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Incarceration Among Street-Involved Youth in a Canadian Study : Implications for Health and Policy Interventions Omura, John; Wood, Evan; Nguyen, Paul; Kerr, Thomas; DeBeck, Kora Nov 7, 2013

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Incarceration Among Street-Involved Youth in a Canadian Study:Implications for Health and Policy InterventionsJohn D Omuraa,b, Evan Wooda,c, Paul Nguyena, Thomas Kerra,c, and Kora DeBecka,daBritish Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, 608-1081 BurrardStreet, Vancouver, BC, CANADA, V6Z 1Y6bSchool of Population and Public Health, University of British Columbia, 5804 Fairview Avenue,Vancouver, BC, CANADA, V6T 1Z3cDepartment of Medicine, University of British Columbia, St. Paul's Hospital, 608-1081 BurrardStreet, Vancouver, BC, CANADA, V6Z 1Y6dSchool of Public Policy, Simon Fraser University, SFU Harbour Centre, 515 West HastingsStreet, Suite 3271, Vancouver, BC, CANADA, V6B 5K3AbstractBackground—Risk factors for incarceration have been well described among adult drug usingpopulations; however, less is known about incarceration among at-risk youth. This study examinesthe prevalence and correlates of incarceration among street-involved youth in a Canadian setting.Methods—From September 2005 to May 2012, data were collected from the At-Risk YouthStudy, a prospective cohort of street-involved youth aged 14 – 26 who use illicit drugs.Generalized estimating equation (GEE) logistic regression was used to identify factors associatedwith recent incarceration defined as incarceration in the previous six months.Results—Among 1019 participants, 362 (36%) reported having been recently incarceratedduring the study period. In multivariate GEE analysis, homelessness (adjusted odds ratio [AOR]=1.60), daily crystal methamphetamine use (AOR= 1.56), public injecting (AOR= 1.33), drugdealing (AOR= 1.48) and being a victim of violence (AOR= 1.68) were independently associatedwith incarceration (all p <0.05). Conversely, female gender (AOR= 0.48), lesbian, gay, bisexual,transgender or two-spirited (LGBTT) identification (AOR= 0.47) and increasing age of first harddrug use (AOR= 0.96) were negatively associated with incarceration (all p <0.05).Conclusion—Incarceration was common among our study sample. Youth who were homeless,used crystal methamphetamine, and engaged in risky behaviors including public injection anddrug dealing were significantly more likely to have been recently incarcerated. Structural© 2013 Elsevier B.V. All rights reservedSend correspondence to: Kora DeBeck, PhD BC Centre for Excellence in HIV/AIDS 608-1081 Burrard Street, Vancouver, B.C.CANADA V6Z 1Y6 Tel: 1 (604) 806-9044 uhri-kd@cfenet.ubc.ca.(john@johnomura.com)(uhri-ew@cfenet.ubc.ca)(pnguyen@cfenet.ubc.ca)(uhri-tk@cfenet.ubc.ca)(uhri-kd@cfenet.ubc.ca)Publisher's Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to ourcustomers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review ofthe resulting proof before it is published in its final citable form. Please note that during the production process errors may bediscovered which could affect the content, and all legal disclaimers that apply to the journal pertain.Competing Interests: Authors declare no other competing interests.NIH Public AccessAuthor ManuscriptInt J Drug Policy. Author manuscript; available in PMC 2015 March 01.Published in final edited form as:Int J Drug Policy. 2014 March ; 25(2): 291–296. doi:10.1016/j.drugpo.2013.10.010.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author Manuscriptinterventions including expanding addiction treatment and supportive housing for at-risk youthmay help reduce criminal justice involvement among this population and associated health, socialand fiscal costs.Keywordsstreet youth; incarceration; drug use; homelessINTRODUCTIONIncarceration is a well established risk factor for various negative outcomes among illicitdrug using populations including: blood-borne infections such as HIV and hepatitis C(HCV) (Massoglia, 2008); relapse and persistent drug use (DeBeck et al., 2009; Galea &Vlahov, 2002); and unemployment (Western, 2002). Although incarceration has not beendemonstrated to effectively reduce problematic drug use (DeBeck et al., 2009), people whouse drugs continue to be incarcerated at a staggering rate (Milloy et al., 2008). This is ofparticular concern as it pertains to youth as evidence suggests that placing high-riskadolescents in close proximity such as in prison facilities may inadvertently reinforceproblem behavior and elevate risk for various adverse health outcomes (Dishion, McCord, &Poulin, 1999). In light of these facts, policy makers in the United States have begun torecognize the importance of preventing the unnecessary and inappropriate incarceration ofyouth (U.S. House of Representatives Committee on Government Reform - Minority StaffSpecial Investigations Division, 2004).Despite this awareness, the prevalence of youth incarceration in North America remainshigh. In 2010, the United States (US) federal juvenile justice system incarceratedapproximately 70,000 youth (Sickmund, Sladky, Kang, & Puzzanchera, 2011). In Canada,on any given day between 2010–2011 approximately 14,800 youth were housed in thecorrectional system (aged 12–17 years at the time of offence), representing a rate of 79youth per 10,000 youth population (Munch, 2011). For street-involved youth specifically,survey data from a cohort study of street youth in Vancouver found that 80.5% reportedhaving ever being incarcerated overnight or longer (Milloy, Kerr, Buxton, Montaner, &Wood, 2009). Marginalized ethnic minority groups are also overrepresented amongstincarcerated youth. In the US, 69% of incarcerated youth are black or Hispanic (Sickmundet al., 2011) and in Canada 26% are of Aboriginal ancestry (Munch, 2011).While the negative impact of incarceration on street youth is increasingly understood, riskfactors for youth incarceration remain poorly studied. To date, much research on this topichas focused on offending or delinquent behaviors (Baron & Hartnagel, 1998; Heinze, Toro,& Urberg, 2004). Analyses that identify such behaviors in homeless and incarcerated youthare useful in demonstrating that risky behaviors appear to increase once a youth becomesimmersed in street life (Thompson, Bender, Windsor, Cook, & Williams, 2010). However,they fail to capture the broader social, behavioral and environmental context in which youthincarceration occurs. Furthermore, studies that do address these more distal factors tend tobe limited by recall bias and cross-sectional designs. To better understand risk factors forincarceration amongst at-risk youth, we sought to longitudinally examine the prevalence andcorrelates of incarceration among a prospective cohort of street-involved youth inVancouver, Canada.METHODSData for this study was collected from the At-Risk Youth Study (ARYS), a prospectivecohort of street-involved youth in Vancouver, Canada. The study has previously beenOmura et al. Page 2Int J Drug Policy. Author manuscript; available in PMC 2015 March 01.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author Manuscriptdescribed in detail (Wood, Stoltz, Montaner, & Kerr, 2006). Eligibility criteria include youthbetween the ages of 14–26 at enrolment, who have used illicit drugs in the past 30 days andprovide written informed consent. In summary, interviews are conducted at baseline andsemi-annually for follow-up. Participants complete an interviewer-administeredquestionnaire and provide blood samples for HIV and HCV serology. The survey includesitems on sociodemographic information, drug use patterns, sexual and drug-related riskbehaviours, and engagement with the criminal justice system. Participants receive a $20CAD monetary compensation at each study visit. The ARYS cohort has been approved bythe research ethics board of Providence Health Care and the University of British Columbia.Data for this study was collected from September 2005 to May 2012. The primary outcomewas reported incarceration in the past six months. This was defined as responding “yes” tothe question “Have you been in detention, prison or jail in the last 6 months?” Thecomparison group was youth who reported no incarceration in the last six months.Explanatory variables of interest included socio-demographic data including: age (per yearolder); gender (male vs. female); sexual orientation (lesbian, gay, bisexual, transgender,two-spirit (LGBTT) vs. heterosexual); Caucasian ethnicity (yes vs. no); homelessness,defined as having no fixed address, sleeping on the street, couch surfing, or staying in ashelter or hostel at some point in the previous six months (yes vs. no); and residence inVancouver's drug use epicenter at some point in the previous six months, which is a well-described and defined area of the city referred to as the `Downtown Eastside' (DTES) (yesvs. no). Substance use variables referring to behaviours in the previous six months included:daily crystal methamphetamine use, injection or non-injection (yes vs. no); daily crackcocaine smoking (yes vs. no); daily cocaine use, injection or non-injection (yes vs. no); dailyheroin use, injection or non-injection (yes vs. no); any injection drug use (yes vs. no); dailymarijuana use (yes vs. no); and heavy alcohol use, defined for females as ≥ four drinks inone day in the last week or ≥ seven drinks containing alcohol per week and for males as ≥five drinks in one day in the last week or ≥ fourteen drinks containing alcohol per week (yesvs. no). Risk factors referring to behaviours in the previous six months included: publicinjection, defined as injecting drugs in public environments including streets, publiclavatories, alleys, parks, parking lots, abandoned buildings, and other public settings (any vs.never); syringe sharing, defined as having lent a used rig to someone else or fixed with asyringe that had already been used by someone else (yes vs. no); unprotected sex, defined asvaginal or anal sex without using a condom (yes vs. no); sex work, defined as havingreceived money, gifts, food, shelter, clothing or drugs in exchange for sex (yes vs. no); drugdealing, defined as selling drugs as a source of income (yes vs. no); and victim of violence,defined as having been attacked, assaulted, or suffered violence (yes vs. no). Other factorsinclude: age of first hard drug use (per year older) which included crack cocaine, cocaine(sniffed or snorted), heroin (sniffed, snorted or smoked) or crystal methamphetamine(smoked or snorted); and methadone program use, defined as ever participating in amethadone program (yes vs. no).Since analyses of factors potentially associated with incarceration included serial measuresfor each subject, we used generalized estimating equations (GEE) for binary outcomes withlogic link for the analysis of correlated data. These methods determine factors associatedwith incarceration throughout the six year and nine month follow-up period and providestandard errors adjusted by multiple observations per person using an exchangeablecorrelation structure. Therefore, this analysis considered data from every participant follow-up visit. Missing data was addressed through the GEE estimating mechanism which uses allavailable pairs method for missing data from dropouts or intermittent missing. All non-missing pairs of data are used in the estimators of the working correlation parameters. First,we used GEE bivariate analysis to determine factors associated with incarceration. To adjustOmura et al. Page 3Int J Drug Policy. Author manuscript; available in PMC 2015 March 01.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author Manuscriptfor potential confounding, all variables that were p < 0.10 in GEE bivariate analyses wereconsidered in a full model. Quasilikelihood under the Independence model Criterion (QIC)statistic with a backward model selection procedure was used to screen all possiblecombinations of candidate variables and identify the model with the best overall fit asindicated by the lowest QIC value. Statistical analyses were performed using SAS softwareversion 9.3 (SAS, Cary, NC). All reported p-values are two-sided and considered significantat p < .05.RESULTSA total of 1019 street-involved youth were enrolled in the study between September 2005and May 2012. Among this sample, 320 (31%) were female, 686 (67%) were of Caucasianethnicity, and the median age was 21 years at baseline (interquartile range [IQR] = 19–23).This sample contributed a total of 3347 observations. The median number of follow-upvisits was 3 (IQR=1–5). The number of youth who reported having ever been incarcerated atbaseline was 638 (63%) and 189 (19%) reported having recently been incarcerated atbaseline. Over the study period, 362 (35%) participants reported having been recentlyincarceration and overall, a total of 610 (18%) observations included a report ofincarceration.The baseline characteristics of all participants stratified by self-reported incarceration in theprevious six months are presented in Table 1. The results of the bivariate and multivariateGEE analyses are presented in Table 2. In multivariate GEE analysis, factors that remainedindependently associated with incarceration included: homelessness (adjusted odds ratio[AOR]= 1.60, 95% Confidence Interval [CI]: 1.28 – 1.99), daily crystal methamphetamineuse (AOR= 1.56, 95% CI: 1.18 – 2.08), public injecting (AOR= 1.33, 95% CI: 1.04 – 1.72),drug dealing (AOR= 1.48, 95% CI: 1.20 – 1.84) and being a victim of violence (AOR= 1.68,95% CI: 1.38 – 2.06). Conversely, female gender (AOR= 0.48, 95% CI: 0.36 – 0.65),LGBTT identification (AOR= 0.47, 95% CI: 0.30 – 0.72) and increasing age of first harddrug use (AOR= 0.96, 95% CI: 0.92 – 0.99) were negatively associated with incarceration.DISCUSSIONIn the present study, we observed a high proportion of youth who reported being indetention, prison or jail in the last six months. Factors positively and most stronglyassociated with incarceration included homelessness, drug dealing and being a victim ofviolence. Daily crystal methamphetamine use and public injecting were also independentlyassociated with incarceration. Factors negatively and most strongly associated and thusprotective from incarceration were female gender and LGBTT identification. Increasing ageof first hard drug use was also independently associated with incarceration.The frequency with which youth in our study were incarcerated is concerning, althoughlargely consistent with prior figures (Milloy et al., 2009; Munch, 2011; Sickmund et al.,2011). Male youth are known to experience higher rates of incarceration, which was alsoindicated in our data (Barrett, Katsiyannis, & Zhang, 2006). Our findings are also similar toprevious studies demonstrating an association between incarceration and crystalmethamphetamine use in youth (Milloy et al., 2009). This association may highlight aspecific drug-use risk factor for youth incarceration, given previous links between crystalmethamphetamine use and initiation of injection drug use (Wood et al., 2006). The trendtowards significance of daily crack cocaine use in our study warrants further examination asan added potential drug-use risk factor for incarceration among youth. Together thesefindings point to opportunities to expand addiction treatment options for youth that may helpreduce problematic stimulant drug use and the subsequent risk of incarceration. Given thatOmura et al. Page 4Int J Drug Policy. Author manuscript; available in PMC 2015 March 01.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author Manuscriptincreased age of first hard drug use was negatively associated with incarceration, our studyalso highlights that upstream prevention efforts that delay or prevent early initiation of harddrug use may reduce interactions with the criminal justice system later in life. This alsostresses the importance of ensuring that age restrictions do not limit access to early addictiontreatment for youth.The strong association found in this analysis between homelessness and incarceration isconsistent with existing literature and has been reported amongst incarcerated adults(Greenberg & Rosenheck, 2008). Homelessness is also associated with injection drug use,injection initiation and high intensity drug use amongst street-involved youth, although itmay be that homeless individuals are more visible to police and therefore more vulnerable toarrest and incarceration (Baron, 1999; Feng et al., 2013; E. Roy et al., 2003; É. Roy, Haley,Leclerc, Boudreau, & Boivin, 2007). Together these findings highlight the role of housing asa determinant of youth health and reinforce the importance of supporting this at-riskpopulation through housing efforts. (E. Roy et al., 2004). Indeed, supportive housinginterventions may have the potential to prevent youth incarceration and its associatedadverse effects by reducing the need for income generation (Debeck, Wood, et al., 2011),reducing high intensity drug use (Feng et al., 2013), and reducing interactions with police onstreets (Ti, Wood, Shannon, Feng, & Kerr, 2013). Moreover, since incarceration is known toimpose high costs on public-sector spending (Henrichson & Delaney, 2012; Miller, Fisher,& Cohen, 2001), our data suggests that investments in housing to reduce youth incarcerationcould help minimize its fiscal burden. Although homelessness may increase vulnerability toincarceration, it is also possible that incarceration leads to homelessness. Incarceration hasbeen shown to be a disruptive life event that can result in loss of housing and increasedeconomic insecurity (Freudenberg, Daniels, Crum, Perkins, & Richie, 2005; Pager, 2003).Given the established harms associated with homelessness, providing youth who exit thecriminal justice system with supportive housing should be a public health priority. It isnoteworthy that incarceration was also strongly associated with being a victim of violence.This further highlights the vulnerability of these youth and underscores the importance ofensuring that appropriate health and social supports are readily available.In addition to housing, another socioeconomic risk factor linked to youth incarceration inour study was drug dealing. Drug dealing is prevalent in social environments whereindividuals have few legitimate means of generating income (DeBeck et al., 2007).Individuals who have been incarcerated are known to be more vulnerable to economicinstability (Bushway, 1998), and prior studies demonstrate that drug dealing is a frequentsource of income generation among people who use injection drugs (Kerr et al., 2008).Although law enforcement is typically the dominant response to address drug dealing,alternative interventions that are less hazardous and potentially of greater societal benefithave been identified. Specifically, one study reported that a high proportion of illicit drugusers were willing to cease engaging in drug dealing, if they had options for low-thresholdemployment (Debeck, Wood, et al., 2011). By providing alternative methods of incomegeneration for economically vulnerable individuals (Reif, Horgan, Ritter, & Tompkins,2004), interventions such as low-threshold employment may reduce engagement in drugdealing and subsequent interactions with the criminal justice system.The identified association between incarceration and public injecting likely reflects the high-risk profile of individuals who inject in public areas (Darke, Kaye, & Ross, 2001), and thefact that those who inject in public are more visible to police. While this may make publicinjectors more susceptible to incarceration, the association may also reflect the destabilizinginfluence of incarceration on the lives of young people (Darke et al., 2001; B. D. Marshall,Kerr, Qi, Montaner, & Wood, 2010).Omura et al. Page 5Int J Drug Policy. Author manuscript; available in PMC 2015 March 01.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author ManuscriptOur finding that street-involved LGBTT youth are much less likely to experienceincarceration has not been previously demonstrated. This is an optimistic finding since as apopulation LGBTT youth are often found to be at high risk for numerous negative healthand social outcomes including incarceration (Himmelstein & Bruckner, 2011). The exactnature of this relationship and its underlying mechanism warrants further investigation.This study has several limitations. First, our sample was not random and therefore may notbe generalizable to other populations. Second, data was collected using self reportedinterviews and is thus vulnerable to response bias. Given the sensitive nature of someinterview questions, respondents may be inclined to report socially desirable responsesleading to under reporting of stigmatizing behaviors such as illicit drug use andincarceration. As a result, our findings are likely conservative estimates. Third, given thenon-randomized nature of this study, the relationships studied may be influenced byconfounders not measured.Our study demonstrates that incarceration is highly prevalent amongst street-involved youthin our setting, an important consideration given the known health and social harmsassociated with incarceration. This study identifies risk factors for youth incarceration,including homelessness, crystal methamphetamine use and engaging in risky behaviors suchas public injection and drug dealing. These findings support the need for the expansion ofyouth-focused evidence-based addiction treatment options in addition to other structuralinterventions available regardless of age. In particular, options include supportive housingand economic empowerment through programs such as low-threshold employment. Thesepublic health oriented interventions may help this high-risk population avoid incarcerationas well as mitigate its potential subsequent negative consequences.AcknowledgmentsThe authors thank the study participants for their contribution to the research, as well as current and pastresearchers and staff. We would specifically like to thank Cody Calloy, Jennifer Matthews, Deborah Graham,Tricia Collingham, Carmen Rock, Peter Vann, Steve Kain and Sabina Dobrer for their research and administrativeassistance. The study was supported by the US National Institutes of Health (R01DA028532) and the CanadianInstitutes of Health Research (MOP–102742). This research was undertaken, in part, thanks to funding from theCanada Research Chairs program through a Tier 1 Canada Research Chair in Inner City Medicine which supportsDr. Evan Wood. Dr. Kora DeBeck is supported by a MSFHR/St. Paul's Hospital-Providence Health Care CareerScholar Award.REFERENCESBaron SW. 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[PubMed: 16723029]Omura et al. Page 8Int J Drug Policy. Author manuscript; available in PMC 2015 March 01.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author ManuscriptOmura et al. Page 9Table 1Characteristics of study sample at baseline stratified by reported incarceration in the last six months (n= 1019).Incarcerated in the last 6 months at baselineCharacteristic Yes n= 189 No n= 830 OR (95% CI) p-valueMedian age (IQR) 22 (20–24) 21 (19–23) 1.05 (0.99 – 1.12) 0.086Gender, n (%) Female 42 (22.2) 278 (33.5) 0.57 (0.39 – 0.82) 0.003 Male 147 (77.8) 552 (66.5)Sexual Orientation, n (%) LGBTT 15 (7.9) 149 (18.0) 0.39 (0.23 – 0.69) < 0.001 Heterosexual 174 (92.1) 681 (82.0)Caucasian ethnicity, n (%) Yes 128 (67.7) 558 (67.2) 1.02 (0.73 – 1.43) 0.896 No 61 (32.3) 272 (32.8)Dropped out of high school, n (%) Yes 152 (80.4) 616 (74.2) 1.43 (0.96 – 2.11) 0.074 No 37 (19.6) 214 (25.8)Homeless a , n (%) Yes 154 (81.5) 589 (71.0) 1.80 (1.21 – 2.68) 0.003 No 35 (18.5) 241 (29.0)Living in DTES a , n (%) Yes 53 (28.0) 231 (27.8) 1.01 (0.71 – 1.44) 0.953 No 136 (72.0) 599 (72.2)Heavy alcohol use b , n (%) Yes 66 (34.9) 311 (37.5) 0.90 (0.64 – 1.25) 0.512 No 123 (65.1) 519 (62.5)Daily marijuana use a , n (%) Yes 94 (49.7) 401 (48.3) 1.06 (0.77 – 1.45) 0.724 No 95 (50.3) 429 (51.7)Daily crystal methamphetamine use a,c , n (%) Yes 30 (15.9) 102 (12.3) 1.35 (0.87 – 2.09) 0.185 No 159 (84.1) 728 (87.7)Daily crack smoking a , n (%) Yes 51 (27.0) 127 (15.3) 2.05 (1.41 – 2.97) < 0.001 No 138 (73.0) 703 (84.7)Daily cocaine use a, c , n (%) Yes 8 (4.2) 34 (4.1) 1.03 (0.47 – 2.27) 0.932 No 181 (95.8) 796 (95.9)Daily heroin use a, c , n (%)Int J Drug Policy. Author manuscript; available in PMC 2015 March 01.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author ManuscriptOmura et al. Page 10Incarcerated in the last 6 months at baselineCharacteristic Yes n= 189 No n= 830 OR (95% CI) p-value Yes 35 (18.5) 91 (11.0) 1.85 (1.20 – 2.83) 0.004 No 154 (81.5) 739 (89.0)Injection drug use a , n (%) Yes 67 (35.5) 231 (27.8) 1.42 (1.02 – 1.99) 0.038 No 122 (64.6) 599 (72.2)Median age of first hard drug use (IQR)15 (13–16) 15 (14–17) 0.94 (0.88 – 0.99) 0.030Methadone program, n (%) Yes 22 (11.6) 54 (6.5) 1.89 (1.12 – 3.19) 0.015 No 167 (88.4) 776 (93.5)Public injection a , n (%) Yes 57 (30.2) 166 (20.0) 1.73 (1.21 – 2.46) 0.002 No 132 (69.8) 664 (80.0)Shared syringes a , n (%) Yes 23 (12.2) 60 (7.2) 1.78 (1.07 – 2.96) 0.025 No 166 (87.8) 770 (92.8)Unprotected sex a , n (%) Yes 112 (59.3) 455 (54.8) 1.20 (0.87 – 1.65) 0.268 No 77 (40.7) 375 (45.2)Sex work a , n (%) Yes 23 (12.2) 78 (9.4) 1.34 (0.82–2.19) 0.250 No 166 (87.8) 752 (90.6)Drug dealing a , n (%) Yes 122 (64.5) 416 (50.1) 1.81 (1.31 – 2.52) < 0.001 No 67 (35.5) 414 (49.9)Victim of violence a , n (%) Yes 106 (56.1) 348 (58.1) 1.77 (1.29 – 2.43) < 0.001 No 83 (43.9) 482 (41.9)aDenotes activities in the previous six monthsbDenotes activities in the previous weekcRefers to any route of consumption (i.e., sniffing, snorting, smoking or injecting)Int J Drug Policy. Author manuscript; available in PMC 2015 March 01.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author ManuscriptOmura et al. Page 11Table 2Univariate and multivariate GEE analysis of factors associated with incarceration among street-involved youthin Vancouver (n=1019).Unadjusted AdjustedCharacteristic OR (95% CI) p-value AOR (95% CI) p-valueAge Per year older 1.06 (1.01 – 1.11) 0.013Gender Female vs. male 0.42 (0.31–0.55) < 0.001 0.48 (0.36 – 0.65) < 0.001Sexual orientation LGBTT vs. heterosexual 0.44 (0.29 – 0.67) <0.001 0.47 (0.30 – 0.72) < 0.001Caucasian ethnicity Yes vs. No 0.90 (0.71 – 1.14) 0.391Dropped out of high school Yes vs. No 1.43 (1.09 – 1.89) 0.011 1.30 (0.97 – 1.75) 0.084Homeless a Yes vs. No 2.02 (1.65 – 2.47) < 0.001 1.60 (1.28 – 1.99) < 0.001Living in DTES a Yes vs. No 1.20 (0.98 – 1.48) 0.085Heavy alcohol use b Yes vs. No 1.12 (0.92 – 1.37) 0.270Daily marijuana use a Yes vs. No 1.13 (0.92 – 1.38) 0.250Daily crystal methamphetamine use a, c Yes vs. No 1.69 (1.31 – 2.20) < 0.001 1.56 (1.18 – 2.08) 0.002Daily crack smoking a Yes vs. No 1.59 (1.24 – 2.04) < 0.001 1.31 (1.00 – 1.72) 0.053Daily cocaine use c Yes vs. No 1.19 (0.71 – 1.98) 0.517Daily heroin use a, c Yes vs. No 1.46 (1.10 – 1.92) 0.008 1.28 (0.93 – 1.77) 0.129Injection drug use a Yes vs. No 1.41 (1.14 – 1.75) 0.002Age of first hard drug use Per year older 0.93 (0.90 – 0.98) 0.002 0.96 (0.92 – 1.00) 0.045Methadone program Yes vs. No 1.06 (0.78 – 1.15) 0.688Public injection a Yes vs. No 1.71 (1.40 – 2.10) < 0.001 1.33 (1.04 – 1.72) 0.025Int J Drug Policy. Author manuscript; available in PMC 2015 March 01.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author ManuscriptOmura et al. Page 12Unadjusted AdjustedCharacteristic OR (95% CI) p-value AOR (95% CI) p-valueShared syringes a Yes vs. No 1.57 (1.11 – 2.22) 0.011Unprotected sex a Yes vs. No 1.07 (0.88 – 1.29) 0.505Sex work a Yes vs. No 1.11 (0.79 – 1.57) 0.536Drug dealing a Yes vs. No 2.00 (1.64 – 2.43) < 0.001 1.48 (1.20 – 1.84) < 0.001Victim of violence a Yes vs. No 1.83 (1.52 – 2.20) < 0.001 1.68 (1.38 – 2.06) < 0.001aDenotes activities in the previous six monthsbDenotes activities in the previous weekcRefers to any route of consumption (i.e., sniffing, snorting, smoking, or injecting)Int J Drug Policy. Author manuscript; available in PMC 2015 March 01.

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