AIM This paper is a report of a study to document researcher, healthcare provider and programme administrators' experiences with ethical issues in research with homeless youths in North America. BACKGROUND While there are legal and ethical guidelines for research with adolescents and with vulnerable populations in general, there are no specific guidelines for the ethical conduct of research with homeless youths. METHODS Using a web-based questionnaire, healthcare and social service providers, programme administrators and researchers working with homeless young people throughout the United States of America and Canada were surveyed in 2005. The survey group consisted of 120 individuals; a total of 72 individuals completed the survey. Survey questions included experiences with using incentives in research with homeless youths, consent and experiences with ethics review boards. Numerical data were analysed using frequencies and cross-tabulations. Text data were analysed qualitatively. FINDINGS Researchers doing mental health and/or substance use research tended to use money as a research incentive, whereas healthcare providers and programme administrators tended to use non-monetary incentives. The majority of respondents reported using written consent for research from homeless youths, including minors. Respondents reporting difficulties with ethics review boards were mainly involved with intervention research. CONCLUSION Consensus is needed from a variety of stakeholders, including homeless youths and service providers, on use of various types of research incentives for different types of research, as well as use of consent for homeless youths who are minors.

AIM:This paper reports a study describing the experiences and perspectives of homeless young people as research participants.BACKGROUND:Worldwide, homeless young people are an especially vulnerable group due to their age, socio-economic disadvantage, and stigmatized status, and can suffer from human rights abuses. Researchers and advocates have noted that we know relatively little about the effects of research participation on adolescents in general, and much less about marginalized adolescents such as homeless young people; nor do we know about their perceptions and experiences as research participants. There is a lack of studies reported to help guide the ethical conduct of research with homeless young people.METHODS:Individual interviews with 30 street and clinic-based homeless young people aged 15-23 years and two focus groups with a total of 13 additional homeless young people were conducted in a large West-coast city in the United States of America. The study took place between January and June 2003. Interviews and focus groups were tape-recorded, transcribed, preliminarily coded, with final coding crosschecked and verified with a second researcher.FINDINGS:The majority of young people reported positive experiences as research participants in the past. None reported coercive research experiences; however, many stated that they would have liked more information about how the data they provided would be used by the researchers. All participants reported that it was important to be provided with research incentives, and thought that small monetary or pre-paid phone cards were appropriate incentives. They did express concerns that larger research incentives could be coercive and harmful for some homeless young people.CONCLUSION:Researchers working with homeless young people should seek greater input from them on the overall design of the study, especially concerning the appropriate use of research incentives.

Correspondence: B. Josephine Ensign, Psychosocial and Community Health, University of Washington, Box 357263, University of Washington, Seattle, Washington 98195-7263, USA. E-mail: bjensign@u.washington.edu ENSIGN B.J . (2006) Journal of Advanced Nursing 54(6), 647–652 Perspectives and experiences of homeless young people Aim. This paper reports a study describing the experiences and perspectives of homeless young people as research participants. Background. Worldwide, homeless young people are an especially vulnerable group due to their age, socio-economic disadvantage, and stigmatized status, and can suffer from human rights abuses. Researchers and advocates have noted that we know relatively little about the effects of research participation on adolescents in general, and much less about marginalized adolescents such as homeless young people; nor do we know about their perceptions and experiences as research participants. There is a lack of studies reported to help guide the ethical conduct of research with homeless young people. Methods. Individual interviews with 30 street and clinic-based homeless young people aged 15–23 years and two focus groups with a total of 13 additional homeless young people were conducted in a large West-coast city in the United States of America. The study took place between January and June 2003. Interviews and focus groups were tape-recorded, transcribed, preliminarily coded, with final coding crosschecked and verified with a second researcher. Findings. The majority of young people reported positive experiences as research participants in the past. None reported coercive research experiences; however, many stated that they would have liked more information about how the data they provided would be used by the researchers. All participants reported that it was important to be provided with research incentives, and thought that small monetary or pre-paid phone cards were appropriate incentives. They did express concerns that larger research incentives could be coercive and harmful for some homeless young people. Conclusion. Researchers working with homeless young people should seek greater input from them on the overall design of the study, especially concerning the appropriate use of research incentives.

The purpose of this study was to document the illness experiences of homeless youth. The research was a focused ethnography with 45 clinic- and street-based homeless youth aged 15 to 23 years. The authors noted gender differences for health-seeking behaviors, with most male youth reporting embarrassment about needing to seek care, and female youth reporting fears over safety issues while ill and homeless. Most youth under age 18 stated that they were often denied health care at hospitals because of their underage status, and youth over age 18 stated that health care bills contributed to their inability to obtain stable housing. Street-based youth reported more illnesses related to substance use and greater reliance on emergency departments for health care than clinic-based youth did. Policies and programs focused on improving the health of homeless youth need to address the differences in illness experiences by age, gender, and sampling site.

OBJECTIVE:To develop homeless-youth-identified process and outcome measures of quality of health care. DATA SOURCES/STUDY SETTING:Primary data collection with homeless youth from both street and clinic settings in Seattle, Washington, for calendar year 2002. STUDY DESIGN:The research was a focused ethnography, using key informant and in-depth individual interviews as well as focus groups with a purposeful sample of 47 homeless youth aged 12-23 years. DATA COLLECTION/EXTRACTION METHODS:All interviews and focus groups were tape-recorded, transcribed, and preliminarily coded, with final coding cross-checked and verified with a second researcher. PRINCIPAL FINDINGS:Homeless youth most often stated that cultural and interpersonal aspects of quality of care were important to them. Physical aspects of quality of care reported by the youth were health care sites separate from those for homeless adults, and sites that offered a choice of allopathic and complementary medicine. Outcomes of health care included survival of homelessness, functional and disease-state improvement, and having increased trust and connections with adults and with the wider community. CONCLUSIONS:Homeless youth identified components of quality of care as well as how quality of care should be measured. Their perspectives will be included in a larger follow-up study to develop quality of care indicators for homeless youth.

Background. There is a need for increased guidance for the ethical conduct of qualitative research with vulnerable populations such as homeless youths.Aim. The purpose of this paper is to provide an overview of the main ethical challenges of conducting qualitative research with homeless youths and to propose possible solutions to these challenges.Methods. This paper was informed by a review of professional guidelines for the ethical conduct of adolescent health research, national (US) and international bioethics bibliographical searches, and personal experience with qualitative research with homeless youths.Findings. The main ethical challenges of conducting qualitative research with homeless youths include establishing and maintaining healthy researcher roles and boundaries, addressing the risks of researcher burn-out and safety issues, assuring optimal confidentiality, and avoiding sensationalism and voyeurism.Conclusion. It is important for qualitative researchers who work with vulnerable populations to ensure that research is conducted in the most ethical way possible.

1. Eye movement desensitization and reprocessing (EMDR) is an integrative therapy that "unlocks" disturbing memories or beliefs and reprocessess them, in some way, so they are no longer as disabling. 2. EMDR can be used for any experientially based psychological problems and has proven especially effective for traumatic imagery associated with posttraumatic stress disorder. 3. A primary benefit of EMDR is its time efficiency, requiring as few as 3 to 5 hours of treatment. 4. Many potential mechanisms (i.e., cognitive, hypnotic, self-disclosure, biological) may account for the effectiveness of EMDR.

A Brief and Effective Treatment for Stress

Purpose: Homeless youth are widely acknowledged as being a particularly medically vulnerable population in the United States. While the health problems of homeless youth are well-established, factors related to monitoring and improving the quality of primary health care for these youth and for subgroups of these youth are not well-established. The purpose of this study was to document the illness experiences of homeless youth, and whether these experiences differed by age and gender.

The purpose of this article is to describe a unique model for the provision of comprehensive primary health care for homeless youth in Seattle, Washington. Through the description of our program, we argue for the use of youth-centric instead of youth-friendly programs. This means a change from using the friendly health program as the central focus to having the young people be the starting point and adapting the health service to meet their needs. We describe how our model of care optimizes chances for homeless youth to establish positive connections with caring adults. We also show how homeless youth have their own street culture, which is of primary importance to them and which has a powerful impact on how they use and view health care.

AIM:The purpose of this study was to conduct an assessment of reproductive health-seeking behaviours, sources of advice, and access to care issues among a sample of clinic-based homeless adolescent women.BACKGROUND:Adolescent women are among the most vulnerable and medically underserved subgroups within the homeless population in the United States. Homeless youth are rarely invited to participate in research aimed at improving their access to appropriate health care. Also, the culture in which they live and the personal experience of being homeless are often not addressed.STUDY METHOD:The research was descriptive, using focus groups and individual interviews with a purposeful sample of 20 female youth, aged 14-23 years.FINDINGS:The women said that they seek health advice from other women, including their mothers even while they are homeless. They reported first trying self-care interventions, and going to clinics when self-care actions no longer worked. They stated that the main barriers to health care were lack of insurance, confusion over consent, transportation problems, lack of respect (from providers) for their own self-knowledge, and judgementalism from providers.CONCLUSION:Using the concept of cultural competency, the results provide insights into how to improve communication and health care services for these women.RECOMMENDATIONS:Health care providers need to recognize and appreciate the lifestyle, beliefs, and adaptive attitudes of homeless youth, rather than labelling them as 'deviant'. All personnel who interact with and on behalf of homeless youth must be adequately trained in general knowledge regarding the health of homeless youth as well as in an understanding of the role that culture plays in their health-seeking behaviours.

There is a lack of information on the health needs of foster care adolescents in emergency shelters or group homes. The purpose of this study was to conduct an assessment of access to health care among shelter-based foster care adolescents in Baltimore, Maryland. The health passports of all the foster care youth staying at two emergency shelters had data extracted to a standardized chart audit tool. In addition, semistructured interviews were conducted with 15 of the adolescents and five shelter staff. Of the 84 passports, only nine (10.7%) had documented up-to-date immunizations, and only one (1.2%) had documented purified protein derivative (PPD) application and reading. A total of 11 (13.1%) met the criteria for significant delay in recommended follow-up to care. Major themes of the interviews revealed that shelter staff and youth were unaware of specific health care recommendations, or were unable to obtain needed health care due to insurance problems or prolonged waiting for appointment times. The results of this health passport audit indicate that shelter-based foster care youth suffer from worse access to health care than do comparable nonshelter-based foster care youth from the same city. Specific public health nursing recommendations are made for improving health supervision for these vulnerable youth.

Models of women's health care have focused on the needs and issues of adult women and have not included those of adolescent women. This bias is true even for feminist-identified researchers and practitioners. Most health services for young women tend to deal exclusively, or in large measure, with their reproductive health, are planned by adults using an adult health care model and do not approach health care provision from a feminist perspective. In addition, there is a lack of information on the special health needs and issues of out-of-the-mainstream adolescent females such as homeless, immigrant, lesbian/bisexual identified young women. The main purpose of this paper is to describe guiding principals, as well as some of the practical pitfalls and ethical dilemmas in the provision of feminist health care for out-of-the-mainstream adolescent women.

Objectives: Homeless adolescent women are at high risk for negative health outcomes including early unplanned pregnancy and sexually transmitted diseases. The purpose of this study was to he:,lr the perspectives of homeless adolescent females on the topics of health issues, self-care and Fertility control, as well as on lessons from being homeless.Design: The research was descriptive. using semi-structured inter views and focus groups with a purposeful sample of 20 clinic-based female youth ages 15-23 years. The data were coded and analyzed following standard qualitative techniques.Results: The youth described female-specific health issues of being homeless, such as problems with hygiene, sexual exploitation, survival sex. Most knew of homeless female youth who had tried self-induced abortions through drugs, herbs or physical abuse. They spoke of fertility control practices of young women living on the streets. The women also spoke of the lessons they had learned while being homeless, including the development of self-sufficiency.Conclusions: The young women in this study were willing to discuss their perspectives and experiences of being homeless. Health care providers should receive increased training in how to ask about sensitive subjects such as survival sex and the practice of self-induced abortions. Programs should be structured to ensure engagement of the women in healthy relationships with adults.

Homeless youth suffer from high rates of health problems, yet little is known about their perceptions of or context for their own health issues. In this study, a combination of qualitative techniques from participatory rural appraisal and rapid assessment procedures was used to investigate the perceptions of health needs of shelter-based youth in Baltimore, ML in the U.S.A. The most common youth-identified health problems included STDs, HIV/AIDS, pregnancy, depression, drug use and injuries. These correlate well with more objective health status data for the same youth. The youth spoke of environmental safety threats of violence and victimization by adults, as well as racism and sexism in their lives. Youth reported that trusted adult figures such as grandmothers are important sources of health advice. Many homeless youth from less than ideal family situations remain in contact with and continue to seek advice from parents and other family members. Health interventions with urban street youth need to acknowledge the primacy of the social context for these youth, as well as the reality of violence as a daily health threat.

OBJECTIVE To examine the health status, risk-taking behaviors, and access-to-care issues of shelter-based homeless adolescents compared with a domiciled adolescent population from the same large US city. SUBJECTS The samples consisted of 109 youth (aged 12-17 years) in emergency shelters and 1010 youth using school-based inner-city clinics. INTERVENTIONS Adolescents completed a health history, which was followed by a physical examination. RESULTS Homeless youth began sexual activity at an earlier age (median, 12 vs 13 years for homeless vs school-based youth), were less likely to have used birth control at their first sexual experience, and were twice as likely to have ever been pregnant. Oral and anal sex, same-sex activities (boys only), multiple sex partners in the past 30 days, depression, and substance use behaviors were reported more often by the homeless sample. The homeless youth were twice as likely to have visited an emergency department in the past 12 months. After adjustment for other risk factors, homelessness was an independent predictor of depression (adjusted odds ratio [OR], 7.0; 95% confidence interval [CI], 3.9-12.6), emergency department use in the past 12 months (adjusted OR, 1.8; 95% CI, 1.2-2.7), and history of pregnancy (adjusted OR, 2.6; 95% CI, 1.3-5.2) in the final logistic regression models. CONCLUSION This study confirms and extends past research indicating that homeless youth exhibit more risk-taking behaviors and suffer from poorer overall health than do nonhomeless youth.

Objectives: To compare the self-reported risk-taking behaviors, health status, and access to care issues of 2 samples of shelter-based homeless youth who had previously been street youth (youth on streets or doubling-up with friends or lovers) and systems youth (youth involved in foster care) and to examine information on the etiology of homelessness, including parent or family of origin risk factors for both samples.Design: The study population consisted of 109 shelter-based homeless youth: 41 street youth and 68 systems youth. A chart audit was completed on all youth, noting documentation of past health problems, reasons for shelter placement, and parental risk factors. Adolescents from both samples completed a health history questionnaire followed by a physical examination. Differences between the 2 samples for behaviors and disease diagnoses were examined using chi(2) and 2-tailed t tests.Results: The street youth exhibited greater risk-taking behaviors and suffered from poorer health status and access to care than did systems youth. The main differences were in substance using and high-risk sexual behaviors. The street youth were more likely to report previous exposure to violence and having been victims of forced sex. Self-reported risk behaviors, including sexual activity and substance abuse were corroborated by more objective information on these items from medical record information. The street youth were more likely to be medically uninsured, to have used an emergency department in the past year, and to have used an emergency department for their last care.Conclusions: There are important variations in health needs between samples of homeless youth, often overlooked in health planning for this population. Knowledge of parent or family of origin risk factors and causes of homelessness provides important contextual information for understanding the risk behaviors and health states of homeless youth.