Homeless Youth

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Homeless Youth: A Concept Analysis Philisie Starling Washington a

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To cite this article: Philisie Starling Washington (2011): Homeless Youth: A Concept Analysis, Journal of Community Health Nursing, 28:3, 168-178 To link to this article: http://dx.doi.org/10.1080/07370016.2011.589244

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Journal of Community Health Nursing, 28:168–178, 2011 Copyright © Taylor & Francis Group, LLC ISSN: 0737-0016 print / 1532-7655 online DOI: 10.1080/07370016.2011.589244

Homeless Youth: A Concept Analysis Philisie Starling Washington

Downloaded by [Philisie Washington] at 17:49 23 August 2011

Prairie View A & M University, Houston, Texas

Introduction. A variety of terms have been used to describe the homeless youth population. Purpose. The purpose of this article is to analyze the conceptual meanings of the term homeless youths by examining the evolution of the concept and its related terms in the current literature. Method. Online databases from 1990–2010 were analyzed using the Rodgers evolutionary approach. Results. The 6 attributes relating to homeless youth were physical location, age, health, behavior, choice, and survival. Conclusion. The analysis provided insight and clarification of homeless youth from a variety of related terms in the literature.

SUMMARY STATEMENT What is Already Known About This Topic • Homelessness among youth is a growing problem in the United States and other countries. • Homeless youths face problems of poor health, high-risk harmful sexual behaviors, drug abuse, violence, and victimization. • The literature has conflicts in defining homeless youths, including their origins, ages, contributing factors, and predisposing behaviors. What This Article Adds • An extensive investigation of nursing and psychology literature regarding the concept homeless youths to provide consensus and clarification of the term. • A presentation of the concept using a model to depict the antecedents, attributes, and consequences, which will provide for a clearer understanding of the term. An estimated 1.5 million homeless youths live in the United States (National Alliance to End Homelessness, 2007). Homeless youths may have been forced to leave home due to substance abuse, physical abuse, or a variety of other mitigating factors (Heir & Korboot, 1990; Kamieniecki, 2001; Martinez, 2006). Homeless teens report high rates of sexually transmitted diseases, addiction, and crime (Fall & Berg, 1996; Martin, Copeland, Gates, & Gilmour, 2006; Wagner, 2006). Yet, little is known about homeless adolescents, other than negative stereotypes

Address correspondence to Philisie Starling Washington, PhD, RN, Prairie View A & M University, College of Nursing, 6436 Fannin Street, Houston, TX 77030. E-mail: [email protected]


HOMELESS YOUTH: A CONCEPT ANALYSIS

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associated with individuals as they enter legal and health care systems. To adequately address the needs of homeless youths, researchers must better understand their culture. This study provides an exemplar case study, clearly define homeless youths, and proposes a conceptual model to be used by nurses and other health care professionals. An exemplar case may best convey the concept of homeless youths (Rodgers & Knafl, 2000). In this study, Paul (a pseudonym) was adopted at age 9 from his drug-addicted mother. Paul ran away from his adoptive family’s rural southeast Texas home at age 16. When Paul arrived at his new physical location, i.e., the streets of a large city, he survived by panhandling; he also chose to abuse drugs. After some time he entered a shelter, which offered stability, temporary employment, and the promise of independence. However, Paul eventually relapsed into drug use; consequently, his health began to decline. Because of his drug-use behavior, the shelter dismissed him and he returned to street life, a familiar location. Paul spent the next 3 years in and out of shelters. Paul returned to live with his biological mother, who had become sober. This arrangement ended when his mother suffered a drug relapse. By age 20, Paul was sober long enough to be accepted back into a youth shelter. He began to attend church regularly and encouraged others to join him for religious services. Unfortunately, Paul soon violated his probation because of drug possession and was incarcerated, which changed his physical location from the streets to a jail cell. Paul was released from jail at age 21, which made him ineligible to return to the previous shelter. Paul then contacted his church, which could not assist immediately. After 3 days, the church was told that Paul had been killed in a hit-and-run accident. It was later discovered that Paul had overdosed and stepped in front of a car while in the presence of former drug-addicted acquaintances. It was also revealed that his adoptive family had not been able to communicate with him for years; he has simply left without a word. The family attested that Paul had not been a bad child, but one who made poor choices, such as choosing not to follow family rules. Many funeral mourners shared stories of how Paul had encouraged them to change their behaviors and seek a better way of life. Paul’s exemplar illuminates common challenges faced by homeless youths. A literature review will describe findings that shaped this study and conceptual model.

LITERATURE REVIEW Nurses are challenged to deliver health promotion and disease prevention interventions to the adolescent population. Health challenges include alcohol abuse, suicide, mental health disorders, and unplanned pregnancies. When homelessness is coupled with risk factors, the need for nursing interventions assumes additional importance. Improving homeless adolescents’ health will likely improve their quality of life and decrease costs to the healthcare system. Homeless youths may also be considered a silent society. They often leave home suddenly, unprepared, against their will, and without financial security. Because of their age, homeless youths possess limited political, legal, and healthcare options. Moreover, these youths lack a voice due to their limited funds, social skills, education, and family support. A variety of terms, including throwaways and runaways, have been used to describe homeless youths. Throwaways are youth who have been forced by parents to leave their home because of belligerent behavior, social rejection, or abandonment. Throwaways denote a somewhat involuntary entry into the homeless state. Runaways suggest youth who have left the home for reasons


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of “family conflict, alienation, and poor social relations” (Heir & Korboot, 1990, p. 762), or to escape physical, emotional or sexual abuse (Martinez, 2006). Penuel and Davey (2000) studied 17 homeless children and described the ways in which shelter-dwelling youths interpreted the terms homeless or homelessness. Youths used the word home to describe their shelter when talking to peers with homes to avoid embarrassment. Wright and Walker (2006) defined homelessness as “rough sleeping, no permanent housing, and lack of a right to secure housing” (p. 467). The researchers grouped homeless individuals into categories such as “rooflessness; houselessness; insecure/impermanent tenures; intolerable housing; concealed housing; involuntary accommodation sharing” (Wright & Walker, 2006, p. 468). Another category suggested was “temporary homelessness” (Penuel & Davey, 2000, p. 225). To better serve the needs of homeless youths, the concept should be clarified. An analysis of the concept will offer insight into use, significance, and application of the concept (Brilowski & Wendler, 2005). Defining the attributes of antecedents and consequences will ensure appropriate use of the concept and contribute theoretical clarity. Literature was reviewed to determine the scope of homeless youths and to seek potential solutions to the problem. Selected literature was grouped according to mode of entry into a homeless state, influences on behavior, sexual issues, international homelessness, psychological diagnoses, and culture/ethnicity. Mode of entry into a homeless state is varied. Kurtz, Jarvis, and Kurtz (1991) found five routes that move youths to streets: (a) previous membership in homeless families, (b) escape from abuse, (c) thrown or pushed away, (d) ejected from home, and (e) unaccompanied immigrants. The decision to enter the street may be influenced by family and delinquency. Matherne and Thomas (2001) studied relationships between family cohesion and adolescent delinquency. Adolescents from nontraditional, disengaged families were involved in delinquent behaviors more often than those from traditional, connected families. Martinez (2006) added abuse, violence, substance use, and peer encouragement of risky behaviors to the list of behavioral influences faced by runaways. Sexual behaviors and the sexual health of homeless youth are concerns for health care providers that manage emergency treatment and plan for long-term effects of chronic sexually transmitted conditions such as herpes, HIV/AIDS, and sterility. Johnson, Rew, and Sternglanz (2006b) explored self-efficacy for condom use, performance of testicular/breast self-exam, safe sexual behaviors, risk, and sexual self-concept. The study compared gender with sexual abuse and degrees of risk. It was found that girls reported more sexual abuse than boys, although girls had better self-concepts. No difference was found in condom usage between abused and nonabused groups. Meanwhile, Tevendale, Lightfoot, and Slocumb’s (2009) study found that girls engaged in unprotected sex more often than boys. Trading sex for money or food (Tyler & Johnson, 2006) and negative influences of drug use on sexual behaviors (Wright & Walker, 2006) have also been found to greatly affect homeless youths. International homelessness is also a growing health and social issue—UNICEF estimates that globally, over one million children live in homelessness. Anteghini, Fonseca, Ireland, and Blum (2001) revealed that health risks for Brazilian youths (e.g., cigarette smoking, drug use, early onset of sexual intercourse, suicide attempts) were similar to those seen in industrialized nations. When comparing age and gender in a study of Canadian homeless youths (n = 40), Linton, Singh, Turbow, and Legg (2009) found higher numbers of males and older youth (26–30 years) that were HIV-positive. Ali and de Muynck (2005) interviewed street children in Pakistan to



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determine perceptions of available health services. Participants often self-medicated for illnesses, and a majority preferred consulting spiritual healers rather than traditional doctors. Psychological diagnoses also impact homeless youth. Slesnick and Prestopnik (2005) studied the psychological attributes of homeless youth using the DSM-IV. Findings revealed that participants of the study had multiple diagnoses (e.g., alcohol dependence/abuse, affective disorders, anxiety disorders, gender differences) as underlying precursors to homelessness. According to findings by Kidd and Shahar (2008), suicidal ideations were strongly tied to self-esteem, feeling trapped (helplessness), and physical abuse. The influence of ethnicity (Asbridge, Tanner, & Worthley, 2005), cultural needs (Barry, Ensign, & Lippek, 2002; Davis, 1996), and genetics (Plomin & Asbury, 2005) on homeless youth behaviors was also found in the literature. Davis (1996) explored the homeless culture and dwelling needs of female homeless participants, many of whom were members of ethnic minorities. Findings revealed that agencies should be culturally sensitive in addressing the unique needs of this population by providing short-term job training programs.

METHODS The evolutionary method of concept analysis (Rodgers & Knafl, 2000) describes concepts as being the result of analysis, abstraction, and identification of ideas. Homeless youths is a concept that has evolved into a cultural colloquialism with negative connotations. Thus, these adolescents are misunderstood and lost in a maze of stereotypes. Evolutionary methodology includes a progression of both theoretical and research literature and articulates attributes, antecedents, consequences, and related concepts. Steps in this analytic method include identification of the concept of interest, its surrogate, and related terms; data collection; description of attributes, references, antecedents, consequences, and related concepts; and presentation of a model case representing the concept (Rodgers, 1989, 1991). Literature findings were grouped and coded as antecedents, consequences, references, terminology, and related concepts (Rodgers & Knafl, 2000). The categories that emerged from the literature review were: homeless youth, drug abuse/addiction, victimization, sexual behavior/abuse, gang behavior, ethical issues, health concerns or issues, psychosocial issues, runaway, and international homeless youth. The working definition of homeless youths was individuals under 21 years of age with no permanent address. Characteristics of homeless youths included a history of drug use, alcohol use, sexual activity or abuse, and delinquency or criminal behavior. Attributes Six attributes of homeless youth were identified using Rodgers and Knafl’s (2000) process: physical location, age, health, behavior, choice, and survival (Table 1). Physical location removes youths from a permanent address to an impermanent location. Youths may relocate until a stable home is found. Age variations depend on youth developmental status, study purpose, sample population, and author preference. Health attributes include homeless youths’ access to preventative and routine healthcare, follow-up treatments, and current health status. Behavior ranges

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TABLE 1 Attributes of the Concept of Homeless Youths


Physical Location

Age

Health

Shelter Friend’s home

Varies 14–23

Street

15–21

Access Lack of health resources Food

Invisible

11–19

Chronic illness

>18

Behavior Abuse history Mental stability Self-destructive behavior Self-protective behavior Stress

Trauma Defiance toward authorities Criminal activity Delinquent behavior

Choice Situational Forced into homeless state Choose to leave Beyond age of institutional support Desire or lack of desire to remain homeless Drug, alcohol, sexual choices

Survival Resilience Connectedness School difficulty Trust/distrust of authority, peers Personal strength

Self-care Trading for survival (sex, drugs) Loneliness

from homeless youths’ behavior to that of parents, caretakers, and peers. These behaviors may affect homeless youths through abuse, neglect, psychological, trauma, criminal activity, victimization, and delinquency (Davis, 1996; Ellickson & Morton, 1999; Gaetz, 2004; Kurtz et al., 1991; McCarthy & Hagan, 1992; Miles & Okamoto, 2008; Miller, Este, Donahue, & Hofer, 2004; Thomas, 2005). Choice refers to selection and decision-making processes of homeless youths. The methods youths use to enter or exit homelessness relate to choices made by or for the youth (Martinez, 2006). Survival is shaped by youths’ ability to adapt to their environment. The adaptation may be positive (resilience) or negative (truancy).

Antecedents Contributing factors of homelessness include “a history of state intervention, wardship, drug and alcohol abuse, and psychiatric illness” (Kamieniecki, 2001, p. 352). Homelessness can extend over a lifetime and across nations (Kamieniecki, 2001; Miller et al., 2004; Raffaelli & Koller, 2005; Seth, Kotwal, & Ganguly, 2005). Further, approximately 21% of homeless adults were homeless as children (Mohr, 2006). Murray (2003) reported that the nature of homelessness can be episodic based on three origins: structural, personal, and accidental. Structural homelessness is based on lack of housing, employment, health benefits, or social services. Personal homelessness is related to divorce, drug abuse, psychiatric illness, and poor interpersonal skills. Accidental homelessness is caused by natural disasters. Supplemental categories include chronic homelessness, episodic homelessness,


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and intermittent or seasonal homelessness. Episodic homelessness is also known as literal and marginal homelessness. Literal homelessness refers to the lack of regular shelter, yet marginal homelessness encompasses tenuous shelter due to socioeconomic status (Murray, 2003).


Gangs and Homeless Youth Although some homeless youths may become involved in gangs, gang behavior is not the norm for homeless youths. Gangs consist of individuals with close neighborhood ties, whereas homeless youths tend to be nomadic in nature (Thomas, 2005). Kyriacou, Hutson, Anglin, Peek-Asa, and Kraus (1998) reported that social networks for high-risk homeless youth may be linked to gangs, which offer peer support. Further, runaways who participate in deviant survival behaviors are likely to develop relationships that result in chronic substance abuse (K. D. Johnson, Whitbeck, & Hoyt, 2005). The result of this new social network is the violation of traditional social behavior, regardless of the positive emotional function of gang membership. Antecedents (Table 2) of homeless youth were placed in their relationship to drug abuse (Gomez, Thompson, & Barczyk, 2010; Martin et al., 2006), sexual abuse/activity (R. Johnson, Rew, & Kouzekanani, 2006a; Rew, Taylor-Seehafer, & Fitzgerald, 2001), HIV/STD infections, and victimization (R. Johnson, Rew, & Kouzekanani, 2006b). Much of the literature focuses on altering these behaviors or identifying the behaviors in various homeless populations based on place of origin. Moreover, homeless youths were often contextualized with belligerent behavior, abuse/addiction (Wright & Fitzpatrick, 2004), troubled youths, family conflict (Kurtz et al., 1991), family dysfunction, and female victimization (MacLean, Embry, & Cauce, 1999).

RESULTS The consequences (Table 2) of youth homelessness depend on those youths’ ability to negotiate the maze of homelessness. Positive consequences include resilience (Rew, Taylor-Seehafer, Thomas, & Yockey, 2001), survival, self-efficacy, improved quality of life (Baer, Peterson, & Wells, 2004), and personal strength to adapt (Rew & Horner, 2003). Negative consequences may be drug addiction, poor quality of life (Zullig, Valois, & Drane, 2005), barriers to academic achievement (Thompson, Bender, Windsor, Cook, & Williams, 2010), and unhealthy life choices (Barry et al., 2002; Morris & Strong, 2004). Other health risk behaviors such as STD or HIV infection (Beech, Myers, & Beech, 2002), sex for survival (Tyler & Johnson, 2006), and delinquency (McCarthy & Hagan, 1992) may lead to absence of skills or stunted educational development (Commander, Davis, McCabe, & Stanyer, 2002). Related concepts are those that resemble the concept but do not share the same attributes (Rodgers & Knafl, 2000). In the literature, homeless youths is a concept seen embedded in homelessness, homeless children, runaways, throwaways, and others (Table 2). The Washington Conceptual Model of Homeless Youth (Figure 1) presents a visual framework of antecedents, attributes, and consequences of the concept of homeless youths. In this model, antecedent boxes are connected because they may appear as one or several antecedents at once.

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TABLE 2 Antecedents, Related Concepts, and Consequences of Homeless Youths Antecedents


General: Delinquent behavior Possible genetic origin Gang behavior Intrapersonal origins:

Psychiatric history or current illness Personal choice Drug abuse Sexual behavior (choices) Personal homelessness Interpersonal origins: Sexual abuse/victimization Drug addictive behavior Family conflicts Relational origins: Strains on family roles Family financial constraints Educational teacher–student conflicts Religious conflicts Environmental origins: Diminished social services

Gang/street influences Health care limits Structural/literal homelessness Accidental/marginal

Consequences

Related Concepts

Resilience Survival Self-efficacy Addiction to drugs, alcohol Quality of health: health seeking behaviors; perception of health; deterrents to health; modification of unhealthy behaviors; access/denial of access to health systems Personal strengths to adapt to the situation Ability to access available resources

Culture of homelessness Homelessness Homeless children Street culture Peer support to run

Length of homelessness Health risk behaviors: cigarette smoking; drug use; sexual activities; self-harm Lack of skill development

Throwaway Houselessness

Lack of permanent housing Rooflessness Temporary homelessness Sheltered youth Runaway

Impermanent tenure Intolerable housing Concealed housing Age (13–21: 11.4 average runaway age; 14–19: average age varies)

Economic constraints homelessness Multidimensional: May encompass all of the above

The broken arrow between antecedents and terms for homeless youth convey that movement is uncertain and progression individualized. Survival and nonsurvival consequences of homeless youth are connected by a broken arrow to show that movement may flow from one consequence to the other, possibly with frequent shifting.


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Antecedents General

• Delinquent behavior • Genetic origin • Gang behavior

Interpersonal

Intrapersonal Current illness Personal choice Drug abuse Sexual behavior Psychiatric Hx

• Sexual abuse/victimization • Drug addictive behavior • Family conflict


• • • • • • • • •

Relational Origins Family role strains Financial constraints Educational conflicts Religious conflicts

Environmental

Multidimensional

• May encompass all origins

• Diminished social services • Gang/street influence • Economic constraints • Health care limits

Throwaway Runaway Rooflessness

Attributes Age Choice HomeLess Youth

Location Survival Health Behavior

Consequences Survival

• Return home • Permanent housing • Independent living • Resilience

Non-Survival

• Drug addiction • Long-term homelessness • Death

FIGURE 1 Washington conceptual model of homeless youths.

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DISCUSSION Concept analyses should initiate questions and areas of future research based on the current study of inquiry (Rodgers & Knafl, 2000). Six attributes of homeless youths (physical location, age, health, behavior, choice, and survival) were found throughout the reviewed literature. These attributes suggest several future research questions:


• • • •

How can nurses who care for homeless youths use, alter, or encourage these attributes? Which core attribute of homeless youth is more prone to positive intervention? How can nursing curriculum prepare nurses to care for homeless youth populations? What are unique health, teaching, promotion, and cultural considerations of homeless youths? • How do nurses provide effective care using evidenced-based practice for homeless youths? The antecedents provide valuable information to nurses who assess homeless adolescents within a context of prevention and health promotion. Early identification of antecedents may redirect interventions of the current concept of homeless youths. Nurses may be able to intervene so that situations are interrupted, resulting in more positive outcomes for homeless youths. Although no small task, youth homelessness may be mitigated if attributes are addressed individually. Consequences of the concept of homeless youths are greatly influenced by choices made by individual youths. Homeless youth consequences depend on youths’ resilience, survival, selfefficacy, addiction, health quality, personal strengths, health risk behavior, and lack of skill development. These consequences depend on homeless youths’ ability to connect with assistance and change deleterious behavior. Consequences are also determined by early intervening factors, including role models, homeless youth programs, and gang membership. Homeless youth has various negative connotations, including drugs, alcohol, violence, and delinquency. Some may empathize with their plight of being thrown away due to family violence, conflict, abuse, and poor academic performance. This concept analysis serves as a baseline for future development of youth homelessness, as well as motivation for further research in homeless youth populations. There is a need for quantitative research on interventions and outcome evaluations for homeless youths regarding sexual behavior, drug use/addiction, health promotion, and improved self-concept. These studies would improve outcomes and address problems before homeless youths become homeless adults. Thus, to best address the issue of homeless youths, future systematic multidimensional studies are suggested. Such studies would clarify behavioral issues, initiate public reforms, address educational deficits, improve access to healthcare, identify opportunities for employment, facilitate housing relief, and promote positive nutritional outcomes. REFERENCES Ali, M., & de Muynck, A. (2005). Illness incidence and health seeking behaviour among street children in Rawalpindi and Islamabad, Pakistan—A qualitative study. Child: Care, Health & Development, 31, 525–532. Anteghini, M., Fonseca, H., Ireland, M., & Blum, R. (2001). Health risk behaviors and associated risk and protective factors among Brazilian adolescents in Santos, Brazil. Journal of Adolescent Health, 28, 295–302. Asbridge, M., Tanner, J., & Worley, S. (2005). Ethno-specific patterns of adolescent tobacco use and the mediating role of accumulation, peer smoking and sibling smoking. Addiction, 100, 1340–1351.



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