Psychosocial risk behaviors in Mexican young women experiencing homelessness

Accepted Manuscript Psychosocial risk behaviors in Mexican experiencing homelessness

young women

Susana Castaños-Cervantes, Nicole M. Vélez-Agosto PII: DOI: Reference:

S0190-7409(18)30682-0 doi:10.1016/j.childyouth.2018.10.041 CYSR 4054

To appear in:

Children and Youth Services Review

Received date: Revised date: Accepted date:

13 August 2018 24 October 2018 25 October 2018

Please cite this article as: Susana Castaños-Cervantes, Nicole M. Vélez-Agosto , Psychosocial risk behaviors in Mexican young women experiencing homelessness. Cysr (2018), doi:10.1016/j.childyouth.2018.10.041

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ACCEPTED MANUSCRIPT Psychosocial risk behaviors in Mexican young women experiencing homelessness

Susana Castaños-Cervantesa,*,1 [email protected], Nicole M. Vélez-Agostob [email protected] Psychology Department, Faculty of Humanities and Social Sciences, La Salle University, Mexico City, Mexico b Physical Therapy Doctoral Department, School of Health Professions, University of Puerto Rico, Medical Sciences Campus. PO BOX 365067 San Juan, Puerto Rico, 00936

Corresponding author.

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Abstract

Psychosocial risk behaviors in young women experiencing homelessness include

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substance use and abuse, risky sexual activity and delinquent behaviors. These behaviors

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negatively impact well-being and diminish quality of life. The purpose of this study was to analyze from a qualitative perspective based on Ajzen’s Theory of Planned Behavior, a series of

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psychosocial risk behaviors among a group of 200 Mexican young women experiencing

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homelessness ages 11 to 20 years old. The participants were selected with a purposive sampling method. Main results showed that social environmental predisposing factors for substance use

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and abuse, sexual risk behavior, and delinquent activities, included peer’s and couple’s

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behaviors, peer initiation of psychosocial risk-taking behaviors, and social pressure. Psychological predisposing factors for substance use and abuse included sensation-seeking and risk perception. The clinical implications of the study highlight the need to consider these social and psychological predisposing factors for psychosocial risk behaviors when designing efficient and sustainable interventions aimed to diminish and prevent these behaviors in young women experiencing homelessness, particularly in the context of Latin American cities.

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Benjamin Franklin 45, Condesa, Cuauhtemoc, Zip Code 06140, Mexico City, Mexico .

ACCEPTED MANUSCRIPT Keywords: psychosocial risk behaviors; homelessness; young women experiencing homelessness; substance use and abuse; risky sexual behavior; theory of planned behavior.

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1. Introduction

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Youth is a developmental period between 11 and 20 years old of rapid physical, psychological, sociocultural, and cognitive changes characterized by efforts to confront and

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surmount challenges and to establish a sense of identity and autonomy. It is also a period fraught

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with many threats to the health and well-being of youth, many of whom suffer substantial impairment and disability. Much of the adverse health consequences experienced by youth are,

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to a large extent, the result of psychosocial risk behaviors.

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Psychosocial risk behaviors are those that are linked to a number of potentially healthdamaging behaviors including, among others, substance use, risky sexual behavior, and

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delinquency (Igra & Irwin, 1996; Kipping, Campbell, MacArthur, Gunnell & Hickman, 2012).

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These behaviors are associated to several negative consequences such as unwanted pregnancies, sexually transmitted infections, severe disability, physical and cognitive impairment, mental

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disorders, poor school performance and dropout, unemployment, loss of healthy relationships, discrimination and social exclusion, legal conflicts, future morbidity and premature mortality (Viner, 2013). Also, they are more prevalent among vulnerable groups such as people experiencing homelessness. Youth experiencing homelessness are those who are expelled from their home or who abandoned it intermittently and, subsequently, permanently. They usually grow up in dysfunctional family environments and communities immersed in social problems without

ACCEPTED MANUSCRIPT effective solutions from government and society (Castaños-Cervantes & Sánchez, 2016). Mexico City is the 7th place worldwide with the highest homeless population (Jegede, 2018), and the 5 th one with extremely high homeless population (Prime, 2014). Mexico has the second largest number of homeless children in Latin America. Nonetheless, there are neither current official

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censuses nor efficient public policies (Pinacho, 2017). With respect to young women

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experiencing homelessness, their prevalence and incidence are unknown. In addition, Mexican

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laws do not even effectively protect women and girls (Human Rights Watch, 2018). Worldwide, young women experiencing homelessness live in conditions of extreme

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vulnerability since they sleep in open public spaces or in homes not intended for human

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habitation (Towe, Hasan, Tariq & Sherman, 2009). They are exposed to all types of diseases and infections. They are victims of abuse and of forced labor and sexual exploitation. They do not

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have access to an education and to health care centers. They are discriminated, socially excluded,

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and marginalized; and they do not receive effective and timely care. Consequently, they commonly carry out various psychosocial risk behaviors. Research with this group (Thrane &

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Chen, 2010) has shown that they typically engage in psychosocial risk behaviors such as

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substance use and abuse, risky sexual activity (e.g., having unprotected sex, not using contraceptive methods, having sex with multiple partners and under the effects of alcohol or

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drugs, etc.), and delinquent behavior (e.g., theft, drug dealing, and prostitution). However, these studies have focused on differences by sex (Harris, Rice, Rhoades, Winetrobe & Wenzel, 2017). Many have been epidemiological research, and they have explored these behaviors from a salubrious view as would be their effects in relation, for example, to HIV infection and other sexually transmitted infections. In addition, there is little information on how young women experiencing homelessness conceptualize and manage risk (MacDonald, 2014) and the reasons

ACCEPTED MANUSCRIPT they give for engaging in psychosocial risk behaviors (Oppong Asante, Meyer-Weitz & Petersen, 2016). Furthermore, most interventions on psychosocial risk behaviors have not been designed for vulnerable groups and ethnic and sexual minorities (Craddock, Rice, Rhoades, & Winetrobe, 2016). More worrisome is the discourse of individualization that underlies the research literature

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as an ideology that holds youth responsible for their circumstances (Watson, 2016). To date, in

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Mexico, information on psychosocial risk behaviors among young women experiencing

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homelessness is very limited and there are no intervention programs for this group or in relation to the prevention and reduction of such behaviors.

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Any psychosocial intervention aimed at reducing and preventing psychosocial risk

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behaviors should consider the decision processes, attitudes, and beliefs of the target population in order to be efficient and sustainable. Qualitative methods are ideal to explore the content of

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beliefs and attitudes of individuals (Smith & Seal, 2008); even more because of formation of new

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myths, norms, and vulnerabilities around a certain phenomenon. The aim of this study was to qualitatively analyze diverse psychosocial risk behaviors

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(i.e., drug, alcohol and tobacco consumption, having unprotected sex, delinquency, drug dealing

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and prostitution) in a group of Mexican young women experiencing homelessness to examine how this collective conceptualizes and manages the risk, the reasons given to carry out these

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behaviors and to assess these behaviors from their own perspective. The Ajzen Model of Planned Behavior (2015) was used as a guide to explore the normative, behavioral and control beliefs of this group. This theory is used to predict an individual’s intention to engage in a behavior at a specific time and place. According to this model, behavioral intentions are influenced by the attitude about the likelihood that the behavior will have the expected outcome and the subjective evaluation of the risks and benefits of that

ACCEPTED MANUSCRIPT outcome. Thus, new information is obtained on their decision processes regarding various psychosocial risk behaviors that make it possible to effectively address such behaviors through efficient interventions. This theory has been used to successfully plan and evaluate numerous interventions for many different behaviors. In addition, this model has previously been used in

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populations experiencing homelessness (Christian & Dominic, 2004, Fearn & White, 2006), and

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to predict risk behaviors in this group (Ream, Barnhart & Lotz, 2012; Rew, Fouladi, Land &

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Wong, 2007).

The Biopsychosocial Model of Risk Taking (Irwin & Millstein, 1986) was used as the

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theoretical reference framework to explain psychosocial risk-taking behaviors in Mexican young

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women experiencing homelessness. According to this model, psychological predisposing factors include sensation-seeking, risk perception, depression, and low self-esteem. Social

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environmental predisposing factors include maladaptive parenting styles, parental modeling of

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risk behaviors, peer behaviors, and socioeconomic status. Given a set of psychological predispositions in a particular social environmental milieu, some youth will engage in

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psychosocial risk-taking behaviors and some will not. In this way, we will be able to acquire

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valuable data regarding what induces young women experiencing homelessness to engage in these behaviors and the reasons for doing so, thus establishing health-endangering life styles that

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jeopardize their futures.

2. Materials and Methods 2.1 Participants Participants recruited were 200 young women experiencing homelessness between 11 and 20 years old (M[DT] = 15.56 [1.71]). Using a purposive sampling method, participants were

ACCEPTED MANUSCRIPT recruited from nine non-governmental organizations in Mexico City that serve children and youth experiencing homelessness as their primary function. Participants were required to 1) reside within the selected shelter during the data collection period, and 2) consent to participate in the study. Participants with insufficient capacity to provide informed consent, and a primary

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diagnosis of intellectual disability or head injury were excluded. This study was reviewed and

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approved by the Academic Board of the Master’s and Ph.D. program in Psychology of the

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National Autonomous University of Mexico. This review serves as the Mexican equivalent to an American IRB Review.

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2.2 Instruments

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To examine participants' psychosocial risk behaviors (i.e., drug, alcohol and tobacco consumption, unprotected sexual activity, theft, drug trafficking and prostitution), a semi-

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structured interview was developed based on Ajzen's Model of Planned Behavior (2015),

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reviewed by three psychologists experts in the subject and in qualitative methodology. For the structured questions, four Likert type response options were used, ranging from Never (1) to

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Always (4). Both open and structured questions included the following aspects: Behavioral

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attitudes and beliefs: An example of a question within this area would be "What advantages [good things] do you think the use of drugs has?". Subjective norm and normative beliefs: An

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example of a question within this area would be "Mention the people that you consider important for you and in agreement with you drinking alcohol". Perceived behavioral control and control beliefs: An example of a question within this area would be "What factors [things], both internal (e.g, taste, desire, etc.) and external (e.g., time and place available, lack of money, etc.), do you think would make it easier for you to have unprotected sex?". Intent: An example of a question within this area would be "How likely is for you to sell drugs this week?".

ACCEPTED MANUSCRIPT 2.3 Procedure Because young women experiencing homelessness undergo unstable living conditions (Coker et al., 2009), the researchers worked with non-governmental institutions that support children and youth experiencing homelessness to acquire access to this population. These

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institutions were informed of the study’s purpose and methods, and assured that researchers

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would follow ethical procedures and guidelines as specified by the American Psychological

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Association (APA, 2017). Permission to conduct the study was provided by the institutions in lieu of parental consent, as legal authority rested with the institutions to provide consent on the

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young women’s behalf. All young women participants in this study did so on a voluntary basis

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and provided their fingerprint as written consent. Participants received information about the study’s general objectives, use of data, and confidentiality agreement. Researchers took care to

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answer participants’ questions without biasing participation choice. Participants were

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empowered to refuse to answer any question or to discontinue study participation at any time. The research took place in collaborating institutions’ on-site classrooms. Participants were

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individually interviewed in Spanish and responses were recorded by the researchers with prior

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consent of both the institutions and the girls. While interviews lasted approximately an average of two hours, no time limit was established. Partipants did not receive financial compensation for

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their participation.

Data Analysis. A content analysis was carried out based on classic grounded theory principles (Denzin & Lincoln, 1998), reaching saturation at 50 interviews. The Atlas TI Version Six computer program was used to identify relevant categories, codes and units of analysis, as well as to quantify the categories in percentages. To establish consensus among the final

ACCEPTED MANUSCRIPT categories, both the categories and the coding system used were reviewed by two experts in qualitative research.

3. Results The consensus on the categories had an inter-rater reliability of .75 according to Cohen's

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Kappa index (Cohen, 1968), which indicates a high degree of agreement and therefore, the

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results obtained are reliable and valid for its interpretation and analysis. It is worth mentioning that all of the quotations presented in this section have been translated.

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The primary topics of the three categories of psychosocial risk behaviors identified in the qualitative analysis are broken down below: illicit drug use, risky sexual behavior and criminal

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activities.

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3. 1 Illicit drug use. The participants consume drugs by 85%, the main toxic substance

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ingested being inhalants, especially “activo”, followed by marijuana. They reported that drugs are acquired within their peer group or on the street by other users, drug dealers or people under

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the same circumstances. At times, they are acquired too through rewarded sex or the exchange of their body; and they also reported that having a dysfunctional family contributes.

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The young women interviewed mentioned that the use and abuse of substances frequently

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leads them to engage in risky sexual relations, to participate in criminal activities to obtain resources that allow them to continue consuming, to problems with authorities, to suffer any type of abuse, to associate with organized crime and be caught by networks of trafficking, prostitution and pornography, and to school dropout and unemployment. Furthermore, the consumption of drugs sets the tone to enter drug trafficking and with it, access to a greater variety of drugs. Regarding the attitude they have toward the use and abuse of substances, participants mentioned knowing the deleterious consequences associated with the consumption of toxic substances as

ACCEPTED MANUSCRIPT they reported that they deteriorate health (e.g., "You get sick more often", "You stop eating", "Your head and stomach hurt", "It's hard for you to breathe ", " You bleed from your nose") and cognitive functions (e.g., "It's so hard to think when using drugs", "I do not concentrate", "I forget things, like where I live, where to find my gang, how old am I"). However, they have a

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substances for various reasons, among which the following stand out:

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favorable attitude toward drug use and despite having such information they ingest toxic

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3. 1. 1 Belonging to a group. Given that in their life history they mentioned having lacked significant emotional relationships or that they were dysfunctional, it is essential for them

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to be accepted, recognized and loved by a group that gives them affection, security, attention,

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and a sense of belonging and identity. Agreements of solidarity, cooperation, exchange and protection are established within the group. However, because they are part of a group and

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accepted by the group, they may have sexual relations with members or participate in activities

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such as drug use and delinquency: "If you are from the gang, you enter or you split, but if you split, they take you out".

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3. 1. 2 Apparent satisfaction of essential needs. Lacking the necessary resources for

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subsistence and having broken with their family, school and community ties, they alleged that they do not usually meet their basic needs for food, clothing and housing. Drug use allows them

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to adjust and face their reality through evasion, given that the drugs apparently satisfy needs such as lack of food: "When I take drugs, I stop feeling hungry", "The drug makes me not want to eat". In addition, they use them as a way to avoid physical and psychological pain: "When you are drugged you no longer remember what happened, you even forget it for a moment". Consequently, drugs can become a means of survival on the street.

ACCEPTED MANUSCRIPT 3. 1. 3 Pleasure. To feel an apparent satisfaction and temporary gratification: "The drug makes me feel cool", "You feel like you could fly and everything is very far", "I like to be drugged all the time". 3. 1. 4 Apparent Immunity. Participants indicated that they also used drugs since they

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believe that they would not be affected; they do not perceive the negative consequences related

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to consumption or are indifferent to it. They consider themselves immune from the harmful

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effects of drugs: "It will not happen to me", "That's for others, nothing has happened to me", "Look at me, I'm very well and see ... nothing has happened to me ", "Nothing happens to you,

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it's a lie, it only affects the idiots", "I already use cocaine and nothing, on the contrary, it feels

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good".

Moreover, participants reported that when they use drugs, they require greater amounts

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and doses to continue experiencing the same sensation of pleasure, so as not to feel hunger, pain

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and to achieve the desired effect: "The problem with the drug is that afterwards it no longer serves you and you have to use more and more, and that is not cool anymore". The requirement

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of a higher dose of drugs leads them to initiate intravenous substance use that is associated with

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an increased risk of suffering from various diseases and infections, including sexually transmitted infections; as they usually share the syringes used for intravenous use.

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Regarding the consumption of alcohol and tobacco, no problem of apparent abuse was found nor was there any information in their clinical history that indicated it. Participants stated that alcohol and tobacco are more expensive, and more difficult to obtain due to Mexican regulations. As such, this consumption was much less frequent (less than 20% of the participants) and apparently, in the case of alcohol, it is not a substance that is to the liking of the participants because it does not produce the pleasurable effects obtained with drugs.

ACCEPTED MANUSCRIPT Finally, facilities that serve young women experiencing homelessness prohibit the use of any drug while they are staying in these shelters. Also, because of addiction’s complexity and pervasive consequences, drug addiction treatment typically must involve many components. These facilities lack the necessary settings and providers (e.g., physicians, psychiatrists,

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psychologists, nurses, etc.) to treat drug addiction. As a result, when young women experiencing

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homelessness have a drug addiction, they are sent to drug-rehabilitation clinics (e.g., “anexos”)

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for at least two or three months. However, in Mexico these drug-rehabilitation centers are not specialized and their conditions are inadequate as many participants reported having been abused

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in these centers. Hence, once participants returned to the facilities, they usually had a relapse and

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continued using drugs. This is because they keep associating with other young women who secretly use drugs (e.g., when participants want to use drugs, they search for places with very

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little control and security such as rooftops, wardrobes, and toilets) without the institutional staff

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knowing about it. Lastly, to avoid being sent to other settings and getting separated from their friends, and to keep using drugs, they tend to escape and abandon these facilities.

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3. 2 Risky Sexual Activity. Risky sexual behaviors were present in 80% of the cases.

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These behaviors included having multiple sexual partners, having occasional sexual encounters, not using contraceptive methods, including condoms, and having sexual relations under the

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effects of drugs or alcohol. Involvement in risky sexual activities increased the probability of becoming pregnant, aborting, and getting a sexually transmitted infection. Approximately 20% have been pregnant, and at least 10% have aborted. More than 50% claimed that they have suffered a sexually transmitted infection, the most common being the Human Papilloma Virus (HPV), followed by chlamydia, gonorrhea, and genital herpes. At least 7% of the participants presented HIV-AIDS.

ACCEPTED MANUSCRIPT It was found that young women experiencing homelessness have little information and knowledge about their sexuality. They do not know important areas of their anatomy and physiology, and how to take care of themselves. With respect to contraceptive methods, they know of the existence of the condom and the

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contraceptive pill. Yet, they rarely use any contraceptive method especially when they have

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sexual relations under the effects of drugs or alcohol. Also, they do not use contraceptive

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methods as participants reported preferring to satisfy the desires of their partner who does not want use condoms. This is to avoid being abandoned by their partners since their couples

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expressed their desires to feel more pleasure while having sexual relations without a condom

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(e.g., "My partner does not like us to use a condom", "My partner says that it does not feel the same", "I do what my partner says to make him happy", "Sometimes I do want to use a condom

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but then he gets angry and tells me he's going to leave me", "If I do not do what he says, he hits

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me or insults me").

Regarding misconceptions about sexuality, they have many myths, prejudices and

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distortions. For example, "menstruation is to get rid of what the body does not need", "you

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cannot get pregnant the first time you make love”, “if you do not get pregnant the first time you have sex it means that you cannot have children at all", "you stop being a virgin if you are kissed

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on the lips", "the condom can be used several times if you wash it well", "the female condom can be used more than once", and "sexually transmitted infections are not so serious as they seem." In fact, more than 50% of the participants did not know what AIDS or HIV is and they were unaware of the effects of the majority of sexually transmitted infections, including whether or not they are curable and treatable. Additionally, they usually have an average of four or five different sexual partners per year, and their relationships are unstable, short-lived and informal.

ACCEPTED MANUSCRIPT Also, they engage in homosexual relationships while being in a shelter. As such, they feel connected, supported, and not alone. On the other hand, in at least 50% of the participants, sexual activity began before the age of 11 as a result of intra-familial sexual abuse. However, for these young women, sexual life

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begins only when they decide to have consensual and voluntary sex. Otherwise, they consider

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that they are still "virgins", "intact".

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Regarding the attitude that participants have towards unprotected sexual activity, it is in approximately 90% of the cases unfavorable since they do not want to get pregnant or contract a

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sexually transmitted infection. However, due to the fact that their partner’s wishes are their

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priority and to avoid loss, abandonment or violence, they do not usually use any contraception method, including condoms.

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Finally, it is important to highlight that young women experiencing homelessness do not

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have easy access to institutional health systems. Likewise, 10% of the participants reported being discriminated against in health centers. Besides, they were not attended and when they received

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care they were victims of sexual harassment (e.g., "The doctor who treated me told me that he

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would cure me if I did him oral sex", "When they treated me, the doctor put his hand inside my vagina without gloves").

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3. 3 Criminal activities. Regarding criminal activities, results showed that robbery is the most frequently performed behavior (70%) followed by drug trafficking (55%) and in a lesser proportion, prostitution (20%). When engaging in illicit activities, 10% of the participants had been convicted in the juvenile justice system. Once convicted, they mentioned that they were associated with risk groups that induced them to use and abuse substances, and to engage in risky sexual activity and criminal behaviors.

ACCEPTED MANUSCRIPT Young women experiencing homelessness indicated that they steal in order to survive, for pleasure and to obtain resources in a quick and accessible way, even if this implies having conflicts with authority, legal problems and exposing themselves to being physically abused, including the possibility of dying (e.g., "You want me to have a normal job with a schedule to

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fulfill so that I earn much less than what I earn now", "I can do what I want when I want and

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there are no rules to follow", "I earn more than you [addressing the researcher] and you work

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eight hours a day").

Drug trafficking usually begins with the use and abuse of substances and is maintained in

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order to consume drugs and obtain resources to survive. It also implies a quick way to collect

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material goods even though it is associated with a higher risk of death, of being convicted in the juvenile justice system, and of being physically and psychologically victimized.

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Both the theft and the sale of drugs are common within their group of peers and the

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resources obtained are shared among the group. When there is a leader, it is this person who collects all the accumulated profits and distributes them unequally. In addition, if they belong to

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a network of organized crime, the acquired goods are directed mostly to the heads, leaving what

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is indispensable to survive those below (e.g., "The boss does not give us everything, but what is given to us is enough to survive", "It is not fair that some are given more than us").

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When families cannot satisfy needs, have low-paid jobs, are unemployed, have a low educational level, or live in precarious conditions, overcrowded and surrounded by other families under the same circumstances, they often fall into delinquency, robbery or prostitution. Consequently, young women’s relationships are structured according to gangs, sexual relations without commitment and robbery or drugs.

ACCEPTED MANUSCRIPT With respect to prostitution, it is usually more common for participants to carry out sexrewarding behaviors; characterized by the trade of sexual activities for food, clothing or housing. When they become part of the prostitution network, it can be the result of having been victims of human trafficking, of being caught by a pimp or of being associated with groups in which this

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activity is common. They know that prostitution makes them prone to suffering greater physical

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violence, including sexual and psychological abuse, to contracting diseases and to being easy

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prey of further aggressions. Yet, they often resist help and avoid reporting due to well-founded fears of physical violence or threats of retribution if they disclose their situation (e.g., "I do not

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have any other option, I'm already here", "I do not want anything to happen to my children",

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“They threaten me with taking away my children or that I will no longer see my brothers"). In addition, they accept their current situation by rationalizing the supposed associated rewards

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(e.g., "I already know that I put myself in danger, that I can die or that something bad can happen

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to me, but at least they pay me well, I can do whatever I want with the money they give me and I earn more than what you earn in a week [addressing the researcher]”). Moreover, they expressed

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that it is important to satisfy the clients' desires (e.g.," It does not matter if they want you to do

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weird things, touch whatever and wherever, in the end, they pay and afterwards you bathe and you already try to forget"). Lastly, the permanence in a shelter or facility helps them to be

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gradually rescued from the networks of prostitution and organized crime. Many times it is necessary to change their identity and locality in order to get completely out of this criminal world. These organizations work with young women experiencing homelessness involved in prostitution by including harm reduction as a necessary response for the short term. Harm reduction is usually coupled with interventions that try to offer safe accommodation, drug treatment, robust counseling and support services. Also, these facilities collaborate with mental

ACCEPTED MANUSCRIPT health providers to develop young women’s confidence and self-esteem, to help them learn new skills and by giving them training for future employment. They accomplish this through a series of interconnected services: street-level outreach, practical assistance, case management, and advocacy efforts with police, the media and the public. Thus, these actions strive to minimize

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endangering conditions, to promote reintegration and to develop healthier relationships with the

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community and society.

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As a final point worth mentioning, it was reported that when a young woman experiencing homelessness carries out a psychosocial risk behavior, she is more likely to incur in

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another psychosocial risk behavior. For example, under the effects of drugs, at least 50% have

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had sexual relations in casual encounters, or with their stable partner in case of having one and without protection. Similarly, approximately 10% indicated that they share needles.

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3. 4 Psychosocial risk behaviors according to the Model of Planned Behavior (Ajzen,

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2015). Findings obtained with the questionnaire based on Ajzen’s Model of Planned Behavior (2015) (see Figure 1) revealed that the probability of performing psychosocial risk behaviors is

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greater for drug consumption, followed by risky sexual activity, drug trafficking, and, finally, to

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a lesser degree, by crime and prostitution. 80% of the participants reported that they most likely used drugs in a week, 70% mentioned that they would have unprotected sex with their stable

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partner if they had one, 50% indicated that they would probably sell drugs, 35% claimed that they would steal, and 15% that they would prostitute themselves.

ACCEPTED MANUSCRIPT Ajzen’s Theory of Planned Behavior applied to several risk behaviors in Mexican Homeless girls

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Figure 1. Graphical representation of Ajzen’s (2015) Theory of Planned Behavior applied to substance use and abuse, risky sexual activity, drug dealing, and prostitution in a group of Mexican homeless girls.

ACCEPTED MANUSCRIPT The probability of engaging in each psychosocial risk behavior was influenced by several factors that will be explained below. Outcomes achieved indicated that the attitude towards the performance of psychosocial risk behaviors was, in its majority, negative, except for the consumption of drugs, which was

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considered a pleasant and fun activity despite being aware that narcotics are harmful to health.

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Participants classified prostitution, drug trafficking and unprotected sexual activity as damaging

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behaviors that were detrimental to their person. Yet, they considered that there are some advantages by engaging in these behaviors such as, for example, obtaining resources quickly and

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easily and feeling a generalized well-being and greater pleasure.

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Regarding significant others, findings showed that family ties, if they exist and are functional (i.e., loving, attentive with their children, affectionate, establish clear rules and

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regulations), provide protection that prevents engaging in the psychosocial risk behaviors

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previously mentioned; given that in 90% of cases they are against performing these behaviors. The missing 10% refers to when family members engage in psychosocial risk behaviors and,

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therefore, constitute a risk factor.

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In contrast, in the majority of the cases interviewed, the peer group and the romantic partner are a risk factor. Although, their peer group and/or couple provide, among other needs, a

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sense of belonging, and a way to avoid abandonment and to obtain protection, security, and affection, they coerced young women experiencing homelessness to engage in psychosocial risk behaviors. Therefore, the normative beliefs of the young women interviewed were influenced by the relative importance they give to people who are significant to them. Thus, in this way, if they have broken their family ties, they will be more willing to follow their group or their partner despite the fact that this implies engaging in behaviors that are detrimental to their well-being

ACCEPTED MANUSCRIPT and health. This is because youth require in a generic and natural way the daily coexistence, affective ties and interdependence to subsist and meet their needs of affection, attachment, care, love, and socialization. Finally, regarding their perception of control, it was observed that the participants

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considered themselves capable of performing these behaviors with the following exceptions:

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being forced to have unprotected sexual relations by their partner, being coerced by their family

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to participate in criminal activities to obtain necessary resources for survival, and being obliged by their peer group to use drugs, carry out illicit activities and have sexual relations, in order to

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belong and be accepted by them. While the participants think they are able to determine whether

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or not to engage in these psychosocial risk behaviors since they consider that these behaviors are under their apparent control, they are aware that external factors exert a greater influence in this

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respect.

4. Discussion

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Young women experiencing homelessness are prone to engaging in several psychosocial

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risk behaviors due to the conditions of vulnerability in which they develop. Results achieved in this study revealed that the primary psychosocial risk behaviors carried out by this group were

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the use and abuse of substances, risky sexual activity and criminal behaviors. These findings concur with previous studies done with the same population in Latin America (Vieria-Dornelles, 2009) and worldwide (Ferguson, 2007). Findings showed that young women experiencing homelessness mainly consume inhalants as means of evasion of their reality. These outcomes coincide with research carried out in other countries (Tucker et al., 2009).

ACCEPTED MANUSCRIPT Regarding risky sexual behavior, it was observed that they frequently have unprotected sexual intercourse with several couples and under the influence of narcotics, which is why they tend to get more sexually transmitted infections. These results agree with those obtained in previous studies (Warf et al., 2010). Likewise, as a result of a routinely sexual activity, with

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numerous couples and without protection, they get pregnant and abort regularly under unsanitary

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conditions. They usually do not have access to health care services or are victims of

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discrimination and harassment. They also tend to lack information on how to have sexual health. In addition to the above, the sexual activity they incur is usually consensual, such as prostitution,

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non-consensual, such as harassment and sexual abuse, or as a method of survival, which is

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commonly referred to as rewarded sex practices. These outcomes coincide with other studies (Heerde, Scholes-Balog & Hemphill, 2015; Moore, 2010).

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Among the illicit activities, the most frequently reported was theft, followed by drug

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dealing and prostitution; concurring with previous findings (Edinburgh & Saewyc, 2009). According to the Biopsychosocial Model of Risk Taking (Irwin & Millstein, 1986), given

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a series of biological, psychological and social predispositions in a particular environment, some

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youth will be involved in carrying out risky behaviors while others will not. Main results showed that social and psychological issues are the primary predisposing factors for engaging in

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psychosocial risk behaviors in a group of young women experiencing homelessness. Social factors observed included dysfunctional families, couples, peers, and the pressure exerted on its members. These social factors influence young women experiencing homelessness to use drugs and alcohol, to have early sexual experiences, to early motherhood and to get involved with the networks of organized crime. Psychological factors found comprised the search for sensations,

ACCEPTED MANUSCRIPT since the use of drugs was associated with pleasure, and the low perception of risk in referring youth who would not be adversely affected in their health by using these substances. In order to identify the beliefs and attitudes associated with carrying out psychosocial risk behaviors in this group, we relied on Ajzen’s Model of Planned Behavior (2015), which explains

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how these beliefs and attitudes affect and predict the psychosocial risk behaviors incurred.

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Within the relevant topics for each of these psychosocial risk behaviors, the influence of peers

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and the couple was observed, as well as the need to survive and the contradictions in terms of negative attitudes towards psychosocial risk behaviors and incurring in them (contradiction in

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attitude-behavior).

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4. 1. Influence of Peers and Couple. The peer group of young women experiencing homelessness, by replacing the family and providing a sense of recognition, appreciation,

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security, solidarity, protection and belonging, is what models and promotes the use of drugs,

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having risky sex and challenging established norms and authorities by inducing theft and drug trafficking as a way of life, among other behaviors (Danielle-Strickland, 2009). The influence of

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peers during youth is one of the factors that best predicts drug use at these ages because of its

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generalized use within the group. By the desire to be admitted and accepted, if the group drinks alcohol or smokes tobacco or marijuana, the youth will imitate these behaviors, coinciding, thus,

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with previous research (Wenzel et al., 2009). This finding contrasts with the individualist position of studies that focus on youth experiencing homelessness, reducing the occurrence of risk factors to personal characteristics or psychological symptoms (Begun, 2017). It is possible that this is due to a fundamental gender difference in terms of homeless experience, in that females tend to depend more on their peers than males to manage their survival. This can be explained by gender and cultural factors. Young women experiencing homelessness suffer sexual

ACCEPTED MANUSCRIPT exploitation, abuse, and discrimination at a higher rate than the general population because of their gender (Misganaw & Worku, 2013). As women they are more vulnerable. They are constantly sexually harassed and abused while being homeless (Castro-Cavero, 2008), and they are object of discrimination, intimidation, and violence (Capuzzi & Gross, 2008). Regarding

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cultural factors, particularly in Mexico, young women are more attached to the family and taught

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domestic labors and how to become a “good wife” (Díaz-Guerrero, 2007) (i.e., obedient,

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submissive, dedicated to taking care of children and their husband, abnegated). Men are encouraged to become independent, self-sufficient, and autonomous. Females are more

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dependent on their peers for survival, especially when being homeless and having broken all

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family, community, and school ties.

With respect to couples, for young women experiencing homelessness the couple is seen

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as a company and form of protection (Murrieta, 2010) at the same time it is a source of abuse and

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violence. Relationships are not formal as it is common for them to be with one or another at the same time. Also, to avoid new situations of abandonment they assume a role of submission,

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obedience and complacency. Their partner forces them to participate in criminal activities, to

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comply with their sexual requirements (Magazine, 2006), and to consume drugs (Gutiérrez & Vega, 1998). These findings may be explained by culture. In Mexico, the affiliative lifestyle is

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very important since the relationships established with other individuals constitute a source of satisfaction. Consequently, Mexicans modify their behavior in order to obtain social approval and belong to the desired group rather than defending their own rights and interests (DíazGuerrero, 2007). Additionally, in this culture femininity is associated with submission, affiliative obedience and weakness. This is how children grow up with an ideology regarding how they should behave and react to certain situations.

ACCEPTED MANUSCRIPT Therefore, for young women experiencing homelessness, social networks and the couple are an important source of companionship and protection, by providing the necessary possibilities for their survival and functioning. However, on the other hand, they constitute a source of violence, insecurity, abuse and delinquency; circumstances that inevitably affect their

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well-being and health.

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4. 2. Need for Survival. Young women experiencing homelessness, faced with the need

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to subsist, alleged resorting to methods of survival that threaten their physical and psychological well-being, such as prostitution, stealing and selling drugs. Other research has shown that one of

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the main reasons for engaging in psychosocial risk behaviors is subsistence, especially when it

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comes to risky sexual activity (Herdee & Hemphill, 2017). The existing literature reveals that there are few external resources, coming from institutions or people, in which young women

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experiencing homelessness can rely and it can be inferred that this lack of support is what leads

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them to develop strategies according to their needs and circumstances. 4. 3. Contradiction in Attitude-Behaviour. Despite having a negative attitude towards

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the performance of illicit behavior and having risky sexual relationships, and knowing the

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consequences associated with drug use, young women experiencing homelessness engage in such behaviors as a way to experience sensations, and to cope with their current circumstances;

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also to belong to a group that allows survival and satisfies both basic and emotional needs. This is a finding not much discussed in the scientific literature that can be explained with Azjen’s Model of Planned Behavior (2015) in conjunction with the particular context in which youth live. Attitudes towards youth psychosocial risk behaviors are mixed and even contradictory, because although they identify with normative beliefs that the behaviors are harmful or incorrect, they recognize that these behaviors are alternatives to the lack of support and significant

ACCEPTED MANUSCRIPT attachments. Additionally, although they perceive themselves with control of carrying them out, they are also coerced in many cases, such as in risky sexual activity and prostitution.

To sum up, findings seem to indicate that the behavioral intention to consume drugs, have

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unprotected sexual intercourse and engage in criminal activities in a group of Mexican young

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women experiencing homelessness is more influenced by external factors (i.e., lack of resources,

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no satisfaction of essential needs and social pressure) and by internal factors (i.e., pursuit of pleasure, perception of risk, and by their normative beliefs), rather than by their behavioral

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beliefs.

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With respect to clinical implications, outcomes show support for interventions that

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address beliefs that predispose young woman that experience homelessness to psychosocial risk

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behaviors. These beliefs are better addressed in empirically evidenced treatments, such as Cognitive Behavioral Therapy or similar modalities where examination of thoughts regarding

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behaviors is done. The cognitive-behavioral therapeutic (CBT) approach helps individuals reframe or challenge their own beliefs, automatic thoughts, and schemas (Kendall, 2012). In

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addition, there have been potentially promising outcomes with cognitive-behavioral approaches

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used with homeless young people (Altena, Brilleslijper-Kater & Wolf, 2010), especially when interventions are brief (Carney & Myers, 2012). CBT’s goal with working in this group could be to restructure distortions that lead to psychosocial risky behaviors. It’s also important to consider gender implications in interventions, addressing them from a multicultural perspective. Young women who experience homelessness are more vulnerable because of the intersection with sexism and gender norms. This particular group relies heavily on what their loved ones do or think in order to engage in psychosocial risk behaviors. Including a gender perspective in therapy

ACCEPTED MANUSCRIPT is crucial to reduce vulnerability.

5. Conclusions Being part of the homeless lifestyle involves substance use and abuse and drug dealing,

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having frequent sexual encounters and adopting values, norms and beliefs contrary to what is

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socially desirable and acceptable. This introduces young women experiencing homelessness to a

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vicious cycle from which they can hardly leave without timely and efficient intervention. Results obtained can be usefully incorporated in the design of intervention programs that address the

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problem of psychosocial risk behaviors taking into account the characteristics and needs of this

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group and with a particular emphasis on their beliefs and on their social networks and interactions. Findings also suggest the possibility that interpersonal relationships are essential to

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predict the occurrence of psychosocial risk behaviors in Mexican young women experiencing

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homelessness and reaffirm the importance of incorporating the perception of individuals in terms of engaging in psychosocial risk behaviors in behavior prediction models. Consequently, the

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present study provides a greater understanding of the psychosocial risk behaviors present in a

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sample of Mexican young women experiencing homelessness, hence allowing the development

problem.

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of effective intervention strategies and contributing, in the long term, to gradually reduce the

One of the limitations of this study was that, although qualitative interviews are the most appropriate method to address research objectives, the study had to rely exclusively on this method. This is due to the existence of limited resources that did not make it possible to add other forms of data collection through which the information could be triangulated and contextualized. In addition, the interview focused on certain psychosocial risk behaviors due to

ACCEPTED MANUSCRIPT practicality, lack of time availability and being a highly floating and transitory population. Furthermore, since it was a non-probabilistic sample, findings achieved cannot be generalized to similar populations in other contexts and to different psychosocial risk behaviors. Finally, unsheltered young women were not represented in this sample because of difficulties in

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recruiting them.

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Ethical statements

We would like to assert that we have abided by the Ethical Principles of Psychologists and Code

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of Conduct as set out by the APA. Ethical approval was given by the Academic Board of the

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Master’s and Ph.D. program in Psychology of the National Autonomous University of Mexico.

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This review serves as the Mexican equivalent to an American IRB Review.

Conflict of Interest

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Declarations of interest None

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The authors, Susana Castaños-Cervantes Ph.D., and Nicole M. Vélez-Agosto, have no conflict of

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interest with respect to this publication.

Geolocation information This study was conducted at the Universidad Nacional Autonoma de Mexico, Avenida Universidad #3000, National Autonomous University of México (UNAM, CU), Coyoacan, México City, 04510.

Financial Support (Funding)

ACCEPTED MANUSCRIPT This study is part of a non-funded research.

Disclosure Statement No financial interest or benefit that has arisen from the direct applications of this research. Acknowledgements

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We would like to express our gratitude to PAIDI, NGO., for their assistance during the planning

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Psychosocial risk behaviors in Mexican young women experiencing homelessness were mainly substance use and abuse, risky sexual activity and criminal behaviors such as theft, prostitution and drug dealing. Psychological predisposing factors for substance use and abuse in Mexican young women experiencing homelessness were sensation-seeking and risk perception. Social environmental predisposing factors for various psychosocial risk behaviors in Mexican young women experiencing homelessness were social pressure and peer’s and couple’s behaviors. Interpersonal relationships seem to be essential to predict the occurrence of various psychosocial risk behaviors in Mexican young women experiencing homelessness.

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Highlights

Figure 1