Sexual and Reproductive Health Care Utilization for Youth Experiencing Homelessness

Abstract

We describe sexual and reproductive health (SRH) behaviors and service utilization among youth receiving a brief intervention at an emergency shelter to increase SRH care. Via a retrospective review, we examined SRH behaviors and service use among youth receiving a brief computerized clinical decision support intervention at emergency shelter intake to assess SRH behaviors and provide personalized SRH services recommendations. Forty-eight youth participated (mean age 16±1.7, 65% individuals assigned female at birth; 80% identified with ≥ 1 risk factors for pregnancy and/or sexual transmitted infections [STIs]). Most (77%) accepted ≥ 1 services at intake and later attended an on-site health clinic appointment where they received SRH services. Most youth participating in a brief intervention to increase SRH care access at an emergency shelter accepted recommended services. Such programs may offer an opportunity to address SRH disparities among youth experiencing homelessness.

Introduction

The 1.6 million U.S. youth experiencing homelessness (YEH) are at increased risk for poor sexual and reproductive health (SRH) outcomes including sexually transmitted infections (STI), Human immunodeficiency virus, and unplanned pregnancy compared to the general adolescent population.¹ YEH in this study are considered sheltered homeless youth as they are individuals who are staying in an emergency shelter.² This population along with unsheltered homeless youth are more likely than the general population to engage in behaviors associated with sexually transmitted infections (STI) and pregnancy including unprotected intercourse, multiple sexual partners, and drug and alcohol use.³ They also experience multiple barriers to accessing and utilization of SRH care: confidentiality, stigma, fear, cost, transportation, and limited scheduling.⁴ Therefore, interventions facilitating access and utilization to evidence-based SRH care are critically needed for this population.

Multiple professional guidelines call for comprehensive youth SRH services, but gaps persist in our understanding and implementation of effective SRH programming among YEH.^{5, 6, 7} Prior work demonstrates that ineffective intervention delivery contributes to suboptimal youth access to and use of SRH services. ^8,9 To reduce SRH disparities and increase service utilization among YEH, we must identify effective interventions reaching this marginalized population. The objective of this study was to describe SRH behaviors and service utilization among youth receiving a brief SRH intervention at emergency shelter intake to increase access and utilization to SRH services.

Methods

We conducted a retrospective review of a SRH intervention program database and the electronic health record (EHR) of a youth health clinic co-located at a youth emergency shelter. The hospital Institutional Review Board approved this study. A waiver of informed assent/consent and a waiver of HIPAA as this is a retrospective review of pre-existing data that presents no more than minimal confidentiality risks to participants and will not adversely affect the rights, welfare of the subjects was granted.

Setting & Population

Cases included youth aged 11-18 years participating in a brief SRH intervention during intake at a youth emergency housing shelter serving the local community between March 12-December 31, 2018.

Intervention

A multi-disciplinary team (shelter staff, nurse practitioners at a youth health clinic co-located with the emergency shelter, and physicians with youth health services research expertise) worked iteratively to design a process to provide screening for SRH needs and brief intervention. For screening, we incorporated a previously designed computerized clinical decision support (CDS) system that uses youth-entered health and behavior data to generate individually tailored SRH service recommendations (I.e., STI testing, condoms, emergency contraception for future or immediate use).⁶ Our team met regularly through the planning and implementation process and recorded field notes. Physician team members provided training on SRH care and the intervention for shelter staff.

Youth were invited to use the CDS intervention during initial housing intake. Youth confidentially reported SRH behaviors using a tablet computer, followed by CDS generation of individually-tailored, evidence-based SRH service recommendations. An emergency shelter staff liaison met privately with youth to review these recommendations and offer EC if indicated, condoms, and a health clinic referral. The staff member documented resource acceptance in the program database. Intervention delivery was limited to the liaison’s hours to ensure consistent implementation of tool.

Data collection

De-identified data obtained from the program database included SRH behaviors [intercourse, condom, and hormonal contraception utilization], STI history, current STI symptoms and service acceptance. For youth attending a clinic referral appointment, we recorded provision of these services: STI testing, STI treatment, pregnancy testing, and hormonal contraception prescription from the EHR. We reviewed team meeting notes and field notes to identify potential factors affecting program implementation and resource use.

Analysis

We summarized data with standard descriptive statistics using SPSS Version 24.0.

Results

229 adolescents presented for emergency shelter during intervention implementation Among the 90 youth presenting when the clinic liaison was present, 48 (53%) completed the intervention. Most (79%) reported prior sexual activity (Table 1). Most (77%) accepted one or more services recommended by the staff member (Table 1). Four individuals assigned female at birth who reported unprotected sexual intercourse in the previous 120 hours were offered EC for immediate use and 50% accepted. All youth attending a clinic appointment (n=33) received one or more SRH services at the appointment (Table 2). Among four individuals assigned female at birth who made a future appointment for long-acting reversible contraceptives (LARC), 3 attended and received a LARC at this appointment.

Table 1:

Adolescent Characteristics and SRH Service Utilization

Demographics (n=48)		n (%)
Age in yrs, mean ± SD		16 ±1.7
Caucasian		19 (40)
African American		19 (40)
American Indian		4 (8)
Asian		4 (8)
Mixed-Race		1 (2)
Individuals assigned female at birth		31 (65)
Reported history of sexual activity
Prior sexual activity		38 (79)
Oral sex		42 (87)
Vaginal sex		39 (82)
Anal sex		12 (26)
Risk factors for pregnancy and/or STI
No hormonal contraception at last intercourse*		25 (80)
No condom at last intercourse		38 (80)
Past STI		8 (16)
Partner with past STI		7 (14)
Current genitourinary symptoms**		18 (37)
SRH service recommendations at initial housing intake
Resource	Recommended, n	Accepted, n (%)
Clinic appointment	48	37 (77)
Printed resource materials	48	37 (77)
Condoms	48	28 (58)
EC for immediate use***	4	2 (50)
EC provided for future use	4	4 (100)

^*for individuals identified female at birth

^**dysuria, dyspareunia, abdominal pain, genital discharge, skin lesions

^***Reported sex with same sex only or both sexes in last 120 hours, n=4

Table 2:

SHR care provided at clinic referral visit (n=33)

Resource	Resource used, n
Hormonal contraception initiated:	11
OCP	5
Injectable	5
Ring	1
Second appointment for non-LARC SRH care:
Made	9
Kept	7
Second appointment for LARC:
Made	4
Kept & LARC placed	3
Condoms	20
EC education	31
EC given for immediate use	1
EC prescription for future use	6
Pregnancy testing	16#
GC testing	15+
Chlamydia testing	15+
HIV testing	12#
Syphilis testing	12#
Wet prep	9+
STI treatment	3+

^#No positive result

⁺Positive results and treatment completed for GC n=1, Chlamydia n=1, Trichomonas n=1

Review of team meeting notes revealed that housing program managers reported youth declining the intervention commonly reported verbally to the shelter staff that they recently had STI screening, were already on birth control, or not sexually active. Thirty of those who declined to complete the intervention accepted condoms. Barriers to intervention delivery included clinic liaison hours of availability and shelter policies on administering EC after-hours.

Discussion

This study found that most youth using a brief SRH CDS intervention at an emergency housing shelter commonly had behavioral practices making them at risk for pregnancy and/or STI. Additionally, most youths accepted one or more recommended SRH services, including condoms, time-sensitive services such as EC for immediate pregnancy prophylaxis, subsequent clinic visits, STI testing and treatment, and contraception.

Although the high utilization of recommended services among these youth demonstrate the potential of this intervention to increase utilization among YEH and ultimately SRH disparities among this population we also identified logistical issues that limited program availability. Due to center staffing constraints, the intervention was not offered when youth entered the housing center on evenings and weekends. Further, almost half of youth declined to use the intervention. Program implementation notes suggest that these youth may have perceived that they had no current SRH health needs. Interestingly, such youth commonly did still want condoms.

Reported sexual activity and condom non-use was significantly higher among our study population compared to the general U.S. high school population where only 38% report prior sexual activity and less than half report condom non-use.¹⁰ These findings underscore the need to effectively link YEH to evidence-based SRH care⁵. Additionally, the negative impact of the COVID-19 pandemic on YEH healthcare access highlights the increasing need for such interventions.¹¹

Study limitations include those typical for retrospective methods; data reflects only that documented in the program database and EHR. No data was collected from those not participating, so we cannot compare health services utilization or health behaviors between these youth and program participants. Generalizability is limited as we examined a youth population at a single Midwest emergency shelter. Our small sample size precluded subgroup analyses.

In conclusion, this study demonstrates that a SRH CDS intervention providing evidence-based, individually tailored SRH recommendations in partnership with a health clinic and youth emergency shelter may offer opportunity to address disparities in access to and utilization of SRH resources among YEH. Future studies should examine factors influencing program implementation and uptake of health services. Should this model be proven effective, similar programs may provide an avenue to facilitate convenient, confidential, and individualized SRH care in other non-traditional settings.