Food insecurity among formerly homeless youth in supportive housing: A social-ecological analysis of a structural intervention

Journal Pre-proof Food insecurity among formerly homeless youth in supportive housing: A socialecological analysis of a structural intervention Sarah Brothers, Jess Lin, Jeffrey Schonberg, Corey Drew, Colette Auerswald PII:

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https://doi.org/10.1016/j.socscimed.2019.112724

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SSM 112724

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Social Science & Medicine

Received Date: 24 June 2019 Revised Date:

3 December 2019

Accepted Date: 4 December 2019

Please cite this article as: Brothers, S., Lin, J., Schonberg, J., Drew, C., Auerswald, C., Food insecurity among formerly homeless youth in supportive housing: A social-ecological analysis of a structural intervention, Social Science & Medicine (2020), doi: https://doi.org/10.1016/j.socscimed.2019.112724. This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2019 Published by Elsevier Ltd.

Manuscript Number: SSM-D-19-01945R1 Title: Food insecurity among formerly homeless youth in supportive housing: A socialecological analysis of a structural intervention Authors: Sarah Brothersa, Jess Linb, Jeffrey Schonbergc, Corey Drewb, Colette Auerswaldd Corresponding Author: [email protected] tel: 919-272-4225 a

Department of Sociology, Yale University, 493 College Street, New Haven, CT, 06511,

United States. b

San Francisco Department of Public Health; University of California, Berkeley School

of Public Health. c

Department of Sociology, San Francisco State University; Berkeley Center for Social

Medicine, University of California, Berkeley. d

i4Y (Innovations for Youth), University of California, Berkeley School of Public

Health. Acknowledgements: We have previously presented aspects of this work at the Society for Adolescent Health and Medicine and the American Public Health Association annual meetings. Our study would not have been possible without our research staff, students, and volunteers including Andrew Campbell, Taylor Cuffaro, Deborah Karasek, Erika Molina, and Janelle Silvis. We are also grateful to the support and collaboration of the building staff. This research was supported by a grants and financial support from the Robert Wood Johnson Health and Society Scholars Program, the UC Berkeley School of Public Health, and the AE Bennett Fund. Our greatest debt of gratitude goes to our participants, who welcomed us to their home and trusted us with their stories.

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Title Food insecurity among formerly homeless youth in supportive housing: A social-ecological analysis of a structural intervention Abstract A growing body of research indicates that structural interventions to provide permanent supportive housing (PSH) to homeless adults within a Housing First approach can improve their health. However, research is lacking regarding the impact of PSH on youth experiencing homelessness. This article seeks to understand how PSH for youth impacts a basic health need— food security— across multiple levels of the social-ecological environment. In January of 2014, San Francisco, California opened the city’s first municipally-funded PSH building exclusively designated for transition-aged youth (ages 18-24). We conducted 20 months of participant observation and in-depth interviews with 39 youth from April 2014 to December 2015. Ethnographic fieldnotes and interview transcripts were analyzed using grounded theory. We present our social-ecological assessment regarding food insecurity for formerly homeless youth in supportive housing. We found that although housing removes some major sources of food insecurity from their lives, it adds others. Many of the participating youth were frequently hungry and went without food for entire days. Mechanisms across multiple levels of the socialecological model contribute to food insecurity. Mechanisms on the structural level include stigma, neighborhood food resources, and monthly hunger cycles. Mechanisms on the institutional level include the transition into housing and housing policies regarding kitchen use and food storage. Interpersonal level mechanisms include food sharing within social networks. Individual level mechanisms include limited cooking skills, equipment, and coping strategies to manage hunger. Although supportive housing provides shelter to youth, effective implementation of the Housing First/PSH model for youth must ensure their access to an affordable nutritious diet. Keywords: San Francisco United States Transition-Aged Youth Homeless Youth Food Insecurity Housing Permanent Supportive Housing Qualitative Research

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Introduction

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United States (Morton et al. 2018). On any given night, 1,259 or more transition-aged youth

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(ages 18-24) are estimated to be homeless in San Francisco (Applied Survey Research 2017).

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Youth experiencing homelessness (YEH) suffer significant disparities in morbidity and mortality

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relative to their housed peers (Institute of Medicine 2009, Edidin et al. 2012, Auerswald et al.

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2016), including a high risk of mental health disorders (Ammerman et al. 2004, Hodgson et al.

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2015), sexually transmitted infections, HIV infection (Medlow et al. 2014), and suicide attempts

Three and a half million youth aged 18 to 25 experience homelessness yearly in the

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(Rew et al. 2001). YEH’s standardized mortality rates are 3 to 37 times higher than the general

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population’s (Allen et al. 1994, Parriott et al. 2013). In addition, YEH suffer from severe food

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insecurity (Dachner and Tarasuk 2002, Whitbeck et al. 2006), defined as a “limited or uncertain

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availability of nutritionally adequate and safe foods, or limited or uncertain ability to acquire

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acceptable foods in socially acceptable ways” (Bickel et al. 2000:6).

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Structural Interventions for Youth

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Interventions for YEH have focused primarily on addressing individual determinants of

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risk through behavioral interventions (Rotheram-Borus et al. 1991, Slesnick et al. 2009). Of

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these, most focus on modifying individual HIV risk or substance use, and few have proven to be

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successful for addressing the significant health disparities faced by YEH (Altena et al. 2010).

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As is the case for all marginalized and excluded youth, health disparities experienced by

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YEH are determined not only by their individual behaviors but also by their social determinants

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of health (SDH), which include shelter, educational opportunities, living and working conditions,

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medical care, local and federal laws and policies, and other social factors that influence health

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(Marmot et al. 2008, Viner et al. 2012). Youth who lack adequate access to these determinants

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suffer poorer health than those who have adequate access (Marmot and Wilkinson 2006).

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Research on YEH has shown that ongoing, recurrent housing instability and other barriers to

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SDH are more significantly related to health disparities than any individual risk behaviors

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(Cheng et al. 2013). However, the majority of current interventions do not address the underlying

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causes of poor outcomes for youth.

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The World Health Organization and the Lancet Commission on Adolescent Health have

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called for structural interventions such as housing to address SDH for YEH (World Health

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Organization 2014, Patton et al. 2016, Marmot et al. 2008). Interventions during this critical

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developmental window can have significant long-term health impacts over the life course

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(Braveman et al. 2011, Bonnie et al. 2014). As per the Lancet Commission Report on Adolescent

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Health and Wellbeing, “investments in adolescent health and wellbeing bring a triple dividend of

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benefits now, into future adult life, and for the next generation of children” (Patton et al. 2016:

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2424). Interventions to ameliorate health inequalities for economically marginalized youth,

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including those experiencing homelessness, are particularly important because they have

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significant health problems and limited access to resources (Patton et al. 2016).

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Housing Interventions for Youth

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Research regarding the effect of youth housing interventions on SDH is limited because

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the majority of interventions for youth to date have mainly provided temporary housing through

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drop-in shelters or transitional housing, which are time-limited housing programs that provide

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stable housing for up to 24 months and often include skills training and supportive services

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(Slesnick et al. 2009, De Rosa et al. 1999). Nevertheless, research has shown that even

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temporary shelter for YEH yields positive benefits, including decreased substance use,

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improvements in mental health, increased number of days housed, and increased savings and

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educational and vocational attainment (Kisely et al. 2008, Frankish et al. 2005, Feng et al. 2013,

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Rashid 2004).

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The current gold standard for adult housing provision is the Housing First model, which

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provides permanent supportive housing (PSH) without requiring that residents change their

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behaviors or participate in supportive services or programs (Tsemberis and Eisenberg 2000).

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The Housing First model has proved successful for improving the health and decreasing the

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mortality of chronically homeless adults (Wolitski et al. 2010, Bean et al. 2013, Martinez and

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Burt 2006, Rog et al. 2014). Recently, there has been increasing interest in providing PSH to

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youth (Gaetz 2014). However, Housing First, like most housing models in which young people

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access emergency, temporary, or more permanent shelter, was designed for adults (Henwood et

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al. 2018, Kozloff et al. 2016) and it remains unclear how to implement PSH so it will be

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developmentally appropriate for youth (Munson et al. 2017).

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YEH are fundamentally different from adults experiencing homelessness in their skill

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sets, needs, and health issues. The United States Interagency Council on Homelessness has called

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for a developmentally appropriate system of care specifically for youth (Vilsack et al. 2013).

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Additional research is needed regarding housing interventions for YEH to inform the

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development of youth-appropriate models for long-term housing (Altena et al. 2010, Gaetz 2014,

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Bonnie et al. 2014).

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Transitions into Housing

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One recent study examined a PSH intervention for youth in Canada and found it

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increased housing stability for YEH with mental illness (Kozloff et al. 2016). However, housing

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stability alone is insufficient because youth need more than shelter to thrive. Some studies have

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found that YEH need and want more structure and support than adults (De Rosa et al. 1999,

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Gaetz 2014), including training in basic skills, like laundry, food shopping, and money

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management, to successfully maintain housing (Holtschneider 2016, Henwood et al. 2018). They

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also need support to attain the education and job training required to transition into independent

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adulthood (Gaetz & O’Grady, 2013). Research on youth transitioning out of homelessness has

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shown that the transition is difficult. One study in Canada found that the youths’ limited

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education, employment experience, and social capital kept them trapped in subsistence-level

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precarity even after they attained independent housing (Thulien et al. 2018). Many youth

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transitioning into housing experience persistent financial insecurity, lack of community

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integration, a decline in hope, and social isolation (Kidd et al. 2016, Karabanow et al. 2016).

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They often return to homelessness (Milburn et al. 2009). There is limited research specifically

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focused on the impact of structural interventions such as PSH on youth transitions out of

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homelessness, including their effects on social determinants of youth health such as food

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security.

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Food Insecurity

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YEH suffer from persistent food insecurity and hunger (Crawford et al. 2014, Reid &

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Klee 1999, Whitbeck et al. 2006, Tarasuk et al. 2009). Their daily lives are constrained by their

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search for sufficient food (Dachner and Tarasuk 2002). Food insecurity, in turn, may impact

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other determinants of health for youth. One study found associations between food security and

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HIV risk among YEH sex workers (Barreto et al. 2017). Food security has been identified as a

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key need for youth interventions (Patton et al. 2016) for several reasons: youth who are still

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growing and maturing have significant nutritional needs and food-related behaviors are largely

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adopted during adolescence. Such behaviors persist throughout the life course, and they are

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significant determinants of health (Viner et al. 2012). However, although food insecurity is

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frequently mentioned by participants in studies on formerly homeless youth transitioning into

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housing (i.e. Garrett et al 2008), there is little research on how supportive housing impacts youth

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food insecurity.

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Our Study

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To study this issue, we capitalized on a unique natural experiment in San Francisco to

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evaluate whether and how PSH impacts food insecurity for formerly homeless youth. In 2014,

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the City and County of San Francisco, in collaboration with a large supportive housing provider,

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opened the city’s first municipally funded PSH building targeted exclusively to transition-aged

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youth. At the time of this study, residents were required to pay thirty percent of their monthly

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income as rent. Non-payment of rent was grounds for eviction. We originally hypothesized that supportive housing would diminish food insecurity.

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However, in our baseline survey data, a majority of respondents reported very low food security,

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defined as reduced food intake and disrupted eating patterns (Coleman-Jensen et al. 2013), after

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moving into the building (Johnson et al. 2019). Three-quarters of respondents reported eating

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fewer meals per day than they wanted and half reported going an entire day without food.

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Importantly, youth reported their food insecurity had not improved, and for some, had worsened,

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relative to before they were housed.

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To understand why the youths’ food insecurity persisted despite housing, we examined

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our in-depth interviews and ethnographic data, in which food insecurity was a dominant theme.

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During our data analysis (Charmaz 1990), it became clear that youth food insecurity was

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determined on multiple levels. The social-ecological model emerged as the best theoretical

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framework for the data. Therefore, we employ it for our analysis of how a structural intervention

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impacts the food security of youth exiting homelessness.

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Social-Ecological Model The social-ecological model allows for close examination of how multiple interactive

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factors in the broader structural and institutional context, as well as interpersonal relationships

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and individual beliefs and behaviors, influence health (Bronfenbrenner 1979, Viner et al. 2012).

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It is rooted in Bronfenbrenner's ecological theory of human development (Bronfenbrenner,

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1979). Bronfenbrenner emphasized that human development is influenced by multiple

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environmental and social mechanisms on interactive and interrelated levels. The model is

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particularly useful for examining mechanisms that influence food security and other significant

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determinants of health and human development.

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The social-ecological model includes the broader societal levels that individuals interact

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with indirectly (the structural and institutional levels) and the levels that individuals interact with

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directly (the individual and interpersonal levels). The structural level encompasses broader

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societal norms including stigma, socio-economic forces including social policies, bureaucratic

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systems, and geographic locations. Mechanisms on the institutional level include local

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institutions such as schools, social service organizations, and medical clinics. The interpersonal

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level encompasses social networks including friends, family, and neighbors. The individual level

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examines how individual behaviors are influenced by knowledge, beliefs, and reactions to

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stressors (Kaufman et al. 2014). The model describes the ways in which factors at each of these

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levels interact with each other and the developing individual, influencing health needs such as

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food security and thus health outcomes, both positively and negatively.

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Here we aimed to understand how a structural intervention designed to ameliorate a key

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social determinant of health (housing) impacts a basic health need (food security) across multiple

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levels of the social-ecological model by studying youth transitioning into PSH.

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Methods

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These findings represent results from our larger mixed methods longitudinal study of how

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PSH impacts the health and well-being of YEH, conducted from April 2014 to August 2017. The

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study was designed to examine the ways a structural intervention might influence a youth’s

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social environment, health behaviors, acquisition of adult competencies, and ultimately their

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physical health. This article is drawn from the first 20 months of ethnographic research from

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April 2014 to December 2015 during which five ethnographers (SB, CA, JL, CD, JS) conducted

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1250 hours of participant observation in total and completed 39 baseline semi-structured in-depth

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interviews.

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Setting When the study building opened in January 2014, residency was available to 18 to 24-

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year-old youth who met the Department of Housing and Urban Development (HUD) definition

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for chronic homelessness. Chronic homelessness is defined as living with a disabling condition

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and experiencing continuous homelessness for at least a year or at least four homeless episodes

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in the past three years. Disabling conditions include substance use disorders, serious mental

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illness, developmental disabilities, PTSD, and cognitive impairments (US Department of

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Housing and Urban Development 2015). Designated local youth service providers referred

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residents to the building. Voluntary supportive services, including case management and

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educational and vocational services, were offered on-site. The building followed the “Housing

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First” model in which all services were opt-in. Sobriety or engagement in employment,

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schooling or vocational training were not required (Tsemberis & Eisenberg, 2000). The building

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contains 43 single occupancy residences. Some units have individual bathrooms; otherwise the

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bathrooms are shared. The kitchen is communal.

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Recruitment All youth living in the housing site were invited to participate. The only inclusion criteria

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was residence in the building. There were no exclusion criteria. We recruited on a rolling basis

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by posting fliers in the building, placing them in residents’ mailboxes, and distributing them at

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monthly meals we hosted. Youth participating in interviews were compensated with $25 in cash

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and a snack or small meal. We obtained written informed consent from all participants. All study

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aspects were reviewed and approved by our community collaborators. This study received ethics

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approval from the UC Berkeley Institutional Review Board.

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Data Collection

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Interviews were conducted at a mean of 3.5 months after youth moved into the building

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(range: 0-12 months). Prior to each interview, researchers clarified to participants that they were

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independent of housing staff and supportive service organizations, and individual information

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was confidential and not shared with supportive services. Four ethnographers (JS, SB, CA, CD)

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conducted interviews in English after collecting demographic information on gender,

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race/ethnicity, and age. No residents were non-English speaking. All interviewers had similar

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training in conducting semi-structured interviews and extensive experience working with

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vulnerable populations. Interviews took place in a private office in the building or in a location

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of the participant’s choosing, including nearby coffee shops, restaurants, or the participant’s

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room. Following grounded theory, interviews were an extended conversation (Charmaz 2014).

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To guide the interviews, ethnographers used a set of general concepts, intended to evoke

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responses detailing how PSH impacted youth health and well-being. These concepts included

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food security, violence, social services, family and social networks, sexual behavior, health

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behavior, engagement in care, income-generating strategies, and perceptions of PSH. Interviews

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were 45 to 120 minutes in length, audio recorded, and transcribed verbatim, with all identifiers

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excised.

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Participant observation included all youth residents of the building, Youth who were not

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formally enrolled in the study were omitted from the analysis. Prior to beginning participant

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observation, researchers identified themselves to youth. The ethnographic component examined

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participants’ central concerns with particular attention to general health and well-being, social

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networks, pets, education, income-generating strategies, drug use, and gender and sexuality. We

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observed participants in their rooms and the building’s common areas, at the monthly meals we

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hosted, in hospitals, walking in the neighborhood, visiting shops, procuring food and supplies,

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and playing with their pets. Ethnographers also ate regularly with participants and accompanied

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youth in their efforts to obtain education, employment, bank accounts, and medical help.

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Ethnographers recorded observations in typed fieldnotes.

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In cases where youth required urgent services, we checked in by phone or in person,

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notified the building’s staff with youth’s permission, and, if appropriate, referred or accompanied

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the participant to relevant agencies. After completing baseline data collection, we formally

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presented our findings to the youth at a dinner we sponsored.

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Analysis

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Constructivist grounded theory is the guiding methodology for data collection and

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analysis. It emphasizes an inductive approach that allows theoretical insights to emerge from

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participant’s lived experience (Charmaz 2014). Consistent with grounded theory (Charmaz

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2014), we simultaneously collected and analyzed the data. Interviews and ethnographic

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fieldnotes were entered into ATLAS.ti software for data management and analysis. Two

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investigators (CA, SB) conducted inductive analysis using grounded theory coding techniques

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including open coding, development of a codebook, and theoretical memos. Initially, CA and SB

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independently coded one transcript and compared results to reach consensus about preliminary

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codes. We then independently coded two transcripts using the agreed-upon codes, compared the

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appropriateness of assigning a particular code to a given passage or quote, and added new codes.

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CA and SB discussed and resolved coding discrepancies through re-reading relevant units of

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text. Once the codebook draft was created, the first author coded all transcripts and wrote

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detailed analytic memos on categories emerging from the data to refine analysis of processes at

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work in the youth’s daily lives. CA and SB then met multiple times to identify and develop

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relationships among categories. Food insecurity emerged during our analysis as a significant

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category. Next, we compared emergent categories with the literature (Charmaz 2014). As

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Charmaz writes, grounded theory analysis can be strengthened “by reaching back into extant

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theory” (1990:1171). During the analytic process, it became clear that the social-ecological

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model fit the data. Thus, although the social-ecological model did not originally inform our

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work, we chose this model as the framework for our results because it allowed us to deepen the

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analytic insights emerging from the data.

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Results

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Sample Characteristics

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We interviewed 39 individuals, including 17 men, 17 women, three transgender women,

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and two genderqueer youth. Their mean age was 22 years (range 18-25). Their most frequently

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reported primary sources of income were: disability benefits such as SSI (7), other government

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support including food stamps (8), part time employment (5), full time employment (4), family

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(2), and educational stipends (2). Eighteen participants identified as African American, nine as

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white, four as Latino/a, four as both African American and Latino/a, two as Native American.

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Two declined to state their racial/ethnic identity. Since we interviewed a small number of

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individuals in a defined social environment, identifying participants by cis- or trans-status, age,

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and/or racial identity could potentially violate their confidentiality. In the interest of

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confidentiality, we refer to participants solely as male or female based on their gender

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presentation.

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Overview of Findings

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PSH removes some major sources of food insecurity. However, many youth were

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frequently hungry and would go days without food. One woman said, “I’m not eatin’ okay, I will

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say. I haven’t ate in like four days because I haven’t had any money lately.”

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Multiple mechanisms across four levels of the social-ecological model influenced

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persistent food insecurity during participants’ first year in PSH. On the structural level,

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mechanisms include differential exposure to risk environments such as spatial inequity, stigma,

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and income and resource inequalities. Specific structural mechanisms that influenced

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participants’ food insecurity included the neighborhood food environment, stigma, and monthly

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hunger cycles. On the institutional level, mechanisms include how housing programs are

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designed and implemented. Specific institutional-level mechanisms that influenced participants’

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food insecurity included the process of moving into housing, and building policies regarding the

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kitchen and food storage. On the interpersonal level, mechanisms include the influence of social

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networks. Specific interpersonal mechanisms that influenced youth food insecurity included food

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sharing in social networks and interpersonal conflict. And, on the individual level, mechanisms

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include knowledge and behavioral reactions to inequities. Specific individual-level mechanisms

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that influenced participant food insecurity included lack of cooking skills or equipment and

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coping strategies in the face of persistent hunger.

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Figure 1 illustrates how a structural level-intervention (housing) impacts a structural-level

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determinant of health (food insecurity) through multiple mechanisms across four levels of the

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social-ecological model. Mechanisms may have positive or negative effects, as indicated by plus

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and minus symbols.

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Figure 1. Impact of Housing on Food Insecurity

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Structural Mechanisms

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Neighborhood Environment: Food Desert

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reason many residents subsist on junk food. The building is located on a block loud with traffic

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and a few hundred feet from a highway on-ramp. The four-lane road in front of its doors is

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backed up with commuter cars most of the day. Few youth who live in the building cross at the

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lights. Instead, they dart and weave across the lanes of traffic. One of the city’s largest shelters is

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a block away on the other side of the highway overpass. Across the street is a 24-hour donut

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shop that also sells weak coffee and burgers and is frequently cited for health code violations.

The housing site is effectively situated in a food desert (Walker et al. 2010), which is one

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Within two blocks of the building are two small bodegas that sell snacks and sodas and a gas

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station.

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Westward from the building are parking lots, low-end auto repair shops, a few older

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residential units, and blocks filled with SROs (single-room occupancy hotels). One block

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eastward, across the busy street and down an alley, are a bespoke women’s clothing shop, a

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coffee franchise, an enormous upscale grocery store, and large glass condominium towers. It is a

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10-minute walk to the nearest subway station, which is surrounded by expensive cafes,

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restaurants, retail shops, luxury hotels, and a massive six-floor mall with a food court,

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restaurants, three floors of shops circling an enormous light- and escalator-filled atrium, capped

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with more restaurants and a multi-plex cinema, and adjoining a manicured garden and fountains.

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During the duration of our fieldwork, we accompanied residents when they filled out job

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applications in this area, including fast food restaurants in the mall, none of them successfully.

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The upscale grocery store in the neighborhood is priced well out of reach of what most

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building residents can afford and is unfriendly to residents. One researcher brought a participant

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there for lunch and bought sandwiches for them, only to find the youth immediately accused of

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stealing the sandwich that had just been purchased. Cheaper supermarkets and food pantries are a

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very long walk or a bus ride distance away. The round-trip bus ride of about $5.50 exceeds the

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daily food budget for most residents. Youth must either pay for transportation to an affordable

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supermarket or endure stigma and judgment while paying for high-end local food. One woman

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explained that because affordable grocery stores are inconveniently far, she subsists on fast food

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most of the month. She said,

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I have enough food stamps to get food, like fast food. I kinda go grocery shopping once a month, and if I run out, then I just wing it the rest of the way on fast food. I don’t like to go grocery shopping twice because Safeway’s all the way down there, and then Whole Foods is so expensive.

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Stigma: Aversion to Homeless Identity Once housed, youth avoided accessing free sources of food, including food banks and

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soup kitchens some had formerly utilized. Several youth perceived these resources as being for

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currently homeless persons and felt they were no longer eligible for services now that they were

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stably housed. Others wanted to avoid the stigma or internalized shame of accessing such

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services. One woman detailed how she had barely eaten for weeks after losing her last job. She

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ran out of food stamps and survived on occasional meals from friends and acquaintances.

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Although she knew of food pantries she could visit, she chose to go hungry instead of putting

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herself in the category of homelessness she wanted to leave behind. She said, There’s food pantries and things like that but I leave that to people who are really homeless and out there and need it and don’t have food stamps and things like that. Another woman drastically changed how she obtained food when she moved into

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housing. When she was homeless, she would eat leftovers from restaurant tables, a strategy she

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stopped using upon entering housing. She reported she is usually hungry two weeks a month.

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She elaborated,

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Before, I had enough to eat but I was homeless. Now, my primary concern is alleviated. But I don’t have enough to eat. Several youths said they felt they drew too much negative attention at soup kitchens because of their young age. One woman said, The way they look at you- I attract so much attention, when you’re homeless like that, being young and shit, and then if you sit down to eat, the way people look at you eat, it’s kind of weird, too, they be payin’ attention. Monthly Hunger Cycles A major cause of food insecurity is the monthly income cycle experienced by residents living from one check to another. Many rely on governmental support, such as general

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assistance, SSI subsidies (for people with disabilities), or food stamps, which they receive at the

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beginning of the month. Per the housing program’s rules, their rent consumes 30% their income,

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leaving them little to budget. They are often broke by the end of the month. Our fieldnotes refer

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regularly to monthly hunger cycles. In July 2015 we wrote, “everyone is hungry, their food

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stamps aren’t coming in for another week.” In May 2015, one ethnographer wrote of a resident,

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He tells me that he’s tight on money because he got food stamps midway through April that he thought were for the remainder of the month but turned out to be through June 8. He used [them] too fast so now he’s out of luck until June.

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By the end of every month, residents frequently go without food. One woman said, Food generally becomes a problem toward maybe the last two weeks of the month on average. It’s just that last week or two, when I’m freakin’ desperate. Employed residents risk food insecurity because employment causes them to lose their

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governmental support, while their low hourly wages may be insufficient to cover rent and food

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costs. Then, if they are injured, terminated, or quit their job, they must reapply for aid, a slow

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process during which they are often hungry. One man said,

18 19 20 21 22

I don’t have any stamps or anything ‘cause I was working so recently. I re-applied but now I have that whole process, and the ones I had from this month are used. So I’ve just been getting ramen noodles ‘cause they’re really cheap. And just eating wherever I can. But not really as much as I like to.

23

Institutional Mechanisms

24

Moving into Housing

25

Youths’ narratives of their move into housing often included accounts of hunger.

26

Covering their initial rent left new residents with little money for food in an unfamiliar

27

neighborhood where they needed to find new sources for their basic needs. One woman

28

described being overjoyed that she now had stable housing, but faced new challenges. The

29

income she previously used for food and other living expenses now also had to cover rent.

16

1 2 3 4 5

Once I got here, the stress was, how am I gonna pay for food, how am I gonna pay my rent, my phone bill, my cigarettes, all this main factor with that little amount of income that I get.

6

One man said, “When I got there… I starved for three days.” One woman said she went hungry

7

after moving into the building until she found a nearby volunteer position that reimbursed her

8

with food.

9 10 11 12 13 14 15 16

Several residents said they did not eat for several days after they moved into the building.

I: Have you been hungry at all since you’ve been [in housing]? P: Once or twice, when I first moved in. Because I had no money for food. But I have resources. I’ve been volunteering at a shelter. They do provide [food] in the shelter. I have a free meal. Kitchen Policies Many residents, some of whom had rarely had access to a kitchen, described the

17

building’s communal kitchen, which contains two stoves and ample counter space, as a boon.

18

One man said,

19 20 21 22

I never had – I could say a free house – I never had a place that I could just eat – except for a foster home.

23

small refrigerators in their rooms allowed some residents to save money, control their diet and

24

prepare nutritious meals. One woman who moved into the building at the same time as her

25

boyfriend said,

26 27 28 29 30 31 32 33

Being able to cook for themselves in the kitchen and store leftovers and ingredients in the

Now we’re buying healthy food again. We have refrigerators and stuff, and now we can cook meals, and it’s so exciting. In addition, some residents said being able to store food in their rooms allowed them to pace their food consumption. One woman said, Food lasts a while, because for the most part, I really don’t eat that much anyway. So if I’m eating like a burger or something from here, I won’t even eat half of it, ‘cause after a while my stomach will tell me that’s enough. And then I’ll just save it for later. And I’ll

17

1 2 3 4

remember it’s in my refrigerator two days later when I’m super hungry, and just devour it. The building management hosted many events in the kitchen including classes,

5

community meetings, and project recruitments, supplying food to encourage resident attendance.

6

One woman said the food provided at building events decreased the amount of food she felt she

7

needed to steal in order to eat.

8 9 10 11 12 13 14 15

I: So you mentioned you were having to steal more when you were homeless? P: Yeah, ‘cause I was hungry. I: How has having housing changed that? P: I guess it’s because of the meetings that we have. There’s usually food there, so I guess that’s a lot helpful for me. So if I just get up and make it to the meeting, then I won’t be hungry.

16

support staff person occasionally used their own money to buy them sandwiches when told

17

residents had not eaten for several days.

18

The building’s staff sometimes provided food to residents. Several residents said one

Some aspects of the building’s policies and spatial layout increased food insecurity.

19

Building management restricted use of communal cooking equipment, forcing residents to

20

procure their own cooking supplies. Residents were not permitted to store personal cooking

21

supplies, utensils, or food in the kitchen. To cook, they needed to carry everything necessary for

22

preparing a meal from their rooms, down one or two flights of stairs. This was a challenge,

23

particularly for youth with physical disabilities or chronic physical illnesses. The work involved

24

in carting everything back and forth led some residents to limit their use of the kitchen. One man,

25

whose girlfriend also lived in the building, said,

26 27 28 29 30

I should be eating better. We have a bunch of appliances. We have a coffee maker, a toaster. We have an egg poacher. We have a blender. We have a juicer. We have everything we need. We just don’t have a place in the kitchen to store it. Another man said he preferred to get fast food rather than cook due to the logistical barriers.

18

1 2 3 4 5

Interpersonal Mechanisms

6

Food Sharing

7

I was in the habit of getting fast food because of the community kitchen. It would be easier, more convenient than going all the way downstairs and cooking and then going all the way upstairs, taking all the pots and pans and groceries down.

Sharing of food within social networks both increased and decreased food security.

8

Demands for food by other residents could be a problem for youth with limited means. One

9

resident explained he rarely cooked because anytime he did, other youth asked him for food, and

10 11 12 13 14 15

he did not have enough to share. He said, I try not to [use the kitchen] because it’s just too much. I hate feelin’ bad when I have to tell someone no. However, providing a fellow resident with food could ensure they had people to ask for food when they were in need. One woman said,

16 17 18 19 20 21

When people used to ask me for food, I used to be like, where’s their other family be to feed ‘em. But at the same time I used to think, “Okay, what if I didn’t have no food? They’ll give it to me so I have to give it to them.” So I would just kiss it up and give them some food because they woulda did it for me.

22

man who lost his job when he severely injured his back subsisted on food other residents shared

23

with him while he waited to receive food stamps. He said,

24 25 26 27 28 29 30 31 32 33

Several people said other residents shared food with them when they were hungry. One

As of the last month, when I didn’t have food, I have a few people in the building I can turn to. They’re really cool. When I didn’t have anything we would go grocery shopping with his EBT [food stamp] card. If I ain’t got somethin’ and he got it, he puts me in the loop. And vice versa. Residents also reported sharing food with members of their social network outside the building. One woman said, I got my food stamps on the third and I’m already half way through my shit. ‘Cause I have to feed my sister. Feeding other people goes into that thing, too.

19

1

Some residents felt obligated to take care of their unhoused friends’ food needs because

2

they felt having housing made them wealthier. These social ties sometimes prevented residents

3

from fully meeting their own food needs.

4

Interpersonal Conflict

5

Many residents avoided the kitchen because they feared altercations with other residents

6

or because they were concerned about food theft. Spending time in the kitchen while cooking or

7

eating could lead to physical or verbal altercations. For instance, one day while a group of

8

residents attended a community meeting, another resident came in angry and tried to topple the

9

soda machine. Another day, we saw a resident shrink away from a man in the kitchen who, she

10

said, had recently punched her in a dispute over the TV remote control. We also witnessed a

11

resident yelling homophobic and ethnic slurs at black and transgender residents who were calmly

12

eating in the kitchen.

13

Food theft was a problem for some residents cooking in the kitchen. To limit the amount

14

of time they spent in the kitchen, many residents returned to their rooms while their food heated.

15

Some returned to the kitchen to find their food stolen. One woman shared her frustration,

16 17 18 19 20 21 22

People have stole food. People done took my whole meal out of the oven. They done took the noodles out the microwave. I come back, my noodles missing. All type of stuff. I don’t cook. I used to. It just – You gotta go all the way downstairs, all the way upstairs, you can’t leave nothin’ on the stove, mother-fuckin’ steal food, all type of problem. So I don’t cook no more. Since residents saved food to stretch it out over time, losing food in the kitchen

23

compromised their ability to manage their food insecurity and increased their distrust in the

24

common areas. Cooking was available to them at an emotional cost of negotiating safe space

25

with other residents, and the physical cost of carrying food and cooking utensils up and down the

26

stairs.

20

1

Individual Mechanisms

2

Cooking Skills and Equipment

3

Many residents rarely or never prepared food in the kitchen because they lacked cooking

4

skills or equipment. One woman explained she wanted to cook for herself to improve her health

5

but felt stymied by her lack of cooking knowledge. She said,

6 7 8 9

I used to just get a lot of food and it would just go to waste because I didn’t know how to cook food that I wanted to eat.

10

when asked about his eating habits, explained he buys food to cook but then cannot prepare it

11

because he lacks the necessary equipment.

12 13 14 15 16 17 18

Residents who lacked cooking equipment either borrowed it or did without. One man,

I: What kind of food do you have in your room? P: I get spaghetti, things like that, you need to cook. I: Do you use the kitchen? P: I would if I had pots and pans. Coping Strategies Many residents had grown accustomed to ignoring their hunger and would not eat for

19

days. One woman, who stated she could not afford to eat, coped by adjusting to feeling hungry

20

and limiting her activity when she had no food.

21 22 23 24 25 26 27 28 29 30 31 32 33

I: Do you ever throughout the month feel hungry? P: Kind of, yeah. My stomach honestly is so used to it- like it’s an off day, I will literally sit in my room and won’t eat anything. A man said he did not notice when he has not eaten. I: Do you eat okay? P: Not really. I really don’t eat a lot every day. I don’t know. I just don’t be eating because – I don’t know. I don’t’ be in the mood. I hate breakfast. I’m usually busy most of the day. And I don’t’ even notice I haven’t ate a lot. I: So what did you eat today? P: Nothin’. I: What did you have yesterday? P: Nothing.

21

1 2 3

Drug Use Some residents said they used drugs to stave off feeling hungry. One man who was

4

detoxing from methamphetamines said, “In this city, it’s easier to get drugs than food.”

5

One man said he used marijuana to diminish hunger pangs. He explained,

6 7 8 9 10 11 12 13 14

Weed, all it does to me is just make me go to sleep now. When I’m hungry and I can’t eat, I just walk and I go to sleep. At least now I don’t have to starve. ‘Cause I can’t even pay for food. Weed I can get for free. Now that I have a cannabis card, I could tell my doctor, ‘I’m stressin’, I haven’t ate for two days.’ If I haven’t ate he’ll give me an edible. At least that’ll keep me high. I won’t stress so much about everybody, and I’ll still have something in my stomach. Theft and Garbage Picking Several residents said they stole food from supermarkets and convenience stores to feed

15

themselves. One described how he steals small items to reduce his hunger and to feed his

16

pregnant girlfriend. He said,

17 18 19 20 21 22 23 24 25 26

A resident told us she ate out of trash cans on a regular basis to stave off hunger. We asked if she

27

ever went hungry, she answered:

28 29 30 31 32 33

P: No, ‘cause if I’m really that hungry, I eat out of trash cans. I have no problem – even if I have food and I’ve eaten that day, if I see food on top of a trash can, I always check to see what it is. I: When was the last time you ate out of a trash can? P: Yesterday. I don’t have very much food. It’s not like I’m not in need.

I’m only takin’ a bag of chips. You can take me [to jail] and all you’re really gonna do is feed me anyway. All I want is the food. But by you takin’ me in, you’re just gonna give me some food I don’t want, but it’s some food. How long do you think they’re gonna hold me for a bag of chips in jail? You kidding me? I know people that steal things from $300 a day, or $10 a day in food or in products. You don’t ever see them go down. So I don’t think for me to just take a bag of chips so me and my lady can eat tonight, which is one bag of chips, which we’re still gonna argue about. I’d rather take that argument. I don’t want us to starve.

Discussion

22

1

We have described how food insecurity persists for formerly homeless youth in PSH.

2

Despite having a home, a kitchen, and space to store food in their rooms, many youth are

3

frequently hungry. We found that interconnected mechanisms on multiple levels of the social-

4

ecological environment lead to, perpetuate, and sometimes abate, persistent food insecurity for

5

the youth in our study.

6

Structural mechanisms that influence youth food insecurity include monthly hunger

7

cycles due to competing expenses and limited income; the location of the building within a food

8

desert where they have limited access to affordable, nutritious food; and perceived and

9

internalized stigma, which causes some residents to reject free food sources. These findings

10

support and extend other research. A study in Toronto that inventoried the food supplies of

11

homeless and at-risk youth also suggests food insecurity increases toward the end of the month

12

when social benefits have run out (Hamelin et al. 2006). Other studies have found that locating

13

housing for formerly homeless youth, or shelters housing school-aged children, in neighborhoods

14

with limited food options increases youth and children’s food insecurity (Richards & Smith

15

2007, Crawford et al. 2014).

16

Stigma has a significant but understudied negative impact on YEH health and well-being.

17

Many YEH view homelessness as a moral and personal failure (Farrugia et al. 2016). Their

18

resulting internalized stigma causes them to avoid services intended for people experiencing

19

homelessness (Reid & Klee 1999, Hickler & Auerswald 2009, Thulien et al. 2018). In addition,

20

some YEH feel threatened by homeless adults leading them to avoid homeless services that

21

predominantly serve an older age group (Ammerman et al. 2004). A study on poverty-related

22

stigma finds poor people distance themselves from other low-income people to feel included in

23

mainstream society (Reutter et al. 2009). Our study shows internalized stigma and aversion to

23

1

homeless services is so strong that some youth will go hungry rather than access services that

2

will provide them with food.

3

On the institutional level, we found the transition into housing is a period of increased

4

vulnerability to food insecurity because of the expenses of moving, and because the unfamiliar

5

location removes the youth from their familiar food sources. The communal kitchen both

6

contributes to and alleviates food insecurity. Research on school-age children in shelters

7

similarly finds that housing policies and limited food storage options increase food insecurity

8

(Richards and Smith 2007). At the interpersonal level, social networks both exacerbate and

9

diminish food insecurity. Research has documented the positive and negative influences of YEH

10

peer networks on issues including drug use, motivation, reliance on survival strategies, and

11

successful integration into housing (Rice et al. 2005, Henwood et al. 2018, Auerswald and Eyre

12

2002). This study adds to those findings by describing how peer networks can diminish food

13

insecurity but can also drain resources because youth feel obligated to provide food to fellow

14

residents and to friends without housing.

15

Finally, on the individual level, our findings document how youth coping strategies,

16

including ignoring hunger, drug use, and theft, can increase food insecurity. These findings

17

resonate with other studies identifying the long-term negative impact of youth coping strategies

18

(Hamelin et al. 2006), including that they make it difficult for youth to transition out of

19

homelessness (Auerswald and Eyre 2002). This study shows that some street-oriented coping

20

strategies continue after youth receive PSH.

21

Youth perspectives on their experiences are essential to inform interventions to improve

22

their health and well-being (Auerswald et al. 2017). This article contributes to research on youth

23

experiences with housing services. Many studies from YEH perspectives document that service-

24

1

provider support is important for facilitating their transition into housing (Garrett el al 2008,

2

Reid & Klee, 1999, Karabanow et al. 2016), but few specifically address the needs of youth

3

transitioning into PSH. Studies on youth experiences in short-term housing find mixed results.

4

For some, it is a positive experience (Holtschneider 2016) that improves their health and reduces

5

their substance use (Kisely et al. 2008). Others describe short-term housing environments as

6

unstable and precarious (Karabanow et al. 2016) or demoralizing and alienating (Kidd et al.

7

2016). This study adds youth perspectives on their food security in PSH and suggests that YEH

8

transitioning into housing are at risk of persistent food insecurity.

9

Structural interventions such as housing aimed at ameliorating only one social

10

determinant of health may have limited efficacy compared to interventions that address the

11

interactions of multiple determinants of health across multiple levels (Slesnick et al. 2009,

12

Braveman et al. 2011, Patton et al. 2016, Bronfenbrenner 1979). Braveman et al. write, “the

13

complex pathways linking social disadvantage to health suggest that seeking a single magic

14

bullet is unrealistic” (2011:391). “Housing first” for youth should not mean “only housing.” The

15

federal funds and programmatic parameters currently designated for housing from HUD define

16

eligibility for PSH projects. However, because allowable costs for HUD are highly restricted for

17

non-housing services, such as food provision, they do not address remaining critical barriers to

18

youth well-being. Community housing programs, in turn, determine specific rules, residential

19

supports, staffing guidelines, and housing locations. It is critical that providers, policy makers,

20

and philanthropists collaborate locally to ensure additional funding for food and other basic

21

needs, such as transportation and internet access, that youth need to successfully transition to

22

adulthood.

23

The standard policy in PSH requires residents to pay thirty percent of income in rent,

25

1

further restricting the ability of formerly homeless youth to meet other basic needs, thus

2

contributing to their food insecurity in housing. This may be a larger problem: research finds that

3

homeless older adults in PSH (Bowen et al. 2019) and low-income adults living with HIV in San

4

Francisco also suffer from food insecurity (Whittle et al. 2015, Whittle et al. 2016). Structural

5

interventions should provide access to adequate and nutritious food to all those dependent on

6

state support, such as PSH residents (Bowen et al. 2019). There is an urgent need for additional

7

research regarding housing models for YEH to establish standards for program implementation

8

that will help youth succeed in their transition into housing.

9

Limitations

10

Our work has several limitations. First, we documented the early phase of a new

11

program. Building policies and the supports provided in the building are evolving. Since this

12

baseline research was completed, addressing youth food insecurity has been a greater priority for

13

building management, partly in response to our findings and a subsequent youth participatory

14

project developed in response to these findings (Johnson et al. 2019). Second, our work takes

15

place in San Francisco, where the cost of living is high and economic inequality is acute. The

16

concentration of poverty and social exclusion may be less severe in other cities and towns, thus

17

limiting the generalizability of our findings. Third, although our study includes the majority of

18

residents at the time, our findings are limited to one PSH building. Fourth, youth who

19

participated in this study may differ significantly from non-participating youth. Lastly, because it

20

took time to build trusting relationships with some residents and enroll them into the study, some

21

residents’ interviews were conducted well after they moved into the building, while others were

22

conducted shortly after their move-in date.

23

Conclusion

26

1

Housing is a necessary but insufficient component for youth to stabilize their lives and

2

build a future. As in other studies, our research suggests YEH need different interventions and

3

supports than adults experiencing homelessness because of their age-based developmental

4

differences as well as differences in life skills, experiences, causes of homelessness, and traumas

5

(Gaetz 2014). During this developmental stage, reward-seeking areas of the brain are dominant,

6

while areas responsible for planning and self-control are still forming (World Health

7

Organization 2014). Youth may need more support than adults to budget, plan, purchase, and

8

prepare nutritious meals. In addition, youth have greater nutritional needs than adults during this

9

critical period for skeletal growth and neurodevelopment (Patton et al. 2016). Nutritional deficits

10

caused by food insecurity during this developmental stage can lead long-term health problems

11

(Wahl 1999).

12

Like housed youth, YEH need guidance regarding life skills and support for their basic

13

needs as they build their identity and future (Thulien et al. 2019). However, YEH may lack the

14

knowledge and skills many of their housed peers learned through exposure and experience. YEH

15

are resilient (Rew et al. 2001), but they require training and support tailored to their specific

16

needs to become independent, self-sufficient adults and to address health concerns accrued

17

during homelessness (Aviles & Helfrich 2004, Munson et al. 2017, Ammerman et al. 2004,

18

Henwood et al. 2018).

19

PSH has great potential to shape a positive health trajectory throughout life for YEH. It

20

addresses a major stressor for YEH, but it is not a standalone solution. Food insecurity may

21

remain a problem for youth in PSH and can be exacerbated by housing. Demonstrated barriers to

22

free or nutritious food call for creative measures for addressing predictable hunger cycles.

23

Potential interventions include food delivery programs, larger rent subsidies, increased monthly

27

1

incomes through additional state financial support, expanded access to food stamps, and a higher

2

monthly limit. In addition, job coaching and classes in budgeting, cooking, and procuring food

3

on limited income could help. Finally, service providers should be sensitive to the complex

4

causes of food insecurity including that youth may be reluctant to use food services and may be

5

feeding their friends with their limited resources.

6

For PSH to better support youth, a multi-sectoral collaborative planning process is

7

needed before and during implementation that includes, but is not limited to, housing providers,

8

case managers, other social and community services (such as agencies providing food stamps

9

and food banks), and YEH to ensure that programs are developmentally appropriate. Other PSH

10

models such as single-site models with individual kitchens or scattered-site models where

11

residents live in separate apartments with individual kitchens (Henwood et al. 2013), may better

12

fit the needs of youth. Finally, PSH models for youth should address causes of food insecurity

13

that persist or develop upon moving into housing, particularly when housing is located in a food

14

desert. They must ensure access to affordable nutritious food from the day youth move in so

15

residents can focus their energies on attaining the stability, education, and employment required

16

to succeed.

17

28

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Structural Level Mechanisms: • Stigma • Food desert • Monthly hunger cycles

Structural Intervention Permanent Supportive Housing

Institutional Level Mechanisms: • Transition into housing • Kitchen issues • Food storage Food Insecurity Interpersonal Level Mechanisms: • Food sharing within Inbuilding social networks Individual Level Mechanisms: • Cooking skills and equipment • Coping strategies

Research Highlights • • • • •

Evaluates the multi-level impact of a structural intervention on youth health. Adds youth focus to literature on housing for people experiencing homelessness. Provides evidence that housing for youth should address food insecurity. Argues that youth voice is critical to develop and evaluate youth housing programs. Describes how social-ecological factors contribute to youth food insecurity.

Sarah Brothers: Writing-original draft, Writing-review & editing, Data curation, Investigation, Formal analysis, Resources, Visualization. Jess Lin: Writing-review & editing, Project administration, Investigation, Resources. Jeffrey Schonberg: Writing-review & editing, Supervision, Investigation, Conceptualization, Methodology. Corey Drew: Writing-review & editing, Investigation. Colette Auerswald: Writing-review & editing, Supervision, Funding acquisition, Data curation, Investigation, Formal analysis, Resources, Visualization, Conceptualization, Methodology.