089886)

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HIV Burden among Youth

Add Your Text Here

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Disparities in HIV diagnosis

Add Your Text Here

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HIV Status Awareness

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HIV Testing is a Critical Component in HIV Prevention/Care

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HIV Testing to Optimize HIV Prevention/Care

“Most people with new HIV infections in the United States are either unaware of their HIV status or know their status but are not receiving care.”

• The Nation’s Health, AJPH, Aug. 2019

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HIV Testing is a Critical Component in HIV Prevention/Care

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Three Integrated Studies

• Study 1: Acute Infection
• 36 acute infections + 36 established,

treatment‐naïve YLH

• Study 2: HIV+ Youth
• 220 in a RCT of Stepped‐Care
• Study 3: HIV‐ Youth
• 1500 in a RCT of eTechnologies

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Each study contrasts efficacy and cost of 3 interventions

• Automated Messaging and Weekly Monitoring

program delivered via text messages

• Peer support intervention delivered via social

media forum

• Coaching, delivered via text messages, phone,

and in‐person

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Cross‐Cutting Themes

• Same interventions tailored to HIV+ & HIV‐ youth
• Technology‐focused with paraprofessionals
• Evidence‐based practices (EBP), not manualized EBI
• Replicate with flexibility based on common features, skills, and

components of EBI

• Test of the CDC recommended interventions: repeat testing &

sustained follow‐up; care linkage; including costs

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Study Outcomes

• Acute infection: Smaller viral reservoirs
• HIV+ Youth: Viral Suppression
• HIV‐ Youth: HIV Prevention Continuum

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Centralized Recruitment Methods

• Youth ages 12‐24 are recruited in Los Angeles County and New Orleans

from homeless shelters, LGBTQIA+ organizations, & community health centers

• Screening with the 4th generation Alere™ HIV Combo test assigns youth to

either: acute infection study (n=36), HIV‐positive stepped care intervention study (n=220), or HIV‐negative randomized four‐arm intervention study (n=1500)

• Participants receive rapid diagnostic fingerstick syphilis test and point‐of‐

care pharyngeal, rectal, and urethral / vaginal CT and NG testing using GeneXpert (90‐min nucleic acid amplification test)

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Community-based Agencies

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Social Media & App-based Recruitment

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Centralized Recruitment Procedures New Orleans & Los Angeles N=1700

Study 1 (ATN 147) Acutely infected and newly identified N=74 Study 2 (ATN 148) Youth Living with HIV N=147 Study 3 (ATN 149) Seronegative Youth at High Risk N=1479

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Multiple Risk Acts among Youth

0.8% 83.4% 15.8%

Baseline Hetero/Lesbian Drug Usage Biomarkers

Just Alcohol Just Marijuana

0.0% 83.6% 16.4%

Baseline MSM/Trans Drug Usage Biomarkers

Just Alcohol Just Marijuana

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Lifetime Risk Factors among Heterosexual Youth

Mental Health Hospitalization – 40% Incarceration – 38% Homelessness – 75%

25% 4% 4% 2% 18% 16% 16%

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Lifetime Risk Factors among MSM/Transgender Youth

Mental Health Hospitalization– 32% Incarceration – 25% Homelessness – 49%

8% 18% 2% 1.0% 9% 8% 14%

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Retention Success and Challenges

Successes

• Maximizing technology
• Real‐time data collection and

entry of study activity and participant information, accessible by all members of field team

• Rapport‐building within site
• Engagement in Coaching

Challenges

• Transient population
• Changing phone numbers,

addresses, jobs, etc.

• Age group
• Weekly survey response

rates

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Study 4 months 8 months 12 months 16 months 20 months 24 months Acute (n=74) 80% 78% 84% 74% 64% 100% Positive (n=147) 84% 78% 81% 79% 65% 100% Negative (n=1479) 79% 75% 72% 70% 62% 89% Total 80% 76% 73% 72% 63% 93%

Follow‐up Rates over 24 months

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Conclusions

• Flexibility
• Multi-faceted retention approach
• On-site treatment of STIs
• Tailored recruitment based on site
• Iterative improvements
• Examine context and needs of youth (e.g, HIV testing, STI

testing, housing services, referrals for mental health and substance abuse treatment)

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Questions and Comments

Thank you!

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Email Addresses of Presenters

Susana A. Lopez, Ph.D.‐ Salopez@mednet.ucla.edu Sung‐Jae Lee, Ph.D.‐ Sjlee@mednet.ucla.edu