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Social network engagement and HIV risk among homeless former foster youth

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Social network engagement and HIV risk among homeless former foster youth

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Content HIV RISKS FOR HOMELESS FORMER FOSTER YOUTH

Social Network Engagement and HIV Risk among Homeless Former Foster Youth

By
Amanda Yoshioka-Maxwell, MSW
May 2018 Degree Conferral
Doctor of Philosophy (Social Work)
University of Southern California

Dissertation Guidance Committee:
Eric Rice, PhD (chair)
Suzanne Wenzel, PhD
Nicole Esparza, PhD
FACULTY OF THE USC GRADUATE SCHOOL

HIV RISKS FOR HOMELESS FORMER FOSTER YOUTH 2
Table of Contents

List of Tables and Figures……….………………………………………………………4
Dedication……………………………………………………………………………….5
Acknowledgements……………………………………………………………………...6
Chapter 1: Introduction………………………………………………………………….8
An Overview of Foster Care and Youth Homeless Risk Factors ……………….9
Social Network Engagement……………………………………………………11
Intersection of Homelessness and Foster Care Experiences..…………………..13
References………………………………………………………………………16
Chapter 2: Exploring the Relationship between Foster Care Experiences and HIV-risk
Behaviors Among a Sample of Homeless Former Foster Youth……………….23
Introduction……………………………………………………………………..23
Background……………………………………………………………...23
Methods…………………………………………………………………………26
Sampling………………………………………………………………...26
Measures………………………………………………………………...27
Sociodemographic variables……………………………………28
Foster care variables……………………………………………28
Homelessness variables…………………………………………29
HIV-risk behaviors……………………………………………..30
Analyses…………………………………………………………………30
Results…………………………………………………………………………...31
Demographics…………………………………………………………....31
Logistic Regressions…………………………………………………….38
Discussion……………………………………………………………………….39
Limitations……………………………………………………………….41
Implications……………………………………………………………...42
References……………………………………………………………………….45
Chapter 3: Exploring the Relationship between Foster Care Experiences and Social
Network Engagement Among a Sample of Homeless Former Foster Youth……52
Introduction………………………………………………………………………52
Background………………………………………………………………52
Theory……………………………………………………………………54
Methods………………………………………………………………………….56
Sampling…………………………………………………………………56
Part 1: Online, self-administered questionnaire………………..57
Part 2: Network assessment……………………………………..57
Measures…………………………………………………………………58
Sociodemographic variables…………………………………….58
Foster care variables…………………………………………….58
Egocentric network variables…………………………………...58
Analyses………………………………………………………………….59
Results……………………………………………………………………………61
Chi Square………………………………………………………………..61
Logistic Regressions……………………………………………………..62
HIV RISKS FOR HOMELESS FORMER FOSTER YOUTH 3
Discussion………………………………………………………………………..63
Limitations……………………………………………………………….65
Implications………………………………………………………………66
References………………………………………………………………………..68
Chapter 4: Investigating the Relationships of Social Network Engagement and HIV-risk
Behaviors Among a Sample of Homeless Former Foster Youth………………...73
Introduction………………………………………………………………………73
Methods…………………………………………………………………………..74
Measures…………………………………………………………………74
Sociodemographic variables…………………………………….75
Foster care variables…………………………………………….75
Homelessness variables………………………………………….76
HIV-risk behaviors……………………………………………...77
Analyses………………………………………………………………….77
Results……………………………………………………………………………78
Discussion………………………………………………………………………..79
Limitations……………………………………………………………….80
Implications……………………………………………………………....81
References………………………………………………………………………..83
Chapter 5: Implications and Future Directions…………………………………………..85
References………………………………………………………………………..89

HIV RISKS FOR HOMELESS FORMER FOSTER YOUTH 4
List of Tables and Figures

Table 2.1 Basic Sample Demographics…………………………………………………32
Table 2.2 Basic Foster Care Demographics……………………………………………..33
Table 2.3 Foster Care Demographics……………………………………………………34
Table 2.4 Homelessness Characteristics Among Former Foster Youth…………………36
Table 2.5 Sex Risk Variables Among Homeless Former Foster Youth…………………37
Table 2.6 Logistic Regression Models Examining Foster Care Experiences Impacting
HIV-risk Behaviors………………………………………………………………39
Table 3.1 Egocentric Network: Alter Foster Care Status by Social and Behavior
Category………………………………………………………………………….62
Table 3.2 Egocentric Logistic Regressions: Foster Care Experiences by Social and
Behavior Category……………………………………………………………….63
Table 4.1 Logistic Regressions for HIV-risk Behaviors on Social Network
Engagement………………………………………………………………………79

HIV RISKS FOR HOMELESS FORMER FOSTER YOUTH 5
Dedication

This dissertation is dedicated to every young person who has so selflessly offered
up the most intimate details of his or her life throughout my clinical and research careers.
From the young women at the group home who inspired, and continue to inform, nearly
every aspect of my research to the homeless young adults who so graciously answered
extremely personal questions about their lives—not only have you informed my research,
but you have all enriched my life personally, teaching me what it is to be hopeful,
humble, curious, and grateful. I hope my work makes an impact in your lives and the
lives of others and that I can make you proud someday.

HIV RISKS FOR HOMELESS FORMER FOSTER YOUTH 6
Acknowledgements
In no way will I be able to acknowledge every person who has helped me along
my journey, and I apologize for those I’ve forgotten, but I would like to thank the many,
many people who have supported me throughout my academic and research career.
To Dr. Eric Rice, for allowing me to explore my research interests and supporting
my love of all things statistical. You gave me space to ask questions and work through
analytic and modeling struggles and always made time for my anxiety (even though you
didn’t have to). I can’t begin to thank you enough for all that I’ve learned from you over
the past few years. The one thing I can give you in return is the promise that I will now
call you “Eric.”
To Dr. Suzanne Wenzel, Dr. Nicole Esparza, Dr. Jacqueline McCroskey, Dr.
Emily Putnam-Hornstein, and Dr. Michael Hurlburt, for supporting me through a number
of academic endeavors and always providing me invaluable guidance and support.
To Seth Yoshioka-Maxwell, for being my biggest supporter throughout this
journey and basically in all aspects of my life. You have never discouraged me from
pursuing any of my dreams, you give me feedback even though I may not always show
appreciation for it, and you have made me laugh every single day of my life for nearly 16
years. For these things and many, many more, I am so grateful.
To my sister, Livi, for always being the loudest fan in my cheering section. I have
always felt supported and loved by you in all that I do. You really are one of my favorite
people in life.
To my sweets, Natalia, for being my best friend and always cheering me on. We
have been through a lot of ups and downs, but you have always been there for me. I can’t
HIV RISKS FOR HOMELESS FORMER FOSTER YOUTH 7
count the times I have complained to you about school, only for you to say, “but you’re
going to save the world!” I’m not sure that I am, but it means the world to me that you
say so.
To Bart…where do I even start? You are one of the most important people in my
life. You’ve believed in me when I couldn’t believe in myself. In no way would I be
where I am today if it hadn’t been for you. I don’t think I can ever thank you enough for
all that you’ve done.
To my dearest Benjamin, for always being the smiling face at the end of each day
and for the joy you have brought to my life.

HIV RISKS FOR HOMELESS FORMER FOSTER YOUTH 8
Chapter 1: Introduction

The composition of this dissertation includes three chapters representing three
analyses. The first two independent analyses create a foundation to be used in the third
analysis. The main objective of this dissertation is to address the potential impact of
foster care experiences on social network engagement and HIV-risk behaviors, which is
an area of research not yet addressed. Given the research that has been conducted on
homeless youth, former foster youth, and social networks, the aims of this dissertation
were to examine a) the impact of foster care experiences on HIV-risk behaviors, b) the
impact of foster care experiences on social network engagement, and c) the ways that
foster care experiences, social network engagement, and HIV-risk behaviors relate to one
another among a sample of homeless former foster youth.
The first of these analytical chapters examines specific foster care experiences,
outlining the rates of these experiences, as well as the impact these experiences have on
HIV-risk behaviors. This analysis was primarily used to establish the range of
experiences among these youth and the literature on HIV risk among homeless former
foster youth. Previous research has focused on the behavioral health of former foster
youth, but no studies have focused on foster care experiences as predictors of HIV risk
among homeless youth. The second of these chapters analyses the same foster care
experiences from the first analysis to determine how they impact the types of connections
homeless former foster youth make in their social networks, as well as the risky
behaviors in which these connections may be engaging. Finally, the third chapter
communicates the attempts to connect the first two analyses using a mediation analysis,
examining the impact of foster care experiences on HIV-risk behaviors, as mediated by
HIV RISKS FOR HOMELESS FORMER FOSTER YOUTH 9
social network engagement. Together, these chapters aim to address the need for a more
nuanced understanding of foster care experiences and the impact they have on social
networks and HIV risk.
An Overview of Foster Care and Youth Homeless Risk Factors
There are nearly 428,000 youth in foster care on any given day in the United
States, with 670,000 youth spending time in foster care in 2015 (U.S. Department of
Health and Human Services, 2008). Foster youth and former foster youth are a
subpopulation of the homeless populace who are at a high risk for factors such as
unemployment, low educational attainment, early parenthood, criminal activity, and
mental health conditions (Daining & DePanfilis, 2007). Childhood abuse is associated
with high rates of substance use and substance abuse disorders, sexual activity at a
younger age, increased risk of certain sexually transmitted illnesses (STIs), and multiple
sex partners, making former foster youth at high risk of experiencing poor behavioral
health outcomes, including HIV and STIs (Ahrens et al., 2010; Benjet, Borges, Medina-
Mora, & Méndez, 2012; Black, Oberlander, & Lewis, 2009; Kerr et al., 2009; Schilling,
Aseltine, & Gore, 2007). Rates of substance use and risky sex practices among older
foster youth are often higher than those for the general public (Braciszewski & Stout,
2012; Carpenter, Clyman, Davidson, & Steiner, 2001; DiClemente, Crittenden, & Rose,
2008; Vaughn, Ollie, McMillen, Scott, & Munson, 2007; White, O’Brien, White, Pecora,
& Phillips, 2008).
Research has indicated that youth exiting foster care are at greater risk for
experiencing homelessness than their peers without a history of foster care (Dworsky,
Napolitano, & Courtney, 2013), and homeless adults are 8 times as likely to have a
HIV RISKS FOR HOMELESS FORMER FOSTER YOUTH 10
history of foster care than the housed general public (Reilly, 2003). Many homeless
youths leave home to escape abuse; a recent study demonstrated that up to 85% of
homeless youths have experienced either physical or sexual abuse before becoming
homeless, with 42% experiencing both (Keeshin & Campbell, 2011). However, despite
the attempts of these youth to escape abuse situations, homelessness puts them at a higher
risk for further victimization, with evidence demonstrating that homeless youth
experience disproportionately high rates of robbery, assault, and sexual assault (Thrane,
Hoyt, Whitbeck, & Yoder, 2006).
As of 2017, in the Unites States, one in 10 young adults aged 18–25 and one in 30
youth aged 13–27 has experienced homelessness over the course of a year (Morton et al.,
2017). This homelessness is a risk factor for a variety of negative outcomes, but rates of
drug use are particularly high for homeless youth, correlating to use at an early age,
polysubstance use, use within the last 30 days, and likelihood of lifetime use.
Homelessness also serves as a risk factor for the presence of a substance abuse disorder
(Bousman et al., 2005; Greene, Ennett, & Ringwalt, 1997; Kipke, Montgomery, Simon,
& Iversom, 1997; Salomonson-Sautel et al., 2008). Moreover, drug use among homeless
youth carries more risks than just the associated poor health outcomes, such as sexual
risk-taking, particularly where combined heroin/stimulant users are concerned (Gleghorn,
Marx, Vittinghoff, & Katz, 1998).
This sexual risk-taking behavior is not merely related to drug use. These
behaviors from this population also include participation in exchange sex, or exchanging
sex for a good or service. Like drug use, exchange sex correlates to additional risks,
including victimization, substance use, suicide attempts, and STIs (Greene et al., 1997).
HIV RISKS FOR HOMELESS FORMER FOSTER YOUTH 11
The rates of exchange sex are higher for homeless youth than for youth who are not
homeless, and these high rates are increased when a substance use history is present
(Chettiar, Shannon, Wood, Zhang, & Kerr, 2010; Greene et al., 1997; Kral, Molnar,
Booth, & Watters, 1997).
Social Network Engagement
Peers play an important role in the lives of homeless young adults (Whitbeck &
Hoyt, 1999). As these young adults move away from family-centered networks and
toward peer-centered networks, homeless youth become highly influenced by their street-
based peers (Furman & Buhrmeter, 1992; Rice, Milburn, Rotheram-Borus, Mallett, &
Rosenthal, 2005; Rice, Stein, & Milburn, 2008). Theories of social networks and risk
amplification offer models for explaining these peer influences and the impact they may
have on individuals’ behavioral health.
One of the central tenets of Social Network Theory posits that similarity breeds
connection (Brechwald & Prinstein, 2011; McPherson, Smith-Lovin, & Cook, 2001).
Consequently, peer behavior has been shown to be strongly correlated with individual
behavior (Weis & Hawkins, 1981). Network characteristics may inform about the types
of behavior in which an individual is likely to engage (Rice, Tulbert, Cederbaum,
Barman-Adhikari, & Milburn, 2012). Thus, in examining the connections and behavioral
health patterns among similar individuals, researchers may gain a clearer understanding
of the rates and prevalence of these behaviors in the greater network. The Risk
Amplification and Abatement Model (RAAM) views negative contact with socializing
agents as amplifying risk while positive contact with socializing agents abates it (Milburn
et al., 2009). This model is an extension of the Risk Amplification Model (RAM), which
HIV RISKS FOR HOMELESS FORMER FOSTER YOUTH 12
focuses solely on the negative outcomes that occur from negative experiences (Cauce,
Paradise, Embry, Morgan, Lohr, Theofelis, ... & Wagner, 1998). Whitbeck and Hoyt
(1999) used the RAAM to show how parental problems and family abuse increase a
youth’s likelihood of engaging with deviant social networks. Findings from the
development of this model indicated that both time spent with deviant networks and time
spent alone impact levels of engagement in drug risk behaviors through the continued
reinforcement of engagement in risk behaviors from the negative contact with socializing
agents. RAAM is a useful model for the population of homeless youth because it attempts
to explain the impact of negative life events and negative developmental trajectories
while considering the effect that positive contact has on abating risk. In this perspective,
negative contact with socializing agents, such as deviant social networks, amplifies risk
of engaging in risk-taking behaviors.
Within the context of the foster care experience, this model can be slightly
expanded to explain why former foster youth may uniquely engage in certain levels of
risk-taking behaviors. Given the experiences common to many former foster youth,
including abuse, instability, and institutionalization, this model may help predict a former
foster youth’s likelihood of engagement in deviant social networks. Therefore, because
homeless former foster youth share similar experiences, they may be more likely to have
unique network characteristics, which, in turn, impact their engagement in risky drug use
behaviors.
For young people with a history of foster care, connectedness is particularly
impactful on wellbeing, in that, engagement in quality relationships is associated with
fewer disruptive behaviors (Joseph, O’Connor, Briskman, Maughan, & Scott, 2014). In
HIV RISKS FOR HOMELESS FORMER FOSTER YOUTH 13
contrast, fewer social ties are associated with additional risk factors and increased
network disruption for those with a history of foster care compared with other young
adult populations (Perry, 2006). Whereas networks are important for youth during
transitional periods, young adults from foster care tend to struggle with maintaining
relationships with their birth families and have a difficult time adjusting to the often-
abrupt changes that come with transitions and discharge (Barth, 1990; Blakeslee, 2011;
Collins, Spencer, & Ward, 2010). Furthermore, homeless former foster youth tend to lack
support during transition out of foster care and be isolated from family, friends, and other
support networks, increasing their risk for poor outcomes (De La Haye et al., 2012;
Fischer & Breakey, 1991).
In addition, studies examining the social networks of homeless young adults
indicate that support networks play a critical role in mitigating the negative effects of
homelessness on mental and behavioral health. Negative network ties have been shown to
increase anti-social behavior, depression, risk-taking behaviors, engagement in drug risk
behaviors, and perceptions of negative social support (Bao, Whitbeck, & Hoyt, 2000;
Ennett, Baily, & Federman, 1990; Halkitis et al., 2013; Kidd, 2003; Rice, Milburn, &
Rotheram-Borus, 2007; Rice & Rhoades, 2013; Rice et al., 2008; Wenzel, Hsu, Zhou, &
Tucker, 2012). Based on the current knowledge about behavioral health outcomes and the
importance of network engagement for former foster youth, this analysis seeks to better
understand network characteristics of homeless former foster youth and how these
characteristics are associated with behavioral health outcomes.
Intersection of Homelessness and Foster Care Experiences
The following three chapters explore the intersection of homelessness and foster
HIV RISKS FOR HOMELESS FORMER FOSTER YOUTH 14
care experiences, specifically how social networks and behaviors lead to HIV risk.
Chapter 2 examines the frequencies of a range of foster care experiences among the
sample of homeless former foster youth, such as time spent in placement, number of
placements, reason for placement, and circumstances surrounding transition out of foster
care, among others. A series of logistic regressions were conducted to determine the
impact of these experiences on HIV-risk behaviors including condomless sex, drug use
with sex, and engagement in exchange sex. Results indicated that time spent in foster care
and number of foster care placements were significantly associated with condom use,
foster care exit age was associated with injection drug use, and homelessness experiences
prior to exit from foster care was associated with drug use during sex and exchange sex.
Chapter 3 built off the previous chapter using those significant foster care
experiences to predict social network engagement. Using the RAAM, the aim of this
analysis was to predict the impact of foster care experiences, including both risk and
protective factors, on the types of alters, or connections, with which youth connect.
Through the use of RAAM, it was hypothesized that foster care experiences impacted
connectivity with other foster youth and other youth engaging in risky behavior. Results
of a series of logistic regressions indicated that youth with alters with a foster care history
also had more alters that engaged in methamphetamine and heroin use. Furthermore,
youth with a higher number of foster care placements were more likely to have alters
using methamphetamines, and youth experiencing homelessness before exiting foster
care were more likely to have alters engaging in condomless sex. These results suggest
that some foster care experiences, ones that have been established as negatively
impacting behavioral health, were associated with having alters engaging in risk.
HIV RISKS FOR HOMELESS FORMER FOSTER YOUTH 15
Chapter 3 attempts to connect the dots of the previous two analyses, examining
the mediating role of social network engagement on the relationship between foster care
experiences and HIV-risk behaviors. The results from this mediation indicated that
although direct paths between some variables were significant, the indirect path through
the mediating variable was not. Although the mediation model was not significant, these
results provide information about the importance of the impact of foster care experience
on network engagement and HIV risk independently and suggest that the path from these
foster care experiences to outcomes of interest are direct. Over all three chapters,
information about the complexity of foster care experiences emerges. Foster care can be
risky or protective where social network engagement and HIV risks are concerned,
indicating the need for a nuanced, in-depth approach to intervention with homeless
former foster youth.

HIV RISKS FOR HOMELESS FORMER FOSTER YOUTH 16
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HIV RISKS FOR HOMELESS FORMER FOSTER YOUTH 21
Rice, E., Tulbert, E., Cederbaum J., Barman-Adhikari, A., & Milburn, N. G. (2012).
Mobilizing homeless youth for HIV prevention: A social network analysis of the
acceptability of a face-to-face and online social networking intervention. Health
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Salomonson-Sautel, S., Van Leeuwen, J. M., Gilroy, C., Boyle, S., Malberg, D., &
Hopfer, C. (2008). Correlates of substance use among homeless youth in eight
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doi:10.1080/10550490802019964
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mental health in young adults: A longitudinal survey. BMC Public Health, 7, 30.
Thrane, L. E., Hoyt, D. R., Whitbeck, L. B., & Yoder, K. A. (2006). Impact of family
abuse on running away, deviance, and street victimization among homeless rural
and urban youth. Child Abuse & Neglect, 30(10), 1117-1128.
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Preliminary FY 2006 estimates as of January 2008. Retrieved from
http://www.acf.hhs.gov/programs/cb/stats_research/afcars/tar/report14.htm
Vaughn, M. G., Ollie, M. T., McMillen, J. C., Scott, L., & Munson, M. (2007). Substance
use and abuse among older youth in foster care. Addictive Behaviors, 32, 1929-
1935. doi:10.1016/j.addbeh.2006.12.012
Weis, J., & Hawkins, D. J. (1981). Preventing delinquency. Washington, DC: OJJDP.
Wenzel, S. L., Hsu, H. T., Zhou, A., & Tucker, J. S. (2012). Are social network correlates
of heavy drinking similar among black homeless youth and white homeless
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HIV RISKS FOR HOMELESS FORMER FOSTER YOUTH 22
Whitbeck, L. B., & Hoyt, D. R. (1999). Nowhere to grow: Homeless and runaway
adolescents and their families. Piscataway, NJ: Transaction Books.
White, C. R., O’Brien, K., White, J., Pecora, P. J., & Phillips, C. M. (2008). Alcohol and
drug use among alumni of foster care: Decreasing dependency through
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Research, 35(4), 419-434.

HIV RISKS FOR HOMELESS FORMER FOSTER YOUTH 23
Chapter 2: Exploring the Relationship between Foster Care Experiences and HIV-
risk Behaviors Among a Sample of Homeless Former Foster Youth
Introduction
One in 10 young adults experience at least one night of homelessness in the U.S.
each year (Morton et al., 2017). Approximately 30% of all homeless adults report a foster
care history compared to 4% among the general public (Courtney & Piliavin, 2003;
Reilly, 2003; Roman & Wolfe, 1995), and research has identified that between 11% and
36% of the foster youth population experience homelessness in their lives (Dworsky,
Dillman, Dion, Coffee-Borden, & Rosenau, 2012). Recent research has begun to
demonstrate high rates of poor behavioral health outcomes among homeless former foster
youth (Hudson & Nandy, 2012; Nyamathi et al., 2012a; Courtney et al., 2011). Separate
work has independently shown increased risk of HIV among foster and former foster
youth (Braciszewski & Stout, 2012; Carpenter, Clyman, Davidson, & Steiner, 2001;
DiClemente, Crittenden, & Rose, 2008; Vaughn, Ollie, McMillen, Scott, & Munson,
2007; White, O’Brien, White, Pecora, & Phillips, 2008). Homeless former foster youth
are a vulnerable population but receive relatively little attention in the scientific literature,
as compared with homeless youth and youth with foster care experiences. Although both
homeless youth and former foster youth independently face increased risk of HIV
(Hudson & Nandy, 2012; Jones, 2012; Yoshioka-Maxwell, Rice, Rhoades, & Winetrobe,
2015),

little research has been conducted on this risk at the intersection of homelessness
and child welfare involvement, necessitating additional exploration, particularly where
HIV-risk behaviors are concerned.

Background
HIV RISKS FOR HOMELESS FORMER FOSTER YOUTH 24
The accumulation of risk factors common to both homeless youth and former
foster youth place homeless former foster youth in the nexus of life experiences that carry
an extreme risk of engaging in HIV-risk behaviors, necessitating an increase in research
to address the unique needs of this population. Foster youth continue to face these risk
factors after emancipation and well into adulthood, but research has not examined
specific issues faced by former foster youth who also experience homelessness.
Regarding engagement in sex risk behaviors, homeless youth (not specifically with foster
care histories) are more likely than housed youth to engage in sex at an earlier age,
engage in inconsistent condom use, use drugs with sex, experience high rates of STIs
including HIV/AIDS, have high-risk partners, have concurrent sex partners, and
participate in exchange sex for money, drugs, shelter, food, and clothing (Halcón &
Lifson, 2004; Johnson, Aschkenasy, Herbers, & Gillenwater, 1996; MacKellar et al.,
2000; Rew, Taylor-Seehafer, & Thomas, 2000). Thus, it is likely that homeless former
foster youth have unique risk experiences, facilitated by the intersection of these two risk-
enhancing life experiences.

Life experiences unique to former foster youth may affect their HIV-risk
behaviors. Approximately 40% of homeless youth in Los Angeles report having been
placed in foster care at some point (Yoshioka-Maxwell et al., 2015).

Because these
youths have been involved in the foster care system, they are eligible for a wide array of
services that other homeless youth are not. Despite these advantages, some former foster
youth have higher levels of HIV-risk behaviors, including engagement in exchange sex,
vaginal intercourse at an earlier age, and more sex partners (Ahrens et al., 2010; Hudson
& Nandy, 2012; Nyamathi, Hudson, Greengold, & Leake, 2012b).

However, studies
HIV RISKS FOR HOMELESS FORMER FOSTER YOUTH 25
examining these behaviors have been limited in the data collected on former foster youth
and have only made gross comparisons between youth with and without foster care
experiences. These studies have not delved into how the heterogeneity of foster care
experiences affects the risk-taking, housing stability, and peer-involvement trajectories of
youth with and without experiences of foster care.
Two manuscripts have explored the risk factors unique to former foster youth. A
typology of homeless former foster youth

(Yoshioka-Maxwell & Rice, 2017) examined
how a generated risk typology related to substance use and sexual risk-taking during
homelessness and found that the risk incurred by many homeless youth was similarly
influential in the lives of homeless former foster youth, affecting behavioral health
outcomes. An additional study of comorbid substance use and mental health disorders
among homeless former foster youth found that service utilization had positive benefits
on this population but that accessing these services could be difficult (Yoshioka-
Maxwell, Rhoades, Winetrobe, & Rice, in press). Although factors such as number of
foster care placements, age at first foster care placement, type of placement, and
experience transitioning out of care affect outcomes for foster youth (Collins, Paris,
Ward, 2008; Courtney & Dworsky, 2006; Courtney, Terao, & Bost, 2004; Newton,
Litrownik, Landsverk, 2000),

these factors have not been accounted for in studies
examining HIV outcomes for homeless former foster youth. The data for most of these
studies have only identified youth with foster care histories, not the specifics or
experiences of the placements or the nature of the transition out of foster care (e.g.,
transitional housing services, independent living program, or job services). Thus, because
of the lack of data on specific experiences in the foster care system, which experiences
HIV RISKS FOR HOMELESS FORMER FOSTER YOUTH 26
serve as either risk or protective factors for HIV-risk behaviors are unclear, as is the
directionality of these relationships for foster youth who subsequently experience
homelessness.
Additional data sampling and analyses should be conducted to determine which
foster care experiences impact HIV-risk behaviors, with the expectation that experiences
unique to the foster care system significantly impact individuals’ risk-taking behaviors
either positively or negatively. Understanding these pathways between foster care
experiences and HIV-risk behaviors will provide information required to adapt future
interventions to meet the unique needs of homeless former foster youth.

Methods
Sampling
Data were collected from 184 homeless former foster youth at a drop-in center in
Hollywood, California using the risk-behavior questionnaire modeled after the YouthNet
Study (Rice, 2012). Foster care experiences were be measured through the Foster Care
Experiences Assessment, which includes quantitative measures of foster care experiences
created from qualitative interviews conducted from a sample of 20 homeless former
foster youth in 2014. Data was collected during 2- to 4-week intervals over three periods
(two summers and one winter) from 2015 to 2016.
Any client receiving services at the respective agency during data-collection
periods was eligible to participate. Recruitment was conducted for approximately 2–4
Foster Care Experiences
• Number of Foster Care placements
• Age at first placement
• Types of placement
• Experience transi;oning out of care
HIV-Risk Behaviors
• Condom use
• Concurrent sex partners
• Exchange sex
• Sex under the influence
HIV RISKS FOR HOMELESS FORMER FOSTER YOUTH 27
weeks; during that time, recruiters were present at the agency to approach youth for the
duration of service provision hours. Youth new to the agency first completed the
agency’s intake process before beginning the study to ensure they met the eligibility
requirements for the agency (and, thus, the study). A consistent set of two research staff
members were responsible for all recruitment to prevent youth completing the survey
multiple times within each data-collection period.
Signed voluntary informed consent was obtained from each youth, with the
caveats that child abuse and suicidal and homicidal intentions would be reported.
Informed consent was obtained from youth 18 years and older, and informed assent was
obtained from youth 14 to 17 years old. The Institutional Review Board (IRB) at the
University of Southern California waived parental consent, as homeless youth younger
than 18 years are unaccompanied minors who may not have a parent or adult guardian
who could give consent. Interviewers received approximately 40 hours of training,
including lectures, role-playing, mock surveys, ethics training, and training in emergency
procedures.
The study consisted of two parts: a computerized self-administered survey and a
social network interview. For the purpose of this analysis, data from only the self-
administered behavioral health survey was used. The self-administered survey included
an audio-assisted version for those with low literacy, and both parts of the survey could
be completed in English or Spanish. All participants received $20 in gift cards as
compensation for their time.
Measures
HIV RISKS FOR HOMELESS FORMER FOSTER YOUTH 28
Sociodemographic variables. Age, race, gender, and sexual orientation were
obtained through self-report measures. Age was calculated by coding the youths’ reported
birth dates into an age based on the date of their interview. Racial categories included
American Indian/Alaska Native, Asian, Black/African American, Native Hawaiian or
other Asian Pacific Islander (API), White, Latino/Hispanic, and mixed race. Due to the
low numbers of American Indian/Alaska Native, Asian, and Native Hawaiian or other
API, those categories were coded into an “other” category. For the purpose of the logistic
regressions performed in this analysis, race was further dichotomized into “Black/African
American” and “all other races.” Questions pertaining to gender included the following
options: male, female, transgender (male to female), and transgender (female to male).
Due to the low number of transgender participants, all responses related to gender were
coded into male or female, depending on the gender with which participants identified.
Variables pertaining to sexual orientation included homosexual, queer, bisexual,
heterosexual, and questioning/unsure. Due to the response rates across the orientations,
sexual orientation was coded into “heterosexual” and “LGBTQ.”
Foster care variables. A number of foster care experience variables were chosen
to describe basic experiences in foster care placements. Age at first foster care placement
was measured on a 7-point scale, ranging from placement at birth to placement at age 17.
Time spent in placement was measured through a 6-point scale, ranging from less than a
year to 15 or more years. Age at exit from foster care was measured on a 4-point scale
and included the categories of 5 years or younger, 6–11 years old, 12–17 years old, and
under 18 years old generally. Housing situation after transitioning out of foster care
included a number of options for housing such as family, family of origin, adoptive
HIV RISKS FOR HOMELESS FORMER FOSTER YOUTH 29
family, transitional living facility, couch surfing, homelessness, independent living,
shelter, jail, rehab, and foster family. Number of foster care placements was measured
through a 5-point scale, ranging from one or two placements to 20 or more placements.
Type of placement included kinship care, foster care, group home, juvenile detention,
psychiatric hospital, and camp. These options were not mutually exclusive but meant to
capture the range of placements that a person may have throughout their childhood.
Reason for placement included physical abuse, sexual abuse, neglect, parental drug
problems, truancy, suicide attempt, personal drug use, parental psychiatric problems,
placement at birth, and other. Finally, general feelings regarding foster care were
obtained. Feelings of being supported and feelings of being respected were measured
through a 5-point scale that included “never,” “almost never,” “sometimes,” “almost
always,” and “always.” For the purpose of the logistic regressions, the questions
pertaining to feelings about placement were coded into three categories: low, medium,
and high levels of support and respect. All foster care variables selected were chosen
based on their importance in previous literature or the frequency of discussion in the
qualitative interviews.
Homelessness variables. Basic information regarding individuals’ homeless
experiences included overall time spent homeless, measured in months and years, and age
at first homelessness, measured in participant age. Timing of homelessness was measured
to gauge whether the individual became homeless either before leaving foster care
(before age 5, between 6 and 11 years old, or between 12 and 18 years old) or after
leaving foster care (as a minor or an adult). Perceived cause of homelessness included the
following responses: aged out of foster care, self-blame, disagreements with
HIV RISKS FOR HOMELESS FORMER FOSTER YOUTH 30
family/friends, kicked out of their house, lost a job/need a job, evicted, “lost my
roommate and couldn’t pay for rent,” drug use, “I stopped trying,” no foster care
resources, no support system, by choice, “I made poor choices,” in need of transitional
services, and family problems from childhood. Time currently spent homeless was
measured using a 6-point scale, ranging from less than a year to 14–18 years. Time spent
homeless over the lifetime was measured using a 6-point scale, ranging from less than a
year to 11–13 years.
HIV-risk behaviors. HIV-risk variables were selected from the YRBS, Youth
Risk Behavior Survey (Brener, Collins, Kahn, Warren, & Williams, 1995), which has
been tested for validity and reliability. Measures included in final models were a series of
dichotomized variables such as ever had sex, condom use at last sexual encounter, drug
use with sex at last sexual encounter, exchange sex during the lifetime, exchange sex
during the last 3 months, condom use with exchange sex, injection drug use during the
lifetime, injection drug use during the last 3 months, and ever had an STI test (other than
HIV). HIV testing behavior was measured with a 3-point scale, with the options
including within the last 3 months, 3–6 months ago, 6 or more months ago.
Analyses
One of the main objectives of this analysis was to explore some of the unique
characteristics of homeless former foster youth and their HIV-risk behaviors. These
analyses were conducted using the Hosmer and Lemeshow (1989) method, and a series of
bivariate regressions were run to determine significant associations. Those significant
associations were then entered into the multivariate models. Thus, most of the analyses
included descriptive statistics of the variety of variables used to categorize this
HIV RISKS FOR HOMELESS FORMER FOSTER YOUTH 31
population. Beyond that, a series of logistic regressions were conducted for HIV-risk
behaviors that may be impacted by foster care experiences and other models for HIV-risk
behaviors that may be impacted by timing of homelessness, as it pertains to foster care
transition. These models were built through the selection of foster care and HIV-risk
variables selected through a series of correlations conducted between related variables
from the literature. For the foster care experience models, individual models were tested
for time spent in foster care, number of foster care placements, and foster care exit age,
each with a series of HIV-risk behaviors. These models controlled for age, race, gender,
sexual orientation, feelings of support in foster care, and feelings of respect in foster care.
For the homelessness timing models, individual models were created for “first
homelessness experience before foster care” and any HIV-risk behaviors that were
significantly correlated. All foster care variables were chosen based on previous
literature’s establishment of risk and protective factors associated with specific
experiences, such as time spent in foster care, number of foster care placements, and age
at exit from foster care. All analyses were conducted using SAS 9.3 (SAS Institute Inc.
2013).
Results
Demographics
Basic demographic statistics were run for sociodemographic, foster care,
homelessness, and HIV-risk behavior variables. As demonstrated in Table 2.1, the
average age of the sample was 21.11 years (SD = 1.95), with most of the youth reporting
their race as Black/African American (47.37%), followed by mixed race (21.05%). White
and Latino youth represented 12.87% of the sample independently. Most of the youth
HIV RISKS FOR HOMELESS FORMER FOSTER YOUTH 32
reported being male (67.63%) and heterosexual (70.41%), with 15.38% reporting their
sexual orientation as bisexual and 8.28% as homosexual.
Table 2.1
Basic Sample Demographics (n = 173)

All Youth
(n = 173)
n (%) Mean SD

Age 21.99 1.95
Race

American Indian/Alaska Native 8 (4.68)

Asian 1 (0.58)

Black or African American 81 (47.37)

Native Hawaiian or other API 1 (0.58)

White 22 (12.87)

Latino/Hispanic 22 (12.87)

Mixed Race 36 (21.05)

Gender

Male 117 (67.63)

Female 48 (27.75)

Transgender- male to female 7 (4.05)

Transgender- female to male 1 (0.58)

Sexual Orientation

Homosexual 14 (8.28)

Queer 3 (1.78)

Bisexual 26 (15.38)

Heterosexual 119 (70.41)

Questioning/Unsure 7 (4.14)

Concerning foster care demographics, Table 2.2 depicts that most of the youth
reported being placed in foster care between 14 and 17 years old (21.47%), 2 and 3 years
old (20.25%), or 11 and 13 years old (17.79%), whereas reports of time spent in the foster
care system covered a broad time span, with 22.98% reporting being in placement for 15
or more years and 20.50% reporting being placed for less than a year. More than half of
HIV RISKS FOR HOMELESS FORMER FOSTER YOUTH 33
the participants (56.43%) reported transitioning out of care before the age of 18, with the
next highest group being 12–17 years old (26.43%). Regarding number of placements,
33.54% of the sample reported one or two placements, 22.36% reported three to four
placements, 16.15% reported 10 or more placements, and 15.53% reported 20 or more
placements. Most of the youth reported spending time in foster homes (65.41%), with
equal percentages of youth reporting placements in kinship care and group homes
(13.21%).
Table 2.2
Basic Foster Care Demographics (n = 173)

All Youth
(n = 173)
n (%)

Age at Placement
At birth
23 (14.11)
Younger than 1
9 (5.52)
2–3 years old
33 (20.25)
4–6 years old
15 (9.20)
7–10 years old
19 (11.66)
11–13 years old
29 (17.79)
14–17 years old
35 (21.47)
Time Spent in Placement

Less than 1 year
33 (20.50)
2–4 years
32 (19.88)
5–7 years
35 (21.74)
8–10 years
13 (8.07)
11–14 years
11 (6.83)
15 or more years
37 (22.98)
Age at Exit from Placement

Under 18 years old
79 (56.43)
12–17 years old
37 (26.43)
6–11 years old
13 (9.29)
5 years old or younger
11 (7.86)
Housing after FC Transition

Family
26 (16.25)
HIV RISKS FOR HOMELESS FORMER FOSTER YOUTH 34
Family of origin
28 (17.50)
Family/adoptive
13 (8.13)
Transitional living facility
19 (11.88)
Couch surfing
10 (6.25)
Homeless
28 (17.50)
Independent living
5 (3.13)
Shelter
6 (3.75)
Jail
10 (6.25)
Rehab
2 (1.25)
Foster family
13 (8.13)
Note. FC = foster care.
Table 2.3 demonstrates that youth reported neglect (38.15%), physical abuse
(30.06%), and parental drug problems (31.79%) as the reasons for placement in foster
care. Housing situation immediately after transition from foster care varied, with 16.25%
reporting living with family members, 17.50% reporting living with their family of
origin, and 17.50% reporting immediate homelessness. When asked about their feelings
regarding foster care, most of the youth reported feeling always (29.19%) or almost
always (25.47%) supported and always (26.25%) or almost always (26.88%) respected.
Table 2.3
Foster Care Demographics (n = 173)

All Youth
(n = 173)
n (%)

Number of FC Placements

1 to 2
54 (33.54)
3 to 4
36 (22.36)
5 to 9
20 (12.42)
10+
26 (16.15)
20+
25 (15.53)
Type of Placement

Kinship
21 (13.21)
Foster home
104 (65.41)
Group home
21 (13.21)
HIV RISKS FOR HOMELESS FORMER FOSTER YOUTH 35
Juvenile detention
5 (3.14)
Emergency shelter
6 (3.77)
Psychiatric hospital
1 (0.63)
Camp
1 (0.63)
Placement Reason

Physical abuse
52 (30.06)
Sexual abuse
25 (14.45)
Neglect
66 (38.15)
Parental drug problems
55 (31.79)
Truancy
18 (10.40)
Suicide attempt
5 (2.89)
Personal drug use
16 (9.25)
Parental psychiatric problems
29 (16.76)
Placed at birth
20 (11.56)
Other
23 (13.29)
Feelings about FC
Support
Never 23 (14.29)
Almost never 23 (14.29)
Sometimes 27 (16.77)
Almost always 41 (25.47)
Always 47 (29.19)
Respect
Never 25 (15.63)
Almost never 28 (17.50)
Sometimes 22 (13.75)
Almost always 43 (26.88)
Always 42 (26.25)

Regarding homelessness demographics, Table 2.4 demonstrates that on average,
youth had been homeless for 2.27 years (SD = 2.74), with an age at first homeless
experience of 16.52 years. A majority (73.33%) of the youth considered themselves
homeless. Concerning first homeless experience, 37.75% reported becoming homeless
after leaving foster care and as an adult, whereas 30.46% reported becoming homeless
before they left foster care between ages 12 and 18 years. The youth reported their causes
of homelessness largely as a result of aging out of the foster care system (29.14%),
HIV RISKS FOR HOMELESS FORMER FOSTER YOUTH 36
followed by self-blame (19.21%), disagreements with family/friends (13.25%), and being
kicked out (13.91%). Most of the youth reported they had currently been homeless for
less than a year (38.67%) and that their time spent homeless over the course of their
lifetime was 3–4 years (26.80%), followed by 5–7 years (22.88%).
Table 2.4
Homelessness Characteristics among Former Foster Youth (n = 173)

All Youth
(n = 173)
n (%) Mean SD

Time homeless 2.27 2.74
Age at first homelessness
16.52 4

Do you consider yourself homeless 121 (73.33)

First homeless experience

Before leaving FC - before 5 years
old
11 (7.28)

Before leaving FC - 6–11 years old 15 (9.93)

Before leaving FC - 12–18 years old 46 (30.46)

After leaving FC - as a minor 22 (14.57)

After leaving FC - as an adult 57 (37.75)

Cause of your homelessness

Aged out of foster care 44 (29.14)

I blame myself 29 (19.21)

Disagreements with family/friends 20 (13.25)

Kicked out 21 (13.91)

Lost a job/need a job 5 (3.31)

Evicted 3 (1.99)

Lost my roommate and can’t pay rent 4 (2.65)

Drugs 1 (0.66)

I stopped trying 2 (1.32)

No FC resources 4 (2.65)

No support system
4 (2.65)
By choice
1 (0.66)
I made poor choices
2 (1.32)
Needed transitional services
4 (2.65)
Family problems from childhood
3 (1.99)
Time homeless - current

HIV RISKS FOR HOMELESS FORMER FOSTER YOUTH 37
Less than 1 year
58 (38.67)
1–2 years
31 (20.67)
3–4 years
32 (21.33)
5–7 years
23 (15.33)
8–10 years
1 (0.67)
11–13 years
3 (2.00)
14–18 years
2 (1.33)
Time homeless - lifetime

Less than 1 year
30 (19.21)
1–2 years
28 (18.30)
3–4 years
41 (26.80)
5–7 years
35 (22.88)
8–10 years
6 (3.92)
11–13 years
4 (2.61)

Finally, regarding HIV-risk behavior, Table 2.5 demonstrates that 90.00% of the
youth reported they had experienced sex, with just less than half (47.71%) having used a
condom at their last sexual encounter. Of the youth who reported ever having sex,
41.18% reported using drugs with sex at their last sexual encounter. For exchange sex,
26.14% reported engaging in exchange sex. Of those participants, 50.00% reported
having engaged in exchange sex recently, and 37.21% reported using a condom during
exchange sex. Of the full sample, 90.75% reported having an HIV test, with 67.52%
tested in the last 3 months and 24.84% tested 3–6 months ago.
Table 2.5

Sex Risk Variables among Homeless Former Foster
Youth (n = 173)

All Youth
(n = 173)
n (%)

Ever had sex 153 (90.00)
Condom use w/ last sex 73 (47.71)
Drug use w/ last sex 63 (41.18)

HIV RISKS FOR HOMELESS FORMER FOSTER YOUTH 38
Exchange sex - lifetime 40 (26.14)
Recent exchange sex 22 (50.00)
Condom use w/ exchange sex 16 (37.21)

Injection drug use - lifetime 25 (14.88)
Injection drug use - recent 14 (40.00)

Ever had HIV test 157 (90.75)
Last HIV test
Last 3 months 106 (67.52)
3–6 months ago 39 (24.84)
6+ months ago 12 (7.64)

Ever had STI test (other than
HIV)
49 (28.32)

Logistic Regressions
For the final multivariable logistic regressions, one-tailed tests were conducted
using the existing literature on risks associated with particular foster care placements.
Table 2.6 indicates that youth were less likely to use condoms as the number of years in
foster care increased (OR = .44, CI = .18, 1.08) and the number of foster care placements
increased (OR = .51, CI = .24, 1.09). Foster youth were less likely to engage in injection
drug use as their age of exit from foster care increased (OR = .25, CI = .06, 1.04), and
youth were significantly more likely to engage in drug use with sex (OR = 2.38, CI =
1.18, 4.80) and exchange sex (OR = 10.25, CI = 2.02, 51.95) if their first homeless
experience was before leaving foster care.

HIV RISKS FOR HOMELESS FORMER FOSTER YOUTH 39
Table 2.6
Logistic Regression Models Examining Foster Care Experiences
Impacting HIV-risk Behaviors (n = 173)

Condom Use Condom Use Injection Drug Use Drug Use with Sex Exchange Sex
N = 173 N = 173 N = 173 N = 173 N = 173
Models OR (95%CI) OR (95%CI) OR (95%CI) OR (95%CI) OR (95%CI)

Foster Care
Experience Models

Age 1.09 (.41, 2.87) .95 (.24, 1.10) .82 (.31, 2.18)
Race .84 (.55, 1.27) .85 (.60, 1.22) .63 (.38, 1.04)*
Gender .54 (.21, 1.38) .48 (.21, 1.08)* .44 (.14, 1.36)
Sexual orientation 1.59 (.61, 4.18) 1.58 (.69, 3.66) 4.53 (1.62, 12.72)***
Placement type 1.12 (.66, 1.90) 1.29 (.83, .99) 1.16 (.73, 1.86)
Feeling supported in
foster care
1.25 (.65, 2.37) 1.14 (.66, 1.96) 1.01 (.48, 2.12)
Feeling respected in
foster care
1.01 (.55, 1.85) .99 (.59, 1.68) .95 (.47, 1.92)
Model 1

Time spent in foster
care
.44 (.18, 1.08)*
Model 2
Number of foster care
placements
.51 (.24, 1.09)*
Model 3
Foster care exit age .25 (.06, 1.04)*

Homelessness with
Foster Care Predictor
Models

Age 1.03 (.51, 2.10) 4.73 (.81, 27.53)*
Race .68 (.48, .97)** 1.10 (.55, 2.19)
Gender .69 (.31, 1.53) .28 (.06, 1.34)
Sexual Orientation 2.21 (.97, 5.02)* .61 (.13, 2.94)
Model 4 & 5
First Homelessness -
before leaving foster
care
2.38 (1.18, 4.80)** 10.25 (2.02, 51.95)***

Discussion
After examining the results of an exploratory analysis of homeless former foster
youth, a number of interesting findings emerged. This sample of youth was largely
composed of African-American and mixed-race youth. These youths were largely placed
HIV RISKS FOR HOMELESS FORMER FOSTER YOUTH 40
in foster care during early childhood or adolescence, with high frequencies of youth
experiencing either less than a year of foster care placement or more than 15 years of
foster care placement. Nearly one fifth of the youth reported homelessness immediately
after transitioning out of foster care, and more than half of youth reported feeling always
or almost always respected and supported while in care.
Regarding homelessness, on average, youth became homeless before the age of
18. One third reported their first homeless experience before leaving foster care during
adolescence, and more than one third reported first experiencing homelessness after
leaving foster care. Where risk behavior was concerned, less than half of the youth
reported using a condom during their last sexual encounter, with higher than average
percentages reporting engaging in drug use with sex and exchange sex. Most of the youth
reported having an HIV test, with more than two thirds being tested in the last 3 months.
For the results of the logistic regressions, youth were significantly less likely to use
condoms with increased time spent in foster care. Youth were also less likely to engage in
injection drug use as their exit age from foster care increased. Finally, youth were
significantly more likely to engage in drug use with sex and exchange sex if their first
homeless experience occurred before leaving foster care.
This examination led to a number of new conclusions within the field of research
on homeless former foster youth. Among the sample of youth from Los Angeles, most
represented a non-White or mixed-race background and had first experienced
homelessness before adulthood. A high number of youth reported extremely long periods
of placement, and many youths reported homelessness upon transition out of foster care,
whereas others reported their first experience of homelessness while still in foster care.
HIV RISKS FOR HOMELESS FORMER FOSTER YOUTH 41
As previous research has established, outcomes for foster youth are impacted by time
spent in placement, experiences of transition out of foster care, and outcomes for foster
youth of color (Collins et al., 2008; Courtney & Dworsky, 2006; Courtney et al., 2004;
Newton et al., 2000). Thus, on a purely descriptive level, these results indicate that there
are areas within the child welfare system that can and should be focused on to impact
outcomes for this population.
Results also indicate that a number of foster care experiences directly impact
HIV-risk behaviors. Youth reported low rates of recent condom use, which is comparable
with research on other samples of homeless youth (Barman-Adhikari, Hsu, Begun,
Portillo, & Rice, 2017; Haley, Roy, Leclerc, Boudreau, & Boivin, 2004; Solorio et al.,
2008; Tucker et al., 2013), whereas rates of engagement in exchange sex were higher
than those of other homeless youth from similar samples (Young & Rice, 2011).
Concerning foster care experiences in particular, these results indicate that long periods
of time spent in care negatively impact condom use, which, in turn, may equate to
increased risk of HIV-risk behaviors. Conversely, age at exit from foster care seems to
serve as a protective factor, as older age of exit from foster care was related to reduced
injection drug use. Finally, timing of homeless experiences provides some insight into
risk factors for this population, in that, both drug use with sex and engagement in
exchange sex were negatively impacted when homelessness was experienced before the
youth exited foster care.
Limitations
Several limitations exist for the analyses conducted. First, the data represent a
cross-sectional analysis of homeless youth from Los Angeles. This cross-sectional nature
HIV RISKS FOR HOMELESS FORMER FOSTER YOUTH 42
indicates that causality cannot be implied. Further, homeless youth in Los Angeles do not
necessarily represent the characteristics of youth across the country, and foster care
experiences, whereas having many factors in common, vary across counties and states.
Thus, foster care experiences may have a considerable amount of variation depending on
the location of the placement. Finally, whereas these analyses include a range of
experiences common to many former foster youth, with the sample of homeless former
foster youth used, understanding which experiences may also be common among
homeless youth without a history of foster care is difficult. To truly understand which
experiences drive HIV-risk behaviors, a sample of homeless youth with and without a
history of foster care would need to be compared. Finally, whereas all data were gathered
through self-report measures and subject to a number of biases, this analysis is more
concerned with youths’ perceptions of experiences, rather than information that may be
more consistent with their placement records.
Implications
Several implications emerged from these results. Services and interventions
geared toward foster youth should take into consideration that most of the youth tend to
be persons of color, are minors or young adults, and have a range of foster care
experiences. Those services targeting HIV-risk behaviors should consider the impact that
foster care placements have on these behaviors, such as the risk factors associated with
long placement periods or experiencing homelessness before exiting foster care, and the
protective factors associated with exiting placement at an older age. Acknowledging
these experiences and addressing their risk and protective factors may contribute to
tailoring interventions that better impact HIV-risk behaviors. On a policy level, these
HIV RISKS FOR HOMELESS FORMER FOSTER YOUTH 43
results indicate that a number of experiences during foster care should be addressed to
reduce risk behaviors at a later time. For example, given the impact of homelessness
before exit from foster care placement, as well as the impact of the number of foster care
placements on HIV-risk behaviors, child welfare services should consider focusing
efforts on reducing instances of homelessness during foster care and the number of
placements for those youth with a high number of risk factors. Currently, statistics on the
number of foster youth experiencing homelessness while under state care have not been
collected and distributed. As such, addressing the issue of homelessness during foster
care is difficult because the basic information about these experiences has not been
gathered. Whereas the lack of information made available on the number of foster youth
experiencing homelessness could lead one to believe that no youth in the child welfare
system are experiencing homelessness, participants’ responses seem to indicate
otherwise.
The youth sampled for this study represent those with some of the largest barriers
to success and who have faced a number of risk factors during their lives. Whereas many
foster youth will go on to experience great success in their lives, the struggles of others,
especially those with the most difficult cases in the child welfare system, should not be
overlooked. Working toward reducing overall time spent in foster care and experiences of
homelessness during foster care may benefit the sexual health of these youth as they
transition into adulthood. Furthermore, better understanding of the protective factors
associated with exiting foster care at an older age is needed, potentially including
developmental milestones, independent living skills offered to older youth, and other
factors that positively contribute to positive transition outcomes. Information on these
HIV RISKS FOR HOMELESS FORMER FOSTER YOUTH 44
experiences could be applied toward interventions, such as STRIVE (Milburn et al.,
2012), an intervention that works with runaway and homeless youth to reduce the number
of runaway and homeless episodes, as well as in reducing HIV-risk behaviors.
Information about a youth’s foster care history could easily be incorporated into the
current curriculum to incorporate foster care-specific factors, such as placement with a
relative or foster parent. The addition of a module on foster-care specific issues could
prove effective at encouraging positive dialogue between youth and their foster parents,
potentially reducing instances of homelessness during foster care.
Whereas these results are only a start toward understanding the impact of foster
care experiences on the lives of homeless youth, they represent points of intervention
within the child welfare system and among homeless service providers that may aid in
reducing HIV-risk behaviors among homeless former foster youth. Future examinations
on the validity and reliability of foster care experience variables to determine the extent
with which these variables can accurately capture the foster care experience and predict
behavioral health outcomes are needed.
HIV RISKS FOR HOMELESS FORMER FOSTER YOUTH 45
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HIV RISKS FOR HOMELESS FORMER FOSTER YOUTH 52
Chapter 3: Exploring the Relationship between Foster Care Experiences and Social
Network Engagement Among a Sample of Homeless Former Foster Youth

Introduction
Recent research has begun to demonstrate high rates of poor behavioral health
outcomes among homeless former foster youth (Courtney et al., 2011; Hudson & Nandy,
2012; Nyamathi et al., 2012; Yoshioka-Maxwell & Rice, 2016). However, given the
number risk factors common to many homeless former foster youth, this population has
received relatively little attention in the scientific literature, as compared with homeless
youth and youth with foster care experiences. Furthermore, because social networks have
been shown to impact behavioral health outcomes for both homeless youth and former
foster youth (Bao, Whitbeck, & Hoyt, 2000; Ennett, Baily, & Federman, 1990; Halkitis et
al., 2013; Joseph, O’Connor, Briskman, Maughan, & Scott, 2014; Kidd, 2003; Rice,
Milburn, & Rotheram-Borus, 2007; Rice & Rhoades, 2013; Rice, Stein, & Milburn,
2008; Wenzel, Hsu, Zhou, & Tucker, 2012) and little research has been conducted on the
networks of homeless former foster youth, there is a need to better understand the
network characteristics of homeless young adults with a history of foster care to impact
outcomes for this at-risk population.

Background
Risk factors common to homeless youth and former foster youth are well-
established, but examination of the social networks of these youth is still in its infancy.
Generally, social networks have been shown to affect behavioral health outcomes among
homeless youth and former foster youth (Bao et al., 2000; Ennett et al., 1990; Halkitis et
al., 2013; Joseph et al., 2014; Kidd, 2003; Rice et al., 2007; Rice & Rhoades, 2013; Rice
HIV RISKS FOR HOMELESS FORMER FOSTER YOUTH 53
et al., 2008; Wenzel et al., 2012). Although networks have been implicated in the risk-
taking behaviors of foster youth and homeless youth, with the exception of one study
(Yoshioka-Maxwell, Rice, Rhoades, & Winetrobe, 2015),

little research to date has
examined the role of networks for youth with histories of both homelessness and foster
care. Outside the context of homelessness, research has established that for former foster
youth, connectedness affects well-being, in that, engagement in quality relationships is
associated with fewer disruptive behaviors (Joseph et al., 2014).

Although family contact
and family support have been associated with resilience (Jones, 2012, 2013), this
population experiences fewer ties and faces more network disruption compared with
other young adult populations (Perry, 2006). Furthermore, long-term foster care and the
process of discharge have been shown to hinder the development of an ideal support
structure by increasing network disruption, which results in sparse social networks and
negatively affects emotional, relational, and behavioral health (Blakeslee, 2011; Collins,
2004; Courtney et al., 2005; Geenen & Powers, 2007; Perry, 2006; Reilly, 2003).
Although networks are important for youth during transitional periods, young adults from
foster care tend to struggle to maintain relationships with birth families and attachments
to supportive adults and have a difficult time adjusting to the often-abrupt changes that
come with transitions and discharge from foster care (Barth, 1990; Berzin, 2008;
Blakeslee, 2011; Reilly, 2003).
Furthermore, negative network ties have been shown have a causal impact on
increased HIV-risk behaviors among homeless youth in general, regardless of foster care
history (Bao et al., 2000; Ennett et al., 1990; Halkitis et al., 2013; Kidd, 2003; Milburn et
al., 2009; Rice et al., 2007; Rice, Milburn, Rotheram-Borus, Mallett, & Rosenthal, 2005;
HIV RISKS FOR HOMELESS FORMER FOSTER YOUTH 54
Rice & Rhoades, 2013; Rice et al., 2008; Wenzel et al., 2012). Studies examining the
social networks of homeless young adults indicate that support networks play a critical
role in mitigating the negative effects of homelessness on mental and behavioral health.
Negative network ties have been shown to increase anti-social behavior, depression, risk-
taking behaviors, engagement in drug risk behaviors, and perceptions of negative social
support (Bao et al., 2000; Ennett et al., 1990; Halkitis et al., 2013; Kidd, 2003; Rice et al.,
2007; Rice & Rhoades, 2013; Rice et al., 2008; Wenzel et al., 2012). Finally, one analysis
examining the sociometric network structure of homeless former foster youth indicated
that former foster youth occupy a unique space within this network, remaining largely
along the periphery, and that this space impacts their engagement in recent and lifetime
substance use, which is important information for determining appropriate interventions
(Yoshioka-Maxwell & Rice, 2016). These results imply that aspects unique to the foster
care subpopulation influence youth affiliation and network structure, indicating a need for
further examination of the factors predicting the formation of these affiliations and this
structure. However, given the crude foster care measures used in these data, additional
analyses specifically focused on homeless former foster youth may be more helpful in
determining network features impacting outcomes for this population. Based on the
current knowledge on behavioral health outcomes and the importance of network
engagement for former foster youth, this analysis seeks to better understand network
characteristics of homeless former foster youth and how these characteristics are
associated with behavioral health outcomes.

Theory
RAAM views negative contact with socializing agents as amplifying risk while
HIV RISKS FOR HOMELESS FORMER FOSTER YOUTH 55
positive contact with socializing agents abates it (Milburn et al., 2009). This model is an
extension of the RAM, which focuses solely on the negative outcomes that occur from
negative experiences. Whitbeck and Hoyt (1999) used the RAAM to show how parental
problems and family abuse increase a youth’s likelihood of engaging with deviant social
networks. Both time spent with deviant networks and time spent alone impact levels of
engagement in drug risk behaviors through the continued reinforcement of engagement in
risk behaviors from the negative contact with socializing agents. RAAM is a useful
model for the population of homeless youth because it attempts to explain the impact of
negative life events and negative developmental trajectories while considering the effect
that positive contact has on abating risk. In this perspective, negative contact with
socializing agents, such as deviant social networks, amplifies risk of engaging in risk-
taking behaviors.
Within the context of the foster care experience, this model can be slightly
expanded to explain why former foster youth may uniquely engage in certain levels of
risk-taking behaviors. Given the experiences common to many former foster youth,
including abuse, instability, and institutionalization, this model may help predict a former
foster youth’s likelihood of engagement in deviant social networks. Therefore, because
homeless former foster youth share similar experiences, they may be more likely to have
unique network characteristics, which, in turn, impact their engagement in risky drug use
behaviors.

Network Engagement
• Engagement with other foster youth
• Engagement with youth engaging in
HIV risk behaviors
Foster Care Experiences
• Number of Foster Care placements
• Age at first placement
• Types of placement
• Experience transiBoning out of care
HIV RISKS FOR HOMELESS FORMER FOSTER YOUTH 56
Additional data sampling and analyses should be conducted to determine which
foster care experiences impact social network engagement, with the expectation that
experiences unique to the foster care system significantly impact individuals’ social
network ties, including the type of ties and behaviors of those ties. Understanding the
pathways between foster care experiences and network engagement may provide
information required to understand the types of social network engagement by former
foster youth that increase their likelihood of engaging in risky networks and behaviors
that can potentially impact other behavioral health outcomes.
Methods
Sampling

Data were collected from 184 homeless former foster youth at a drop-in center in
Hollywood, California using the risk-behavior questionnaire modeled after the YouthNet
Study (Rice, 2012). Foster care experiences was be measured through the Foster Care
Experiences Assessment, which includes quantitative measures of foster care experiences
created from qualitative interviews conducted from a sample of 20 homeless former
foster youth in 2014. Data was collected during 2- to 4-week intervals over three periods
(two summers and one winter) from 2015 to 2016.
Any client receiving services at the respective agency during data-collection
periods was eligible to participate. Recruitment was conducted for approximately 2–4
weeks; during that time, recruiters were present at the agency to approach youth for the
duration of service provision hours. Youth new to the agency first completed the
agency’s intake process before beginning the study to ensure they met the eligibility
requirements for the agency (and, thus, the study). A consistent set of two research staff
HIV RISKS FOR HOMELESS FORMER FOSTER YOUTH 57
members were responsible for all recruitment to prevent youth completing the survey
multiple times within each data-collection period.
Signed voluntary informed consent was obtained from each youth, with the
caveats that child abuse and suicidal and homicidal intentions would be reported.
Informed consent was obtained from youth 18 years and older, and informed assent was
obtained from youth 14 to 17 years old. The Institutional Review Board (IRB) at the
University of Southern California waived parental consent, as homeless youth younger
than 18 years are unaccompanied minors who may not have a parent or adult guardian
who could give consent. Interviewers received approximately 40 hours of training,
including lectures, role-playing, mock surveys, ethics training, and training in emergency
procedures. The study consisted of two parts: a computerized self-administered survey
and a social network interview.
Part 1: Online, self-administered questionnaire. Participants privately entered
answers into the computer as they read questions on the computer screen or listened to
the questions being read to them. Preprogrammed skip patterns advanced participants to
the next appropriate question after a response was entered. These methods reduced
nonresponse rates to sensitive questions about potentially socially undesirable activities,
such as sexual behaviors, illicit substance use behaviors, and criminal activity (Ghanem,
Hutton, Zenilman, Zimba, & Erbelding, 2005; Jones, 2003; Macalino, Celentano, Latkin,
Strathdee, & Vlahov, 2002; Metzger et al., 2000; Turner et al., 1998).
Part 2: Network assessment. After the youth indicated relevant members of their
social networks, questions about types of relationships and attributes of each nomination
(i.e., alter) were asked. The same name generator developed for YouthNet

(Rice, 2012)
HIV RISKS FOR HOMELESS FORMER FOSTER YOUTH 58
was used. Name generators involved questions designed to elicit the naming of relevant
alters along some specified criterion (Laumann, Marsden, & Prensky, 1991).
Respondents were given a prompt defining a criterion, such as “Who do you turn to for
advice or support?” In the YouthNet study, extensive qualitative work was conducted
before study implementation to create questions to elicit the nomination of significant
network ties among homeless youth. The resultant name generator includes 17 prompts
related to the following: people you talk to, hang out/kick it/chill with; people you have
sex with or hook up with; people you party with or drink or use drugs with; old friends
from home; people you talk to (on the phone, by email); people from where you are
staying (squatting with); people you see at this agency; and other people you know on the
streets.
Measures
Sociodemographic variables. Age, race, gender, and sexual orientation were
obtained through self-report measures. Age was calculated by coding the youths’ reported
birth dates into an age based on the date of their interview. Racial categories included
American Indian/Alaska Native, Asian, Black/African American, Native Hawaiian or
other API, White, Latino/Hispanic, and mixed race. Due to the low numbers of American
Indian/Alaska Native, Asian, and Native Hawaiian or other API, those categories were
coded into an “other” category. For the purpose of the logistic regressions performed in
this analysis, race was further dichotomized into “Black/African American” and “all
other races.” Questions pertaining to gender included the following options: male,
female, transgender (male to female), and transgender (female to male). Due to the low
number of transgender participants, all responses related to gender were coded into male
HIV RISKS FOR HOMELESS FORMER FOSTER YOUTH 59
or female, depending on the gender with which participants identified. Variables
pertaining to sexual orientation included homosexual, queer, bisexual, heterosexual, and
questioning/unsure. Due to the response rates across the orientations, sexual orientation
was coded into “heterosexual” and “LGBTQ.”
Foster care variables. A number of foster care experience variables were chosen
to describe basic experiences in foster care placements. Age at first foster care placement
was measured on a 7-point scale, ranging from placement at birth to placement at age 17.
Time spent in placement was measured through a 6-point scale, ranging from less than a
year to 15 or more years. Age at exit from foster care was measured on a 4-point scale
and included the categories of 5 years or younger, 6–11 years old, 12–17 years old, and
under 18 years old generally. Housing situation after transitioning out of foster care
included a number of options for housing such as family, family of origin, adoptive
family, transitional living facility, couch surfing, homelessness, independent living,
shelter, jail, rehab, and foster family. Number of foster care placements was measured
through a 5-point scale, ranging from one or two placements to 20 or more placements.
Type of placement included kinship care, foster care, group home, juvenile detention,
psychiatric hospital, and camp. These options were not mutually exclusive but meant to
capture the range of placements that a person may have throughout their childhood.
Reason for placement included physical abuse, sexual abuse, neglect, parental drug
problems, truancy, suicide attempt, personal drug use, parental psychiatric problems,
placement at birth, and other. Finally, general feelings regarding foster care were
obtained. Feelings of being supported and feelings of being respected were measured
through a 5-point scale that included “never,” “almost never,” “sometimes,” “almost
HIV RISKS FOR HOMELESS FORMER FOSTER YOUTH 60
always,” and “always.” For the purpose of the logistic regressions, the questions
pertaining to feelings about placement were coded into three categories: low, medium,
and high levels of support and respect. All foster care variables selected were chosen
based on their importance in previous literature or the frequency of discussion in the
qualitative interviews.
Egocentric network variables. Egocentric network variables were taken from
the network survey answered by the youth regarding their social networks. Measures of
alter centrality, network density, and average total ties were created from the egocentric
network data to provide context to the larger social network. Two types of network-based
variables were used for this analysis. First, variables regarding the types of ties present in
individuals’ networks were used, including ties from home, foster care, a group home,
kinship care, a partner, a friend, or staff and ties that youth talk to about sex, or felt they
could confide in. Second, variables regarding the behaviors of individuals’ ties were
used, including ties who engage in condomless sex, object to condom use, use
methamphetamines, use heroine, use cocaine, or use injection drugs. All of these network
ties were recorded and used as dichotomized variables, with the exception of centrality,
density, and average total ties, which were used as continuous data.
Analyses
One of the main objectives of this analysis was to explore some of the unique
characteristics of homeless former foster youth and their network engagement. Because
the descriptive statistics of homeless former foster youth were previously established, for
this analysis, demographics for this population were only provided for foster care
demographics. Beyond that, a series of logistic regressions were conducted for network
HIV RISKS FOR HOMELESS FORMER FOSTER YOUTH 61
engagement behaviors that may be impacted by foster care experiences. These models
were built through the use of variables previously established as impactful for this
population. For the foster care experience models, individual models were tested for time
spent in foster care, number of foster care placements, foster care exit age, and “first
homelessness experience before foster care” with types and behaviors of ties the youth
indicated. These models controlled for age, race, gender, sexual orientation, feelings of
support in foster care, and feelings of respect in foster care. All foster care variables were
chosen based on previous literature’s establishment of risk and protective factors
associated with specific experiences, such as time spent in foster care, number of foster
care placements, and age at exit from foster care. All analyses were conducted using SAS
9.3.
Results
Chi-Square
After descriptive statistics were completed for homeless and foster care
demographics, chi-square tests were run to determine if differences existed by type of tie
and alter behavior when youth did or did not have alters who were also in foster care.
Table 3.1 demonstrates that youth with home-based peers had more alters without a
history of foster care (χ
2
= 6.98, df = 1, p = .01). Youth with alters who objected to
condom use had more alters without a history of foster care (χ
2
= 8.35, df = 1, p = .01).
Youth with alters who used heroin (χ
2
= 13.08, df = 1, p < .001) or used injection drugs
(χ
2
= 7.00, df = 1, p = .01) had more alters with a history of foster care.

HIV RISKS FOR HOMELESS FORMER FOSTER YOUTH 62
Table 3.1

Egocentric Network: Alter Foster Care Status by Social and Behavior Category (n = 163)

Foster Care Alter Non-Foster Care Alter Chi-Square

n (%) n (%) χ2

Social Network Engagement

Type of Tie

Home-based 18 (11.46) 43 (27.39) 6.98**
Partner 6 (3.92) 16 (10.46) 1.16
Friend 13 (8.33) 72 (46.15) 1.34
Staff 4 (2.61) 14 (9.15) 0.09
Talk to about sex 14 (9.15) 46 (30.07) 0.58
Talk to about HIV testing 14 (9.21) 27 (24.34) 2.88
Someone they can confide in 13 (8.50) 48 (31.37) 0.19
Someone they can get advice from 13 (8.50) 47 (30.72) 0.47

Alter Behavior

Condomless sex 5 (3.31) 18 (11.92) 0.06
Objects to condom use 9 (5.88) 12 (7.84) 8.35**
Uses meth 6 (4.11) 12 (8.22) 2.06
Uses heroin 5 (3.40) 2 (1.36) 13.08***
Uses cocaine 4 (2.67) 7 (4.67) 2.21
Uses injection drugs 4 (2.70) 3 (2.03) 7.00**
*p < .05, **p < .01, ***p < .001.

Logistic Regressions
For the final multivariable logistic regressions, two-tailed tests were conducted
using the existing literature on risks associated with particular foster care placements.
Controls included in the models in Table 3.2 were age, race, gender, sexual orientation,
placement type, feelings of support while in foster care, and feelings of respect while in
foster care. Significant results from the logistic regressions indicated that youth with
more time spent in foster care were significantly more likely to have alters with a history
of foster care (OR = 4.98, CI = 1.49, 16.62), youth with higher numbers of foster care
placements were more likely to have home-based alters (OR = 2.25, CI = 1.03, 4.89), and
HIV RISKS FOR HOMELESS FORMER FOSTER YOUTH 63
youth experiencing homelessness for the first time before exiting foster care were less
likely to have alters they considered friends (OR = .38, CI = .19, .80). Regarding alter
behaviors, youth experiencing homelessness for the first time before exiting foster care
were more likely to have alters engaging in condomless sex (OR = 4.65, CI = 1.40,
15.50), and youth with higher numbers of foster care placements were more likely to
have alters engaging in methamphetamine use (OR = 3.75, CI = 1.16, 12.19).
Table 3.2

Egocentric Logistic Regressions: Foster Care Experiences by Social and Behavior
Categories (n = 163)

Time in Foster
Care
Number of Foster
Care Placements
Foster Care Exit
Age
First Homelessness -
Before Foster Care

n = 153 n = 153 n = 153 n = 153

OR (95%CI) OR (95%CI) OR (95%CI) OR (95%CI)

Social Network
Engagement
Type of Tie

Home-based 2.13 (.92, 4.62) 2.25 (1.03, 4.89)* 1.53 (.28, 8.32) 1.76 (.84, 3.67)
Foster care (any)
4.98 (1.49,
16.62)**
1.03 (.38, 2.83) 1.43 (.15, 13.97) 1.67 (.63, 4.41)
Partner 1.08 (.32, 3.64) 3.32 (.90, 12.28) >999 (<.001, >999) 1.21 (.36, 4.03)
Friend .61 (.30, 1.27) 1.44 (.68, 3.05) .32 (.06, 1.67) .38 (.19, .80)**
Staff 1.51 (.44, 5.22) 2.00 (.58, 6.91) >999 (<.001, >999) 1.09 (.34, 3.51)
Talk to about sex .56 (.26, 1.19) .93 (.43, 2.04) 1.65 (.79, 3.42) .79 (.38, 1.65)

Alter Behavior

Condomless sex .79 (.38, 1,65) 1.53 (.52, 4.50) 1.29 (.14, 11.79) 4.65 (1.40, 15.50)**
Objects to
condom use
1.29 (.18, 9.16) .83 (.10, 6.90) .08 (.00, 1.92) 6.11 (.54, 68.78)
Uses meth 1.10 (.37, 3.31) 3.75 (1.16, 12.19)* 1.13 (.12, 10.86) 2.00 (.67, 5.97)
Uses heroin 1.23 (.16, 9.68) 2.56 (.34, 19.24) .06 (.00, 1.54) 3.55 (.34, 36.91)
Uses cocaine .53 (.13, 2.20) 1.99 (.45, 8.72) .42 (.04, 4.40) 4.18 (.79, 22.00)
Uses injection
drugs
.99 (.15, 6.7) 1.56 (.23, 10.64) >999 (<.001, >999) 4.17 (.41, 42.18)

*p < .05, **p < .01, ***p < .001.
Discussion
HIV RISKS FOR HOMELESS FORMER FOSTER YOUTH 64
After examining the results of an exploratory analysis of homeless former foster
youth, a number of interesting findings emerged. A series of chi-square tests were run to
determine if network engagement significantly differed according to the foster care status
of the youths’ alters. Results indicated that youths whose alters did not have a history of
foster care were more likely to have home-based alters, which makes sense given the
likelihood of their connection to individuals from home. These youths also had more
alters who objected to condom use, indicating certain risky sex behaviors among the
alters without a history of foster care. Youths whose alters did have a history of foster
care had more alters engaging in drug use behaviors, including methamphetamines and
injection drug use. Previous literature has shown that some foster care experiences are
significantly associated with methamphetamine use and having alters who engage in
methamphetamine use (Yoshioka-Maxwell et al., 2015).
Further analyses indicated that foster care experiences such as time spent in foster
care, number of foster care placements, and homelessness experiences before
transitioning out of foster care were significantly associated with the type of alter
reported in the youths’ networks. Namely, whereas time spent in foster care was
associated with having alters from foster care, a higher number of placements was
significantly associated with more home-based peers. These results suggest that time
spent in foster care and number of foster care placements are two different experiences
that impact the type of tie the youth engage with after they transition out of care. One
potential cause for these differences may stem from the ability to establish network
connections. Having a larger number of foster care alters makes sense if a youth has spent
more time in placement, whereas a disruption of social networks may arise if youth are
HIV RISKS FOR HOMELESS FORMER FOSTER YOUTH 65
moved from on placement to another. This disruption may force youth to connect with
home-based peers, given the turnover in social networks that results from multiple
placements. Additionally, youth with experiences of homelessness before transitioning
out of foster care were less likely to have alters they considered friends, perhaps implying
that having a risk factor, such as childhood homelessness, impacts the types of alters a
youth has and the number of positive and supportive ties in their lives.
Concerning alter behaviors, youths with experiences of homelessness before
transitioning out of foster care were more likely to have friends engaging in condomless
sex, suggesting that earlier experiences of homelessness additionally serve as a risk factor
for alter behaviors. Furthermore, youth with higher numbers of foster care placements
were more likely to have alters engaging in risk behaviors, indicating that homeless
former foster youth experiencing some risk factors while in foster care connected with
youth who engaged in HIV-risk behaviors. These results suggest that certain foster care
experiences and risk factors within foster care negatively impact the types of alters with
which youths engage. Time spent in placement was not significantly associated with alter
behaviors, potentially indicating that the effect of network disruption, evident from
homeless experiences and multiple foster care placements, negatively impacts the types
of alters with which youths are connected. Frequent network disruptions may be
associated in some way with engagement with risky alters.
Limitations
Several limitations exist for the analyses conducted. First, the data represent a
cross-sectional analysis of homeless youth from Los Angeles. This cross-sectional nature
indicates that causality cannot be implied. Further, homeless youth in Los Angeles do not
HIV RISKS FOR HOMELESS FORMER FOSTER YOUTH 66
necessarily represent the characteristics of youth across the country, and foster care
experiences, whereas having many factors in common, vary across counties and states.
Thus, foster care experiences may have a considerable amount of variation depending on
the location of the placement. Finally, whereas these analyses include a range of
experiences common to many former foster youth, with the sample of homeless former
foster youth used, understanding which experiences may also be common among
homeless youth without a history of foster care is difficult. To truly understand which
experiences drive network engagement, a sample of homeless youth with and without a
history of foster care would need to be compared. Finally, whereas all data were gathered
through self-report measures and subject to a number of biases, this analysis is more
concerned with youths’ perceptions of experiences, rather than information that may be
more consistent with their placement records.
Implications
The results of these analyses suggest that specific foster care experiences impact
the types of alters homeless former foster youth identify in their social networks and the
types of behaviors in which their networks engage. The importance of these interactions
lies in the significance of network engagement in overall outcomes for youth. Knowledge
gathered from RAAM and previous research (Milburn et al., 2009) suggests that negative
contact with a socializing agent amplifies individual risk, whereas positive contact abates
this risk. As a result, focus on the network engagement of this population is required to
understand the role of network alters in amplifying or abating risk. From the current
study, experiences of foster care impacted the types of potentially positive interactions
the youths had with socializing agents, such as alters from home or alters they consider
HIV RISKS FOR HOMELESS FORMER FOSTER YOUTH 67
friends, while putting youth at risk for negative interactions with socializing agents who
engage in risky sex and drug behaviors. Additionally, because network behaviors impact
an individual’s behaviors, these analyses have far-reaching implications for the
behavioral health of homeless former foster youth. These results can be broadly applied
to a number of health and behavioral health interventions. Thus far, research has focused
on the use of social networks to target health outcomes among homeless youth but has
not considered those experiences unique to youth with a foster care history. For example,
the peer-led HIV-prevention intervention, “Have You Heard?” (Rice, Tulbert,
Cederbaum, Barman-Adhikari, & Milburn, 2012), incorporates peer networks to impact
HIV-risk behaviors. Initial testing has shown positive effects for HIV testing, but this
intervention does not incorporate differences in the social networks of homeless former
foster youth or the fact that youth with a history of foster care have high rates of HIV-risk
behaviors, including substance use. Without fully understanding the impact of foster care
experiences on homeless youth, specifically targeting the risk factors common to this
population is difficult. Focusing efforts on including social network engagement into
behavioral health interventions will more holistically address factors impacting
behavioral health.

HIV RISKS FOR HOMELESS FORMER FOSTER YOUTH 68
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HIV RISKS FOR HOMELESS FORMER FOSTER YOUTH 73
Chapter 4: Investigating the Relationship between Social Network Engagement and
HIV-risk Behaviors Among a Sample of Homeless Former Foster Youth

Introduction
The accumulation of risk factors common to both homeless youth and former
foster youth place homeless former foster youth at extreme risk of engaging in HIV-risk
behaviors, necessitating an increase in research to address the unique needs of this
population. The previous analyses have established significant relationships between
foster care experiences and HIV-risk behaviors, as well as foster care experiences and
social network engagement. However, there is still a need to understand if and how these
variables fit together. As previously mentioned, networks impact behavioral health
outcomes for both homeless youth and foster youth independently. To date, only one
published manuscript has explored the aspects of homeless former foster youths’ social
networks and the manner in which they impact risk behaviors (Yoshioka-Maxwell, Rice,
Rhoades, & Winetrobe, 2015). This previous study was limited in the depth of
measurement used for both foster care experiences and network engagement. As such,
research suggests that a link exists between homeless youth and HIV-risk behaviors (Bao,
Whitbeck, & Hoyt, 2000; Ennett, Baily, & Federman, 1990; Halkitis et al., 2013; Joseph,
O’Connor, Briskman, Maughan, & Scott, 2014; Kidd, 2003; Milburn et al., 2009; Rice,
Milburn, & Rotheram-Borus, 2007; Rice, Milburn, Rotheram-Borus, Mallett, &
Rosenthal, 2005; Rice & Rhoades, 2013; Rice, Stein, & Milburn, 2008; Wenzel, Hsu,
Zhou, & Tucker, 2012); however, no studies have examined this relationship with a
sample of homeless former foster youth.
HIV RISKS FOR HOMELESS FORMER FOSTER YOUTH 74
As previous studies have established that social networks impact behavioral
health outcomes for homeless youth and former foster youth, the position of foster care
experiences within the relationship between social networks and homeless experiences
must also be established. Yoshioka-Maxwell et al. (2015) established a relationship
among foster care experiences, the presence of substance-using network connections, and
substance-use outcomes. In this analysis, a relationship was established between a history
of foster care and increased methamphetamine use among homeless youth. However,
upon further examination, this relationship was found to be no longer significant after
accounting for the mediation of the presence of meth-using network alters. In other
words, among a sample of homeless youth, foster youth were significantly more likely to
have connections in their network that use methamphetamines, and having these network
connections predicated increased methamphetamine use for the foster youth. Whereas the
previous analysis used simplified measures for network connectivity and foster care
experiences, it established that network engagement may mediate the relationship
between foster care experiences and behavioral health risk factors. As such, this analysis
seeks to determine if there is a mediating relationship among foster care experiences,
social network engagement, and HIV-risk behaviors for homeless former foster youth.

Methods
Measures
Network Engagement
• Engagement with other foster youth
• Engagement with youth engaging in
HIV risk behaviors
Foster Care Experiences
• Number of Foster Care placements
• Age at first placement
• Types of placement
• Experience transiBoning out of care
HIV-Risk Behaviors
• Condom use
• Concurrent sex partners
• Exchange sex
• Sex under the influence
HIV RISKS FOR HOMELESS FORMER FOSTER YOUTH 75
The same sample and measures from the previous two analyses were used. No
measures were changed for the third analysis.
Sociodemographic variables. Age, race, gender, and sexual orientation were
obtained through self-report measures. Age was calculated by coding the youths’ reported
birth dates into an age based on the date of their interview. Racial categories included
American Indian/Alaska Native, Asian, Black/African American, Native Hawaiian or
other API, White, Latino/Hispanic, and mixed race. Due to the low numbers of American
Indian/Alaska Native, Asian, and Native Hawaiian or other API, those categories were
coded into an “other” category. For the purpose of the logistic regressions performed in
this analysis, race was further dichotomized into “Black/African American” and “all
other races.” Questions pertaining to gender included the following options: male,
female, transgender (male to female), and transgender (female to male). Due to the low
number of transgender participants, all responses related to gender were coded into male
or female, depending on the gender with which participants identified. Variables
pertaining to sexual orientation included homosexual, queer, bisexual, heterosexual, and
questioning/unsure. Due to the response rates across the orientations, sexual orientation
was coded into “heterosexual” and “LGBTQ.”
Foster care variables. A number of foster care experience variables were chosen
to describe basic experiences in foster care placements. Age at first foster care placement
was measured on a 7-point scale, ranging from placement at birth to placement at age 17.
Time spent in placement was measured through a 6-point scale, ranging from less than a
year to 15 or more years. Age at exit from foster care was measured on a 4-point scale
and included the categories of 5 years or younger, 6–11 years old, 12–17 years old, and
HIV RISKS FOR HOMELESS FORMER FOSTER YOUTH 76
under 18 years old generally. Housing situation after transitioning out of foster care
included a number of options for housing such as family, family of origin, adoptive
family, transitional living facility, couch surfing, homelessness, independent living,
shelter, jail, rehab, and foster family. Number of foster care placements was measured
through a 5-point scale, ranging from one or two placements to 20 or more placements.
Type of placement included kinship care, foster care, group home, juvenile detention,
psychiatric hospital, and camp. These options were not mutually exclusive but meant to
capture the range of placements that a person may have throughout their childhood.
Reason for placement included physical abuse, sexual abuse, neglect, parental drug
problems, truancy, suicide attempt, personal drug use, parental psychiatric problems,
placement at birth, and other. Finally, general feelings regarding foster care were
obtained. Feelings of being supported and feelings of being respected were measured
through a 5-point scale that included “never,” “almost never,” “sometimes,” “almost
always,” and “always.” For the purpose of the logistic regressions, the questions
pertaining to feelings about placement were coded into three categories: low, medium,
and high levels of support and respect. All foster care variables selected were chosen
based on their importance in previous literature or the frequency of discussion in the
qualitative interviews.
Homelessness variables. Basic information regarding individuals’ homeless
experiences included overall time spent homeless, measured in months and years, and age
at first homelessness, measured in participant age. Timing of homelessness was measured
to gauge whether the individual became homeless either before leaving foster care
(before age 5, between 6 and 11 years old, or between 12 and 18 years old) or after
HIV RISKS FOR HOMELESS FORMER FOSTER YOUTH 77
leaving foster care (as a minor or an adult). Perceived cause of homelessness included the
following responses: aged out of foster care, self-blame, disagreements with
family/friends, kicked out of their house, lost a job/need a job, evicted, “lost my
roommate and couldn’t pay for rent,” drug use, “I stopped trying,” no foster care
resources, no support system, by choice, “I made poor choices,” in need of transitional
services, and family problems from childhood. Time currently spent homeless was
measured using a 6-point scale, ranging from less than a year to 14–18 years. Time spent
homeless over the lifetime was measured using a 6-point scale, ranging from less than a
year to 11–13 years.
HIV-risk behaviors. HIV-risk variables were selected from the YRBS (Brener,
Collins, Kahn, Warren, & Williams, 1995), which has been tested for validity and
reliability. Measures included in final models were a series of dichotomized variables
such as ever had sex, condom use at last sexual encounter, drug use with sex at last
sexual encounter, exchange sex during the lifetime, exchange sex during the last 3
months, condom use with exchange sex, injection drug use during the lifetime, injection
drug use during the last 3 months, and ever had an STI test (other than HIV). HIV testing
behavior was measured with a 3-point scale, with the options including within the last 3
months, 3–6 months ago, 6 or more months ago.
Analyses
The main objective of this analysis was to explore the relationship among foster
care experiences, network engagement, and HIV-risk behaviors within the sample of
homeless former foster youth. Individual logistic regressions were conducted for foster
care experiences and HIV-risk behaviors for the analysis in Chapter 2 and foster care
HIV RISKS FOR HOMELESS FORMER FOSTER YOUTH 78
experiences and social network engagement in Chapter 3. These significant relationships
were entered into individual mediation models using a SAS macro. Once this process was
completed, the models were examined to determine the significance of the indirect effect
through network engagement. By default, the Sobel test was used in the macro. Given the
shift away from using the Sobel test for significance (Hayes, 2009), additional bootstrap
tests were run to determine if any significant confidence intervals existed. These models
controlled for age, race, gender, sexual orientation, feelings of support in foster care, and
feelings of respect in foster care. For the analyses, five models were tested for mediation.
Model 1 tested the relationship between experiences of homelessness before exiting
foster care and engagement in exchange sex, mediated by the presence of social network
alters engaging in condomless sex. Model 2 tested the relationship between a large
number of foster care placements and engagement in exchange sex, mediated by the
presence of home-based alters. Model 3 tested the relationship between a large number of
foster care placements and drug use during sex, mediated by the presence of alters who
use methamphetamines. Model 4 tested the relationship between a large number of foster
care placements and condom use, mediated by the presence of friends from home. Model
5 tested the relationship between a large number of foster care placements and condom
use, mediated by the presence of alters who use methamphetamines. All analyses were
conducted using SAS 9.3.
Results
Results for all five models indicated that whereas the relationships between foster
care and both social network variables and HIV-risk behaviors were previously
significant, the mediation analyses were not. Additional logistic regressions were tested
HIV RISKS FOR HOMELESS FORMER FOSTER YOUTH 79
between the social network engagement variables and HIV-risk behaviors. Table 4.1
indicates that two of the five models were significant at p < .05. However, once entered
into the full models, the relationships were no longer significant for the mediation.
Table 4.1

Logistic Regressions for HIV-risk Behaviors on Social Network Engagement

All Youth
(n = 153)
Social Network
Engagement
OR (95% Cl) OR (95% Cl) OR (95% Cl) OR (95% Cl)

Condom use Injection drug
use
Drug use with
sex
Exchange sex
Alter - condomless sex
1.00 (.75, 1.35) .89 (.61, 1.30) .85 (.63, 1.15) .71 (.42, 1.22)
Alter - from home
.95 (.47, 1.96) .97 (.37, 2.50) .99 (.48, 2.04) .52 (.12, 2.32)
Alter - friend
.96 (.84, 1.11) 1.13 (.91, 1.40) .94 (.82, 1.08) .96 (.73, 1.30)
Alter - using meth
.89 (.65, 1.22) .76 (.55, 1.04)* .60 (.30, .92)** .98 (.64, 1.50)

Discussion
The results indicated that whereas there were significant relationships between
foster care experiences and both social network engagement and HIV-risk behaviors, and
despite two models also showing significant results for the relationship between network
engagement and HIV-risk behaviors, the final models were not significant. Whereas these
results were unexpected, important information can still be gathered. For instance, foster
care experiences themselves are the variables driving these relationships, for the results
elucidated the importance of foster care experiences and the impact they have on
outcomes. Thus, specific foster care experiences impact both HIV-risk and social
network engagement, and this impact can be positive or serve to increase the risk factors.
Finally, whereas the initial sample contained enough participants for adequate
power, the final models, containing only youth with the specific predictors and outcomes
selected, may have been too small to power these mediation models. Much larger
HIV RISKS FOR HOMELESS FORMER FOSTER YOUTH 80
samples would be required to power predictive models with high-risk behaviors. For
example, by the time the mediation analysis tested the relationship between the number
of foster care placements and drug use with sex, mediated by the presence of alters using
methamphetamines, the sample size was reduced to 33. Upon closer examination of the
individual paths among the three components of the mediation model, the social network
variables, whereas significantly associated with both foster care experiences and HIV-
risk behaviors, were not significantly associated with the same variables that accounted
for the significant paths between foster care experiences and HIV-risk behaviors. All
three components of the models are significantly associated with one another, but they
are differently associated with the expected mediator.

Limitations
Several limitations exist for the analyses conducted. First, the data represent a
cross-sectional analysis of homeless youth from Los Angeles. This cross-sectional nature
indicates that causality cannot be implied. Further, homeless youth in Los Angeles do not
necessarily represent the characteristics of youth across the country, and foster care
experiences, whereas having many factors in common, vary across counties and states.
Foster Care Experiences
• Number of Foster Care placements
• Age at first placement
• Types of placement
• Experience transi;oning out of care
HIV-Risk Behaviors
• Condom use
• Concurrent sex partners
• Exchange sex
• Sex under the influence
Network Engagement
• Engagement with other foster youth
• Engagement with youth engaging in
HIV risk behaviors
Foster Care Experiences
• Number of Foster Care placements
• Age at first placement
• Types of placement
• Experience transiBoning out of care
HIV RISKS FOR HOMELESS FORMER FOSTER YOUTH 81
Thus, foster care experiences may have a considerable amount of variation depending on
the location of the placement. Finally, the final mediation model was not significant,
which may be the result of the sample size for the final mediation models but could also
indicate that the variables should be modeled differently. Both a larger sample size and
alternate modeling strategies should be attempted before conclusions are dawn about the
cause of this issue.
Implications
Several interesting implications emerged from these analyses. Primarily, homeless
youth with and without a history of foster care are often lumped together and treated as
one population. These results indicate that, at least regarding the relationship between
network engagement and HIV-risk behaviors, these two categories of homeless youth
should not necessarily be paralleled. Previous literature has established relationships
between network engagement and HIV-risk, but the inclusion of foster care experiences
makes for a unique interaction between these variables (Bao et al., 2000; Ennett et al.,
1990; Joseph et al., 2014; Kidd, 2003; Perry, 2006; Rice et al., 2007; Rice & Rhoades,
2013; Rice et al., 2008). Research has primarily focused on either homeless youth or
former foster youth, without considering the unique experiences of those youth at the
intersection of those experiences.
The second implication is the importance placed on the impact of foster care
experiences on both network engagement and HIV-risk behaviors. Some experiences in
foster care significantly impact the types of connections young people make and the types
of HIV-risk behaviors in which they engage. Given the role of these experiences in these
models, this information provides vital factors to be considered when designing
HIV RISKS FOR HOMELESS FORMER FOSTER YOUTH 82
interventions for homeless youth. The large number of homeless youth with a foster care
history deems that interventions should be tailored to address the protective factors and
risk factors emerging from their foster care experiences. For example, as the results of
these analyses have shown, a larger number of foster care placements negatively impacts
both social network ties and HIV-risk behaviors. Therefore, a focus on HIV-risk
prevention should include the impact of network disruptions resulting from many foster
placements and the likelihood that homeless former foster youth experiences may impact
condom use, injection drug use, engagement in exchange sex, and drug use with sex.
These results indicate that experiences of homelessness and high numbers of placements
can lead to several negative outcomes for these vulnerable youth, and policy changes
could curtail some of these effects by reducing the number of placements and addressing
homeless experiences during foster care placement.

HIV RISKS FOR HOMELESS FORMER FOSTER YOUTH 83
References

Bao, W. N., Whitbeck, L. B., & Hoyt, D. R. (2000). Abuse, support, and depression
among homeless and runaway adolescents. Journal of Health and Social
Behavior, 41(4), 408-420.
Brener, N. D., Collins, J. L., Kann, L., Warren, C. W., & Williams, B. I. (1995).
Reliability of the youth risk behavior survey questionnaire. American Journal of
Epidemiology, 141(6), 575-580.
Ennett, S. T., Baily, S. L., & Federman, E. B. (1990). Social network characteristics
associated with risk behaviors among runaway and homeless youth. Journal of
Health and Social Behavior, 40(March), 63-78.
Halkitis, P. N., Kapadia, F., Siconolfi, D. E., Meoller, R. W., Figueroa, R. P., Barton,
S.C., & Blachman-Forshay, J. (2013). Individual, psychosocial, and social
correlates of unprotected anal intercourse in a new generation of young men who
have sex with men in New York City. American Journal of Public Health,
103(5), 889-895. doi:10.2105/AJPH.2012.300963.epub2013Mar14
Hayes, A. F. (2009). Beyond Baron and Kenny: Statistical mediation analysis in the new
millennium. Communication Monographs, 76(4), 408-420.
Joseph, M. A., O’Connor, T. G., Briskman, J. A., Maughan, B., & Scott, S. (2014). The
formation of secure new attachments by children who were maltreated: An
observational study of adolescents in foster care. Developmental
Psychopathology, 26(1), 67-80.
Kidd, S. E. (2003). Street youth: Coping and interventions. Child and Adolescent Social
Work Journal, 20(4), 235-261.
HIV RISKS FOR HOMELESS FORMER FOSTER YOUTH 84
Milburn, N. G., Rice, E., Rotheram-Borus, M., Mallett, S., Rosenthal, D., Batterham, P.,
… Duan, N. (2009). Adolescents exiting homelessness over two years: The Risk
Amplification and Abatement Model. Journal of Research on Adolescence, 19(4),
762-785. doi:10.1111/j.1532-7795.2009.00610.x
Perry, B. L. (2006). Understanding social network disruption: The case of youth in foster
care. Social Problems, 53(3), 371-391.
Rice, E., Milburn, N. G., & Rotheram-Borus, M. J. (2007). Pro-social network influences
on HIV/AIDS risk behaviors among newly homeless youth in Los Angeles. AIDS
Care: Psychological and Socio-medical Aspects of AIDS/HIV, 19(5), 697-704.
Rice, R., Milburn, N. G., Rotheram-Borus, M., Mallett, S., & Rosenthal, D. (2005). The
effects of peer group network properties on drug use among homeless youth.
American Behavioral Scientist, 48, 1102-1123. doi:10.1177/0002764204274194
Rice, E., & Rhoades, H. (2013). How should network-based prevention for homeless
youth be implemented? Addiction, 108(9), 1625-1626. doi:10.1111/add.12255
Rice, E., Stein, J. A., & Milburn, N. (2008). Countervailing social network influences on
problem behaviors among homeless youth. Journal of Adolescence, 31(5), 625-
639. doi:10.1016/j.adolescence.2007.10.008
Wenzel, S. L., Hsu, H. T., Zhou, A., & Tucker, J. S. (2012). Are social network correlates
of heavy drinking similar among black homeless youth and white homeless
youth? Journal of Studies on Alcohol and Drugs, 73(6), 885-889.
Yoshioka-Maxwell, A., Rice, E., Rhoades, H., & Winetrobe, H. (2015).
Methamphetamine use among homeless former foster youth: The mediating role
of social networks. Journal of Alcoholism and Drug Dependence, 3(2), pii: 197.
HIV RISKS FOR HOMELESS FORMER FOSTER YOUTH 85
Chapter 5: Implications and Future Directions
The goal of this dissertation was to examine some of the experiences of former
foster youth within the context of youth homelessness. Furthermore, and given the
previous literature regarding the vulnerability of homeless former foster youth (Courtney
et al., 2011; Hudson & Nandy, 2012; Nyamathi et al., 2012), their increased rates for
engagement in risk behaviors (Braciszewski & Stout, 2012; Carpenter, Clyman,
Davidson, & Steiner, 2001; DiClemente, Crittenden, & Rose, 2008; Vaughn, Ollie,
McMillen, Scott, & Munson, 2007; White, O’Brien, White, Pecora, & Phillips, 2008),
and the impact of social networks on these behaviors (Bao, Whitbeck, & Hoyt, 2000;
Ennett, Baily, & Federman, 1990; Halkitis et al., 2013; Joseph, O’Connor, Briskman,
Maughan, & Scott, 2014; Kidd, 2003; Rice, Milburn, Rotheram-Borus, 2007; Rice &
Rhoades, 2013; Rice, Stein, & Milburn, 2008; Wenzel, Hsu, Zhou, & Tucker, 2012),
there was a need to examine, in detail, the relationships among foster care experiences,
HIV-risk behaviors, and social network engagement.
Because little research has addressed the population of homeless former foster
youth, the entire chapter 2 focused on examining the range of experiences common to
homeless former foster youth and the impact of those experiences on HIV-risk behaviors.
Results from these analyses indicated that homeless former foster youth had a number of
risk factors that stemmed from specific foster care experiences. Increased time spent in
foster care and a higher number of foster care placements were negatively associated with
condom use. Experiencing homelessness before exiting from foster care was associated
with drug use during sex and engagement in exchange sex. Conversely, exiting foster
care at an older age was significantly associated with decreased injection drug use,
HIV RISKS FOR HOMELESS FORMER FOSTER YOUTH 86
suggesting that exiting foster care later in adolescence was somehow protective against
some HIV-risk behaviors.
Chapter 3 examined the association between foster care experiences and social
network engagement. In these results, homeless former foster youth whose alters also had
a history of foster care were more likely to have alters in their networks who used heroin
and injection drugs. In examining the impact of foster care experiences on network
engagement, the results indicated that a large number of foster care placements was
significantly associated with the presence of alters who use methamphetamines and that
the experience of being homeless before exiting foster care was associated with the
presence of alters the youths considered friends and those who engage in condomless sex.
Chapter 4 used the information gathered from the first two analyses to test a
mediation analysis on the relationship between foster care experiences and HIV-risk
behaviors, mediated by social network engagement. The results from this last series of
regressions indicated that whereas significant results emerged for direct paths, indirect
effects were not significant. These results can be interpreted to mean that the significant
path for foster care experiences is one that independently impacts both HIV-risk
behaviors and social network engagement.
A number of important implications emerged from these results. First, these
analyses confirm that foster care experiences impact both social network engagement and
HIV-risk behaviors. This finding is important for intervention development and adaption
because it provides additional factors that may be important for intervening in homeless
youth HIV-risk behaviors. Second, foster care experiences are multi-dimensional; not
only do different experiences uniquely impact outcomes, but the same experiences can
HIV RISKS FOR HOMELESS FORMER FOSTER YOUTH 87
impact two outcomes differently, as well. This finding is important because it highlights
the need to treat interventions for homeless youth as complex systems that require an in-
depth perspective on the unique ways individuals experience foster care. Finally, the
demographic and statistical results indicate that there is much work to be done at the
policy level concerning foster care experiences. Several experiences during foster care
should be addressed to reduce the occurrence of risk behaviors at a later time. For
example, given the impact of homelessness before exit from foster care placement, child
welfare policies could focus on reducing any instances of homelessness during foster care
and the number of placements for youth with a high number of risk factors. Currently,
statistics on the number of foster youth experiencing homelessness while under state care
have not been collected and distributed. As such, understanding how to address the issue
of homelessness during foster care is difficult.
Whereas the lack of information available on the number of foster youth
experiencing homelessness could lead one to believe that no youth in the child welfare
system experiences homelessness, participants’ responses indicate otherwise. Policy
changes should consider the impact these experiences have on youth behavioral health
outcomes and focus on increasing those experiences that lead to positive outcomes, such
as an older age at exit from foster care, while reducing the experiences that contribute to
risky behaviors and poor outcomes.
Several limitations exist for the analyses conducted. First, the data represent a
cross-sectional analysis of homeless youth from Los Angeles. This cross-sectional nature
indicates that causality cannot be implied. Further, homeless youth in Los Angeles do not
necessarily represent the characteristics of youth across the country, and foster care
HIV RISKS FOR HOMELESS FORMER FOSTER YOUTH 88
experiences, whereas having many factors in common, vary across counties and states.
Thus, foster care experiences may have a considerable amount of variation depending on
the location of the placement. Finally, whereas these analyses include a range of
experiences common to many former foster youth, with the sample of homeless former
foster youth used, understanding which experiences may also be common among
homeless youth without a history of foster care is difficult. To truly understand which
experiences drive network engagement, a sample of homeless youth with and without a
history of foster care would need to be compared. Finally, hypotheses regarding
mediation were not confirmed with this analysis, potentially due to several other factors
that may be predictive of HIV-risk behaviors and social network engagement, as well as a
small sample size that may not have had the power to predict these models. As previously
mentioned, foster care experiences are varied and cannot be condensed into one unique
experience. As such, ensuring that these experiences are not only measured with as much
detail as possible, but that they also be included in interventions targeting the behavioral
health of homeless former foster youth is important. Future directions in the field of
research for this population should include further examination of the differences among
homeless youth with and without a history of foster care to determine which foster care
experiences impact risk behaviors among homeless youth. Additional studies using
longitudinal data analysis would be helpful for tracking HIV risks and social network
composition and engagement over time. Particularly because homeless youth are still
encountering the developmental changes of adolescence and young adulthood, examining
the changes in network composition may be of use in determining the impact of networks
on HIV-risk behaviors.
HIV RISKS FOR HOMELESS FORMER FOSTER YOUTH 89
References
Bao, W. N., Whitbeck, L. B., & Hoyt, D. R. (2000). Abuse, support, and depression
among homeless and runaway adolescents. Journal of Health and Social
Behavior, 41(4), 408-420.
Braciszewski, J. M., & Stout, R. L. (2012). Substance use among current and former
foster youth: A systematic review. Children and Youth Services Review, 34, 2337-
2344. doi:10.1016/j.childyouth.2012.08.011
Carpenter, S. C., Clyman, R. B., Davidson, A. J., & Steiner, J. F. (2001). The association
of foster care or kinship care with adolescent sexual behavior and first pregnancy.
Pediatrics, 108(3), e36. doi:10.1542/peds.108.3.e46
Courtney, M. E., Dworsky, A., Brown, A., Cary, C., Love, K., & Vorhies, V. (2011).
Midwest evaluation of adult functioning of former foster youth: Outcomes at age
26. Chicago, IL: Chapin Hall at the University of Chicago.
DiClemente, R. J., Crittenden, C. P., & Rose, E. (2008). Psychosocial predictors of HIV
associated sexual behaviors and the efficacy of preventions interventions in
adolescents at-risk for HIV infection: What works and what doesn’t?
Psychosomatic Medicine, 70(5), 598-605.
Ennett, S. T., Baily, S. L., & Federman, E. B. (1990). Social network characteristics
associated with risk behaviors among runaway and homeless youth. Journal of
Health and Social Behavior, 40(March), 63-78.
Halkitis, P. N., Kapadia, F., Siconolfi, D. E., Meoller, R. W., Figueroa, R. P., Barton,
S.C., & Blachman-Forshay, J. (2013). Individual, psychosocial, and social
correlates of unprotected anal intercourse in a new generation of young men who
HIV RISKS FOR HOMELESS FORMER FOSTER YOUTH 90
have sex with men in New York City. American Journal of Public Health,
103(5), 889-895. doi:10.2105/AJPH.2012.300963.epub2013Mar14
Hudson, A. L., & Nandy, K. (2012). Comparisons of substance abuse, high-risk sexual
behavior, and depressive symptoms among homeless youth with and without a
history of foster care placement. Contemporary Nurse, 42(2), 178-186.
Joseph, M. A., O’Connor, T. G., Briskman, J. A., Maughan, B., & Scott, S. (2014). The
formation of secure new attachments by children who were maltreated: An
observational study of adolescents in foster care. Developmental
Psychopathology, 26(1), 67-80.
Kidd, S. E. (2003). Street youth: Coping and interventions. Child and Adolescent Social
Work Journal, 20(4), 235-261.
Nyamathi, A., Branson, C., Kennedy, B., Salem, B., Khalilifard, F., Marfisee, M., …
Leake, B. (2012). Impact of nursing intervention on decreasing substances among
homeless youth. American Journal of Addiction, 21(6), 558-565.
doi:10.1111/j.15210391.2012.00288.x
Perry, B. L. (2006). Understanding social network disruption: The case of youth in foster
care. Social Problems, 53(3), 371-391.
Rice, E., Milburn, N. G., & Rotheram-Borus, M. J. (2007). Pro-social network influences
on HIV/AIDS risk behaviors among newly homeless youth in Los Angeles. AIDS
Care: Psychological and Socio-medical Aspects of AIDS/HIV, 19(5), 697-704.
Rice, E., & Rhoades, H. (2013). How should network-based prevention for homeless
youth be implemented? Addiction, 108(9), 1625-1626. doi:10.1111/add.12255
HIV RISKS FOR HOMELESS FORMER FOSTER YOUTH 91
Rice, E., Stein, J. A., & Milburn, N. (2008). Countervailing social network influences on
problem behaviors among homeless youth. Journal of Adolescence, 31(5), 625-
639. doi:10.1016/j.adolescence.2007.10.008
Vaughn, M. G., Ollie, M. T., McMillen, J. C., Scott, L., & Munson, M. (2007). Substance
use and abuse among older youth in foster care. Addictive Behaviors, 32, 1929-
1935. doi:10.1016/j.addbeh.2006.12.012
Wenzel, S. L., Hsu, H. T., Zhou, A., & Tucker, J. S. (2012). Are social network
correlated of heavy drinking similar among black homeless youth and white
homeless youth? Journal of Studies on Alcohol and Drugs, 73(6), 885-889.
White, C. R., O’Brien, K., White, J., Pecora, P. J., & Phillips, C. M. (2008). Alcohol and
drug use among alumni of foster care: Decreasing dependency through
improvement of foster care experiences. Journal of Behavioral Health Services &
Research, 35(4), 419-434.

Abstract (if available)

Abstract Introduction: One in 10 young adults experience at least one night of homelessness in the U.S. each year. Approximately 30% of all homeless adults report a foster care history compared to 4% among the general public. Recent research has begun to demonstrate high rates of poor behavioral health outcomes among homeless former foster youth. Although both homeless youth and former foster youth independently face increased risk of HIV, little research has been conducted on this risk at the intersection of homelessness and child welfare involvement, necessitating additional exploration, particularly where HIV-risk behaviors are concerned. ❧ Methods: Data were collected from 184 homeless former foster youth at a drop-in center in Hollywood, California using the risk-behavior questionnaire. A series of logistic regressions were conducted for HIV-risk behaviors that may be impacted by foster care experiences and other models for HIV-risk behaviors that may be impacted by timing of homelessness, as it pertains to foster care transition. ❧ Results: This sample of youth was largely composed of African-American and mixed-race youth. These youths were largely placed in foster care during early childhood or adolescence, with high frequencies of youth experiencing either less than a year of foster care placement or more than 15 years of foster care placement. Nearly one fifth of the youth reported homelessness immediately after transitioning out of foster care, and more than half of youth reported feeling always or almost always respected and supported while in care. For the results of the logistic regressions, youth were significantly less likely to use condoms with increased time spent in foster care. Youth were also less likely to engage in injection drug use as their exit age from foster care increased. Finally, youth were significantly more likely to engage in drug use with sex and exchange sex if their first homeless experience occurred before leaving foster care. ❧ Discussion: Services and interventions geared toward foster youth should take into consideration that most of the youth tend to be persons of color, are minors or young adults, and have a range of foster care experiences. Those services targeting HIV-risk behaviors should consider the impact that foster care placements have on these behaviors, such as the risk factors associated with long placement periods or experiencing homelessness before exiting foster care, and the protective factors associated with exiting placement at an older age. Acknowledging these experiences and addressing their risk and protective factors may contribute to tailoring interventions that better impact HIV-risk behaviors. Additionally, child welfare services should consider focusing efforts on reducing instances of homelessness during foster care and the number of placements for those youth with a high number of risk factors.

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Asset Metadata

Creator Yoshioka-Maxwell, Amanda (author)

Core Title Social network engagement and HIV risk among homeless former foster youth

School School of Social Work

Degree Doctor of Philosophy

Degree Program Social Work

Publication Date 04/12/2018

Defense Date 03/05/2018

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag foster youth,HIV,homeless youth,Homelessness,OAI-PMH Harvest,social network analysis

Language English

Contributor Electronically uploaded by the author (provenance)

Advisor Rice, Eric (committee chair), Esparza, Nicole (committee member), Wenzel, Suzanne (committee member)

Creator Email abarron@usc.edu,aymaxwell@gmail.com

Permanent Link (DOI) https://doi.org/10.25549/usctheses-c89-9230

Unique identifier UC11669030

Identifier etd-YoshiokaMa-6243.pdf (filename),usctheses-c89-9230 (legacy record id)

Legacy Identifier etd-YoshiokaMa-6243.pdf

Dmrecord 9230

Document Type Dissertation

Rights Yoshioka-Maxwell, Amanda

Type texts

Source University of Southern California (contributing entity), University of Southern California Dissertations and Theses (collection)

Access Conditions The author retains rights to his/her dissertation, thesis or other graduate work according to U.S. copyright law. Electronic access is being provided by the USC Libraries in agreement with the a...

Repository Name University of Southern California Digital Library

Repository Location USC Digital Library, University of Southern California, University Park Campus MC 2810, 3434 South Grand Avenue, 2nd Floor, Los Angeles, California 90089-2810, USA