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Transitions into and out of homelessness among street-involved youth in a Canadian setting Cheng, Tessa; Wood, Evan; Feng, Cindy X.; Mathias, Steve; Montaner, Julio; Kerr, Thomas; DeBeck, Kora Sep 30, 2013

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TRANSITIONS INTO AND OUT OF HOMELESSNESS AMONGSTREET-INVOLVED YOUTH IN A CANADIAN SETTINGTessa Cheng1,2, Evan Wood1,5, Cindy Feng3, Steve Mathias4, Julio Montaner1,5, ThomasKerr1,5, and Kora DeBeck1,2Tessa Cheng: tessac@sfu.ca; Evan Wood: uhri-ew@cfenet.ubc.ca; Cindy Feng: cindy.feng@usask.ca; Steve Mathias:puddy_steve@yahoo.com; Julio Montaner: jmontaner@cfenet.ubc.ca; Thomas Kerr: uhri-tk@cfenet.ubc.ca; KoraDeBeck: kdebeck@cfenet.ubc.ca1British Columbia Centre for Excellence in HIV/AIDS, St. Paul’s Hospital, 608 - 1081 BurrardStreet, Vancouver, BC, Canada V6Z 1Y62School of Public Policy, Simon Fraser University at Harbour Centre, 515 West Hastings Street,Suite 3271, Vancouver, BC, Canada V6B 5K33School of Public Health, University of Saskatchewan, Health Sciences Building, 107 WigginsRoad, Saskatoon, SK, Canada S7N 5E54Department of Psychiatry, University of British Columbia, 2255 Wesbrook Mall, Vancouver, BC,Canada V6T 2A15Department of Medicine, University of British Columbia, 2775 Laurel Street, 10th Floor,Vancouver, BC, Canada V5Z 1M9AbstractThe impact of transitions in housing status among street youth have not been well explored. Thisstudy uses a generalized linear mixed effects model to identify factors associated with transitionsinto and out of homelessness among a prospective cohort of 685 drug-using street-involved youthaged 14–26. In multivariate analysis, high intensity substance use, difficulty accessing addictiontreatment, incarceration, sex work, and difficulty accessing housing (all p < 0.05) eithersignificantly facilitated or hindered housing transitions. Findings highlight the importance ofexternal structural factors in shaping youth’s housing status and point to opportunities to improvethe housing stability of vulnerable youth.KeywordsHomelessness; drug use; street-youth; addiction treatment; risk behavior; incarceration© 2013 Elsevier Ltd. All rights reserved.Send correspondence to: Evan Wood, MD, PhD, ABIM, FRCPC, Director, Urban Health Research Initiative, B.C. Centre forExcellence in HIV/AIDS, University of British Columbia, St. Paul’s Hospital, 608-1081 Burrard Street, Vancouver, B.C., V6Z 1Y6,Canada, Tel: (604) 806-9116, Fax: (604) 806-9044, urhi-ew@cfenet.ubc.ca.Competing Interests:Authors declare no competing interests.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.NIH Public AccessAuthor ManuscriptHealth Place. Author manuscript; available in PMC 2014 September 01.Published in final edited form as:Health Place. 2013 September ; 23: 122–127. doi:10.1016/j.healthplace.2013.06.003.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author ManuscriptINTRODUCTIONHomelessness is an enduring concern among street-involved youth and is associated with arange of health and social harms (Marshall et al., 2009, Weber et al., 2002, Weir et al., 2007,Feng et al., 2012). Specifically, homeless youth have been found to be at greater risk ofinjection drug use (Feng et al., 2012, Roy et al., 2003), and high rates of HIV risk behavior(Lloyd-Smith et al., 2008), including sex-work (Weber et al., 2002) and engaging inunprotected sex (Marshall et al., 2009). Conversely, residential stability has been identifiedas protecting against these and other health and social harms (Roy et al., 2011).Because homeless youth are a hidden population, there is no generally accepted estimate forthe prevalence of youth homelessness around the world or in North America. In the UnitedStates, a 1999 survey estimated that 1.6 million youth had experienced an episode ofhomelessness (Hammer et al., 2002), and the number of homeless youth in Canada isreported to range from 150,000 to 300,000 (Evenson and Barr, 2009). However, beyonddescribing harms of homelessness, to implement effective policy responses to this growingproblem, a better understanding of how youth become homeless and how they transition outof homelessness is required. Therefore, this study sought to identify factors associated withtransitions into and out of homelessness among a cohort of street-involved youth inVancouver during the period of September 2005 to May 2012.METHODSStudy designData for this study was obtained from the At-Risk Youth Study (ARYS), a prospectivecohort study of street-involved youth in Vancouver, Canada. The cohort began in 2005 andhas been described in detail previously (Wood et al., 2006). In brief, snowball sampling andextensive street-based outreach methods were employed. To be eligible, participants atrecruitment had to be aged 14–26 years, use illicit drugs other than marijuana in the past 30days, and provide written informed consent. At enrollment, and on a bi-annual basis,participants completed an interviewer-administered questionnaire that included questionsrelated to demographic information and drug use patterns. Participants also meet with astudy nurse and provided a blood sample for serologic testing. At each study visit,participants are provided with a stipend ($20 CDN) for their time. The University of BritishColumbia’s Research Ethics Board has approved the study.For the present analyses, ARYS participants were eligible if they completed a baselinesurvey and had at least one follow-up study visit between September 2005 and May 2012.Transitions in housing status were identified based on reported homelessness (e.g., no fixedaddress, sleeping on the street, couch surfing, or staying in a shelter or hostel) (yes vs. no) inthe last six months. The following four categories for housing status based on twoconsecutive study follow-up visits were constructed: consistently homeless, consistentlyhoused, homeless to housed, and housed to homeless. The “consistently homeless” categoryincluded reports where participants indicated that they had been homeless in twoconsecutive study visits, and the “consistently housed” category included reports whereparticipants indicated that they had not been homeless in two consecutive study visits.Reports where participants indicated that they had been homeless in one study visit and nothomeless in the subsequent visit, were grouped in the “homeless to housed” category andrepresented a transition out of homelessness. Reports where participants indicated that theyhad been housed in one study visit and homeless in the subsequent visit were grouped in the“housed to homeless” category and represented a transition into homelessness.Cheng et al. Page 2Health Place. Author manuscript; available in PMC 2014 September 01.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author ManuscriptVariables of interestTo identify factors associated with transitions into and out of homelessness, we considered anumber of explanatory variables of interest including the following socio-demographicfactors: gender (female vs. male); age (per year older); ethnicity (Caucasian vs. other); beingin a stable relationship, defined as being legally married, common law, or having a regularpartner (yes vs. no); and regular employment, defined as having at least one source ofincome from a regular job (distinguished from temporary, casual, and non-legal forms ofincome generation by separate response options) (yes vs. no). Drug use variables included:frequent alcohol use, defined as having more than four drinks per day (yes vs. no); bingedrug use, defined as a period of using drugs more often than usual (yes vs. no); dailyinjection or non-injection heroin use (yes vs. no); daily injection or non-injection cocaineuse (yes vs. no); daily injection or non-injection crystal methamphetamine use (yes vs. no);and daily crack cocaine smoking (yes vs. no). Other variables considered included: sexwork, defined as exchanging sex for money, drugs, or gifts (yes vs. no); participation in drugdealing (yes vs. no); having difficulty accessing addiction treatment, based on the question:“In the past 6 months, have you ever tried to access any treatment program but wereunable?” (yes vs. no); incarceration, defined as being in detention, prison, or jail overnightor longer (yes vs. no); and difficulty accessing housing services, defined as needing housingservices but being unable to access them, was included as a marker of housing availability inVancouver (yes vs. no). All drug use and behavioral variables refer to activities in the pastsix months.Statistical analysisWe used generalized linear mixed effects methods (GLMM) to model transitions intohomelessness (housed to homeless), and out of homelessness (homeless to housed). The“consistently housed” and “consistently homeless” groups were used as a comparison forthese two outcome levels, respectively. The GLMM method was used in order to modelgroup and individual differences simultaneously (Krueger and Tian, 2004), and describe thechange in individual trajectories over time (Finucane et al., 2007). We used GLMMunivariate analysis to determine factors associated with transitions into and out ofhomelessness in unadjusted analyses. To adjust for potential confounding and identifyfactors that were independently associated with our outcomes of interest, all variables wereentered in a multivariate logistic GLMM model. All statistical analyses were performedusing SAS software version 9.2 (SAS, Cary, NC). All p-values are two sided.RESULTSDuring the study period, 996 participants were recruited into ARYS among whom 685participants were eligible for this analysis, including 219 (32.0%) women, and 447 (65.2%)persons of Caucasian ethnicity. The median age of participants in the study sample was 22years (inter quartile range [IQR] = 20–24). This sample contributed a total of 2,997observations. The median number of follow-up visits was 4 (IQR= 3–5), and the mediannumber of months between study visits was 6.5 (IQR = 5.8–8.9). Participants were understudy follow-up for a median of 25.4 months. A baseline comparison of those who were andwere not excluded revealed no statistically detectable differences with respect to baselineage, gender, and homelessness (p > 0.05); however, those included in the study were morelikely to be Caucasian (p = 0.016). An analysis of differences in drug use between these twogroups found that those included in the study were more likely to use crystalmethamphetamine daily (p = 0.038).Among our sample of 685 participants, over study follow up there were 864 observations of“consistently homeless” (n = 405, 59.1% of sample), 735 observations of “consistentlyCheng et al. Page 3Health Place. Author manuscript; available in PMC 2014 September 01.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author Manuscripthoused” (n = 320, 46.7%% of sample), 461 observations of transitions out of homelessness(“homeless to housed”) (n = 386, 56.3% of sample), and 252 observations of transitions intohomelessness (“housed to homeless”) (n = 213, 31.1% of sample). The characteristics of thestudy sample at baseline stratified by homelessness (last six months) are presented in Table1. The univariate GLMM analyses of socio-demographic, behavioral, and other riskvariables associated with transitions into and out of homelessness are presented in Table 2.The results of the multivariate GLMM analysis are shown in Table 3. Factors that remainedindependently associated with transitioning into homelessness included: Caucasian ethnicity(adjusted odds ratio [AOR] = 1.48, 95% confidence interval [CI]: 1.07–2.04), frequentalcohol use (AOR = 2.53, 95%CI: 1.55–4.14), daily crack cocaine smoking (AOR = 2.33,95%CI: 1.43–3.79), recent incarceration (AOR = 1.97, 95%CI: 1.29–3.01), and difficultyaccessing housing (AOR = 7.22, 95%CI: 4.40–11.84). Factors negatively associated withtransitioning into homelessness include: older age (AOR = 0.94, 95%CI: 0.88–0.99), femalegender (AOR = 0.62, 95%CI: 0.43–0.90) and being in a stable relationship (AOR = 0.70,95%CI: 0.50–0.97). Factors that were positively associated with transitioning out ofhomelessness included: being in a stable relationship (AOR = 1.42, 95%CI: 1.11–1.83) andinvolvement in sex work (AOR = 1.70, 95%CI: 1.03–2.79), and factors that were negativelyassociated with transitioning out of homelessness included: daily heroin use (AOR = 0.64,95%CI: 0.43–0.95), daily crystal methamphetamine use (AOR = 0.67, 95%CI: 0.46–0.97),difficulty accessing addiction treatment (AOR = 0.65, 95%CI: 0.42–0.99), recentincarceration (AOR = 0.72, 95%CI: 0.53–0.99) and difficulty accessing housing (AOR =0.20, 95%CI: 0.13–0.30).DISCUSSIONIn the present study, we observed a high rate of transitioning in and out of homelessness,with 213 (31%) participants making at least one transition into homelessness, and 386 (56%)making at least one transition out of homelessness over the study period. Recentincarceration and difficulty accessing housing were both positively associated withtransitions into homelessness and negatively associated with transitions out of homelessness.Conversely, being in a stable relationship was negatively associated with transitioning intohomelessness and positively associated with transitioning out of homelessness. Other factorsthat were positively associated with transitioning into homelessness included Caucasianethnicity, frequent alcohol use, and daily crack smoking, while older age and female genderwere negatively associated with this transition. Daily heroin use, daily crystal meth use, anddifficulty accessing addiction treatment were all negatively associated with transitions out ofhomelessness, while involvement in sex work was positively associated with this transition.The associations between high intensity drug use and housing transitions found in our studyis consistent with existing literature. Indeed, the relationship between housing instability andsubstance use is well established (Milburn et al., 2006, Roy et al., 2003, Corneil et al.,2006), and residential stability has been linked with decreased alcohol and polydrugconsumption among street-youth in other settings (Roy et al., 2011).Given the relationship between substance use and homelessness, and the potential foraddiction treatment to reduce problematic drug use, it was particularly concerning that youthwho successfully transitioned out of homelessness were significantly less likely to reportdifficulty accessing treatment. While individual motivation to enter or comply withaddiction treatment can influence access, a prior study found that the most common barrierto addiction treatment reported by youth is long wait lists (Wong et al., 2009). Otherreported barriers include strict behavioral requirements, prohibitive fees, and inconvenientor problematic locations (Hadland et al., 2009). Our findings suggest that increasing accessCheng et al. Page 4Health Place. Author manuscript; available in PMC 2014 September 01.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author Manuscriptand reducing barriers to evidence-based forms of addiction treatment likely has considerablepotential to reduce the health and social harms associated with homelessness by supportingtransitions out of homelessness.While our findings suggest that substance use appears to be an important factor in housingtransitions, difficulty accessing housing was the factor that was most strongly associatedwith both transitions into and out of homelessness indicating that housing availability is akey driver of youth homelessness, rather than individual behavior. The success of the“Housing First” model has demonstrated that improved health outcomes and well-being canbe achieved through the provision of well-managed fully supported housing, regardless ofwhether individuals continue to engage in drug and alcohol use (Padgett et al., 2011, Gulcuret al., 2003, Gurstein and Small, 2005). Although moving street-involved persons to privateindoor locations may have unintended consequences (e.g. illicit drug dealing, drugoverdose) (Erickson, 2001), structural interventions to increase access to and availability ofcarefully supervised supportive housing for youth will likely have a greater impact thanaddressing substance use.The finding that exposure to the criminal justice system was associated with transitions intohomelessness and negatively associated with transitions out of homelessness among youthfurther highlights the influence of structural factors in shaping youths’ housing status andalso suggests that there are gaps in current services for this vulnerable population. Thesefindings also underscore the challenges associated with using the criminal justice system torespond to problematic substance use. Incarceration among people with illicit drug addictionhas been shown to predict syringe sharing (Milloy et al., 2008) and HIV incidence (Jůrgenset al., 2009), and has been negatively associated with injection drug cessation (DeBeck etal., 2009). The unintended negative consequences of incarceration have led to repeated callsfor addiction to be addressed as a public health and not a criminal justice issue (Wood et al.,2010). Our findings support the importance of a public health approach to addiction andindicate that reducing exposure to the criminal justice system among young people who useillicit drugs may promote housing stability among this vulnerable population and reducehealth related harms. Although some interventions to provide alternative correctionsmeasures for youth have been introduced in our study setting (e.g. the Youth Offenders Act,1984 and the Youth Criminal Justice Act, 2003), observers suggest that these initiatives havenot achieved their stated objectives (Maclure et al., 2003). Our analysis suggests thatadditional and decisive action to intervene early with youth and provide health and socialsupports to reduce non-violent youth’s exposure to the criminal justice system should be apublic policy priority.The results from this study also point to three protective factors that merit attention. Firstly,older youth were less likely to transition into homelessness, which may be due to a greaterability to navigate social services and a readiness to leave street life (Karabanow, 2008).Secondly, those in a stable relationship were less likely to transition into and more likely totransition out of homelessness. While stable relationships appear to be a positive influencein relation to housing, it is important to note that prior studies have found that intimatepartnerships among street-involved youth can also be a source of risk and have beenassociated with increased violence and transitions into injection drug use particularly amongfemale youth (Small et al., 2009, Fast et al., 2010, Crofts et al., 1996, van Ameijden et al.,1994). Further study is required to better understand the complex dimensions and impacts ofintimate partnerships among street-involved youth. Thirdly, involvement in sex work wasassociated with transitioning out of homelessness, which may reflect the lack of economicopportunities for youth (Sauvé, 2003) and provides additional evidence for investing in job-related skills training and job-seeking services for youth (Sonenstein et al., 2011).Cheng et al. Page 5Health Place. Author manuscript; available in PMC 2014 September 01.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author ManuscriptOverall, these findings underscore the importance of addressing structural factors,specifically housing availability, exposure to the criminal justice system, and employmentopportunities to ensure that youth are prevented from entering homelessness and are fullysupported in their transition to stable housing. This is consistent with previous research thatemphasizes the importance of structural factors for a range of public health concerns (DesJarlais, 2000, Heimer et al., 2002, Blankenship et al., 2000). The results from this study alsoconverge with previous research on exiting homelessness, which found that recentlyhomeless individuals were able to consistently exit homelessness if they were connectedwith minimum wage employment and at least one stably housed friend or family member(Marr, 2012).It is also of note that movement through institutions such as shelters, criminal justicesettings, and addiction treatment (for those able to access it) may represent a form of“institutional cycling”, perpetuated by a lack of housing and other structural factors notedabove. Previous research among adults has identified institutional cycling as a calculatedsurvival practice, where marginally housed individuals rotate through different institutionsas a means to meet their basic needs (DeVerteuil, 2003). Consequently, those who transitioninto and out of homelessness may be seen as a larger group of “institutional cyclers” ratherthan two distinct groups. This issue remains to be explored among marginally housed youth,although breaking this pattern of institutional cycling should be a priority for governments,as youth may develop routines based on services’ availability, rather than make efforts todisengage from service use (DeVerteuil, 2003).LimitationsThere are several limitations to this study. First, as with other prospective cohorts of street-involved youth, ARYS participants were not recruited using randomized sampling, andtherefore these findings may not generalize to other drug-using youth populations inVancouver or other settings. However, extensive street-based outreach was used, and thedemographic profile of our participants is similar to other street-youth samples in Vancouver(Miller et al., 2006, Ochnio et al., 2001). Secondly, although we used multivariate analysisto address the issue of potential confounders, our results may be influenced by variables notexamined in this study including detailed assessments of mental health issues. Thirdly, themeasures used in this study rely on self-report, and are therefore vulnerable to recall andsocial desirability bias.ConclusionIn summary, our study indicates that drug use behaviors and key structural factors includingaccess to addiction treatment services, housing availability, exposure to the criminal justicesystem, and employment opportunities are associated with transitions into and out ofhomelessness. Increasing structural supports, especially supportive housing and providingyouth with economic empowerment, may have the greatest impact on reducing youthhomelessness and associated harms.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 Callon, Deborah Graham, Peter Vann, Steve Kain,Tricia Collingham, and Carmen Rock for their research and administrative assistance. We also thank the helpfulsuggestions of the anonymous peer-reviewers for their constructive comments and suggestions on an earlier draft ofthis manuscript.Funding:Cheng et al. Page 6Health Place. Author manuscript; available in PMC 2014 September 01.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author ManuscriptThe study was supported by the US National Institutes of Health (R01DA028532) and the Canadian Institutes ofHealth Research (MOP–102742). This research was undertaken, in part, thanks to funding from the CanadaResearch Chairs program through a Tier 1 Canada Research Chair in Inner City Medicine which supports Dr. EvanWood. Dr. Kora DeBeck is supported by a MSFHR/St. Paul’s Hospital Foundation-Providence Health Care CareerScholar Award. 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Uncovering patterns of HIV risk throughmultiple housing measures. AIDS and behavior. 2007; 11:31–44. [PubMed: 17828588]Wong J, Marshall BDL, Kerr T, Lai C, Wood E. Addiction Treatment Experience among a Cohort ofStreet-Involved Youths and Young Adults. Journal of Child & Adolescent Substance Abuse. 2009;18:398–409.Cheng et al. Page 8Health Place. Author manuscript; available in PMC 2014 September 01.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author ManuscriptWood E, Stoltz JA, Montaner JS, Kerr T. Evaluating methamphetamine use and risks of injectioninitiation among street youth: the ARYS study. Harm reduction journal. 2006; 3:18. [PubMed:16723029]Wood E, Werb D, Kazatchkine M, Kerr T, Hankins C, Gorna R, Nutt D, Des Jarlais D, Barre-SinoussiF, Montaner J. Vienna Declaration: a call for evidence-based drug policies. Lancet. 2010;376:310–2. [PubMed: 20650517]Cheng et al. Page 9Health Place. Author manuscript; available in PMC 2014 September 01.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author ManuscriptCheng et al. Page 10Table 1Characteristics of street-involved youth at baseline (n=685).Characteristic Total (%)(n =685) Homeless†p - valueYes (%)(n =493) No (%)(n =192)Older age Median (IQR) 22 (20–24) 22 (20–24) 22 (19–24) 0.057Gender (Female vs. male) 219 (32.0) 146 (29.6) 73 (38.0) 0.034Caucasian ethnicity (Yes vs. no) 447 (65.2) 337 (68.4) 110 (57.3) 0.006Stable relationship (currently) (Yes vs. no) 199 (29.0) 127 (25.8) 72 (37.5) 0.002Regular employment† (Yes vs. no) 386 (56.4) 283 (57.4) 103 (53.6) 0.373Frequent alcohol use (>4 drinks/day)† (Yes vs. no) 403 (58.8) 64 (13.0) 17 (9.0) 0.994Binge drug use*† (Yes vs. no) 194 (28.3) 159 (32.3) 35 (18.2) <0.001Daily heroin use*† (Yes vs. no) 80 (11.7) 56 (11.4) 24 (12.5) 0.676Daily cocaine use*† (Yes vs. no) 27 (3.9) 25 (5.1) 2 (1.0) 0.015Daily crystal meth use*† (Yes vs. no) 99 (14.5) 80 (16.2) 19 (9.9) 0.034Daily crack smoking† (Yes vs. no) 115 (16.8) 94 (19.1) 21 (10.9) 0.011Difficulty accessing addiction treatment † (Yes vs. no) 78 (11.4) 67 (13.6) 11 (5.7) 0.004Incarceration† (Yes vs. no) 134 (19.6) 114 (23.1) 20 (10.4) <0.001Drug dealing† (Yes vs. no) 368 (53.7) 284 (57.6) 84 (43.8) <0.001Sex work† (Yes vs. no) 69 (10.1) 56 (11.4) 13 (6.8) 0.073Difficulty accessing housing† (Yes vs. no) 165 (24.1) 152 (30.8) 13 (6.8) <0.001*Injection or non-injection use†Refers to activities in the past six monthsHealth Place. Author manuscript; available in PMC 2014 September 01.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author ManuscriptCheng et al. Page 11Table 2Univariate generalized linear mixed-effects analyses of factors associated with transitioning into and out ofhomelessness among street-involved youth in Vancouver (n=685).CharacteristicHoused to Homeless vs. Consistently Housed Homeless to Housed vs. Consistently HomelessOdds Ratio (95% CI) p - value Odds Ratio (95% CI) p - valueOlder age (Per year older) 0.96 (0.91 – 1.01) 0.106 1.01 (0.97 – 1.06) 0.528Gender (Female vs. male) 0.55 (0.40 – 0.76) <0.001 1.09 (0.85 – 1.39) 0.507Caucasian ethnicity (Yes vs. no) 1.38 (1.03 – 1.86) 0.034 0.86 (0.68 – 1.10) 0.236Stable relationship (currently) (Yes vs. no) 0.60 (0.45 – 0.82) 0.001 1.46 (1.16 – 1.85) 0.002Regular employment† (Yes vs. no) 0.96 (0.72 – 1.29) 0.790 1.34 (1.07 – 1.69) 0.012Frequent alcohol use (>4 drinks/day)† (Yes vs. no) 2.10 (1.56 – 2.81) <0.001 0.87 (0.69 – 1.09) 0.230Binge drug use*† (Yes vs. no) 1.96 (1.42 – 2.71) <0.001 0.66 (0.51 – 0.85) 0.001Daily heroin use*† (Yes vs. no) 1.66 (1.11 – 2.49) 0.015 0.64 (0.45 – 0.92) 0.016Daily cocaine use*† (Yes vs. no) 1.30 (0.40 – 4.29) 0.664 0.52 (0.22 – 1.21) 0.128Daily crystal meth use*† (Yes vs. no) 1.12 (0.70 – 1.80) 0.630 0.60 (0.42 – 0.84) 0.003Daily crack smoking† (Yes vs. no) 2.54 (1.67 – 3.87) <0.001 0.85 (0.61 – 1.18) 0.316Difficulty accessing addiction treatment† (Yes vs. no) 2.00 (1.19 – 3.36) 0.009 0.46 (0.31 – 0.69) <0.001Incarceration† (Yes vs. no) 2.76 (1.87 – 4.07) <0.001 0.57 (0.43 – 0.77) <0.001Drug dealing† (Yes vs. no) 2.26 (1.65 – 3.11) <0.001 0.69 (0.53 – 0.89) 0.004Sex work† (Yes vs. no) 1.06 (0.60 – 1.89) 0.845 1.20 (0.76 – 1.90) 0.421Difficulty accessing housing † (Yes vs. no) 7.89 (4.89 – 12.73) <0.001 0.18 (0.12 – 0.27) <0.001*Injection or non-injection use†Refers to activities in the past six monthsHealth Place. Author manuscript; available in PMC 2014 September 01.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author ManuscriptCheng et al. Page 12Table 3Multivariate generalized linear mixed-effects analyses of factors associated with transitioning into and out ofhomelessness among street youth in Vancouver (n=685).CharacteristicHoused to Homeless vs. Consistently Housed Homeless to Housed vs. Consistently HomelessAdjusted Odds Ratio (95% CI) p - value Adjusted Odds Ratio (95% CI) p - valueOlder age (Per year older) 0.94 (0.88 – 0.99) 0.030 1.02 (0.97 – 1.07) 0.387Gender (Female vs. male) 0.62 (0.43 – 0.90) 0.011 1.01 (0.76 – 1.33) 0.968Caucasian ethnicity (Yes vs. no) 1.48 (1.07 – 2.04) 0.018 0.87 (0.68 – 1.13) 0.301Stable relationship (currently) (Yes vs. no) 0.70 (0.50 – 0.97) 0.030 1.42 (1.11 – 1.83) 0.007Regular employment† (Yes vs. no) 0.96 (0.70 – 1.33) 0.823 1.27 (0.99 – 1.63) 0.065Frequent alcohol use (>4 drinks/day)† (Yes vs. no) 2.53 (1.55 – 4.14) <0.001 0.68 (0.46 – 1.02) 0.062Binge drug use*† (Yes vs. no) 1.39 (0.97 – 1.99) 0.073 0.78 (0.59 – 1.03) 0.081Daily heroin use*† (Yes vs. no) 1.46 (0.93 – 2.31) 0.102 0.64 (0.43 – 0.95) 0.028Daily cocaine use*† (Yes vs. no) 0.65 (0.18 – 2.31) 0.501 0.71 (0.29 – 1.75) 0.454Daily crystal meth use*† (Yes vs. no) 1.03 (0.61 – 1.73) 0.915 0.67 (0.46 – 0.97) 0.034Daily crack smoking† (Yes vs. no) 2.33 (1.43 – 3.79) 0.001 0.92 (0.63 – 1.34) 0.660Difficulty accessing addiction treatment† (Yes vs. no) 1.60 (0.91 – 2.81) 0.103 0.65 (0.42 – 0.99) 0.044Incarceration† (Yes vs. no) 1.97 (1.29 – 3.01) 0.002 0.72 (0.53 – 0.99) 0.041Drug dealing† (Yes vs. no) 1.42 (0.99 – 2.04) 0.060 0.95 (0.72 – 1.27) 0.728Sex work† (Yes vs. no) 0.83 (0.44 – 1.57) 0.566 1.70 (1.03 – 2.79) 0.039Difficulty accessing housing† (Yes vs. no) 7.22 (4.40 – 11.84) <0.001 0.20 (0.13 – 0.30) <0.001*Injection or non-injection use†Refers to activities in the past six monthsHealth Place. Author manuscript; available in PMC 2014 September 01.

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