EXPLORING THE HEALTH OF WOMEN WHO EXPERIENCED HOMELESSNESS DURING ADOLESCENCE

Homelessness remains a significant global issue with substantial health consequences related to the experiences of homelessness. The consequences for people who experience homelessness are typically associated with high levels of risk, violence, and negative health outcomes. Developmental levels and gender contribute significantly to outcomes. As a developmental stage, adolescence is a time of establishing healthy practices for adulthood. Adolescent experiences with homelessness have negative consequences for future health as well as some economic status. Homeless youth have been identified as a medically underserved and vulnerable population. A significant body of literature has explored the outcomes of mental health, sexual practices, risky behaviors, and substance abuse related to adolescents who are homelessness. However, exploration of the lived experiences of adolescent females while homeless related to strengths used for caring for their health is limited. This includes a need to understand how women who experienced homelessness during adolescence engaged in health promotion and accessed health information. Adolescent females are at greater risk for acts of violence against them, have specific physical and emotional needs as well as perspectives regarding their health and well-being. The purpose of this study was to explore how women who experienced homelessness during adolescence met basic health needs, utilized resources and negotiated met while trying to maintain their health. A qualitative exploratory approach to inquiry using semi-structured interviewing was used with a purposive convenience sample of nine women obtained from a communitybased agency. Inclusion was limited to women who experienced homelessness during adolescence, defined as between the ages of 12-24, who are English speaking and not actively suicidal or psychotic. Qualitative content analysis (QCA) was used to analyze transcripts with attention to manifest and latent content. Processes to maintain trustworthiness were implemented. Six categories were identified and two themes emerged from the analysis of the data. The categories are listed as (1) hunger; (2) staying safe, warm and rested; (3) keeping clean; (4) resourcefulness; (5) challenges encountered; (6) insights and recommendations. The two themes that emerged and were (1) survival takes precedence; and (2) remaining invisible. Implications for nursing knowledge, practice and education were discussed. Recommendations included further research specific to female adolescents who are homeless, education of nurses and nursing students related to meeting the needs of female adolescents who are homeless, and policy implications.

v To my husband David and our children Tanya and Lara there are no words to truly express how much you mean to me and for the years of unconditional love and understanding as we took this long journey together. My love and gratitude is unending. I look forward to special times once again. To the extended members of my family I am so grateful to all of you for your support and understanding. It has been a long road thank you for walking it with me.
To my many colleagues at Rhode Island College I thank you for taking this journey with me as well and providing the support and encouragement to keep going. I

Introduction
Concern and respect for those less fortunate was embedded in my childhood and Catholic upbringing. My father's stories of hunger and leaving home to work on farms at a very young age left a lasting impression on me and stayed with me throughout my nursing education. As a pediatric nurse practitioner, I became increasingly aware of the needs of adolescents. My personal belief is that adolescents/youth are more often in greater need of assistance in navigating life than those other periods of development, especially if they have not had what is considered a traditional childhood.
A few years ago I had an opportunity to take a trip to a pacific coast state where a large number of young people were noted to be living on the streets with backpacks and skateboards. Observing the large amount of young people on the streets piqued my attention. In addition signs in many windows announcing that bathrooms were only for paying customers sparked an interest in what prompted this type of advertisement. People who lived in the area described a "problem" with homeless individuals and their use of community resources. I began to imagine what I would do if I was without a place to wash, brush my teeth, or care for my elimination needs if I were living on the streets. The journey to a better understanding of vulnerable adolescent populations began from that encounter.
In 2010, President Obama signed into law The Affordable Care Act that acknowledges the need for preventative health care and health promotion for all citizens. Unfortunately, some segments of the population will continue to be at a disadvantage for achieving optimal health. Individuals experiencing poverty and homelessness are one segment, which are disadvantaged. A subset of this population is youth/adolescent-experiencing homelessness.
Although all ages can be affected by homelessness and each developmental level is impacted differently by the consequences of homelessness, youth/adolescent homelessness has significant ramifications for a productive and secure future (Ammerman et al., 2004;Burt, 2002;Rew, 1996). Adolescence is a time of greater vulnerability during which behavior patterns are being set for adulthood. As a result of homelessness, children and youth experience greater numbers of illnesses with an increase in the severity of illness (Feldmann & Middleman, 2003;Healthy People 2012;HRSA, 2001). Mental health issues and disruption in physical, emotional, social and cognitive development for youth who experience homelessness has been reported in the literature (Hodgson, Shelton, van den Bree, & Los, 2013;Kirst, Frederick & Erickson, 2011;Whitbeck & Hoyt, 1999;Whitbeck, Johnson, Hoyt & Cauce, 2004). Some estimates imply more than six times greater risk to health than that of individuals who are not homeless (National Coalition for the Homeless [NCH], 2008[NCH], , 2009a[NCH], , 2009b and are three times more likely to report moderate to severe illness (Ensign & Bell, 2004; National Center on Family Homelessness, 2011). A reported five thousand young people die on the streets due to illness or assault on a yearly basis (National Conference of State Legislatures, 2013). Attainment of a stable consistent education is also impacted by homelessness resulting in increased delinquency (Annie E. Casey Foundation, 2013b;NCH, 2008).
Homelessness in the United States remains an ongoing social issue, present at local, national, and global levels. Low income, financial and capital inequalities, policies, structural issues, and lack of affordable homes are considered to be the primary factors contributing to homelessness (NCH, 2009a(NCH, , 2009c. However, in the case of youth/adolescents the primary reasons for homelessness appear to be related to disruption of family relationships. This includes abuse, gender issues, substance abuse, and change in family dynamics such as divorce or remarriage which lead to youth running away, being thrown out, or discarded (Aratani, 2009;Bearsley-Smith, Bond, Littlefield, & Thomas, 2008;Edidin, Ganim, Hunter, & Karnik, 2012;Robertson & Toro, 1999).
The exact number of youth experiencing homelessness is elusive. Factors associated with limited access to accurate estimates of youth/adolescent experiencing homelessness can be attributed to the transient and hidden nature of this subpopulation, as well as the inconsistent definition of homelessness (Edidin et al., 2012;Robertson & Toro, 1999). Estimates in the area of 1.6 million (NCH, 2008) to 1.7 million (Hammer, Finkelhor, & Sedlak, 2002) adolescent/youth are reported to experience homelessness. Statistics from The National Runaway Safeline (2013) for 2012 based on slightly more than seventeen thousand calls suggest a total of 52% of the youth calling were on the street. Of the total calls, 40% of the callers were white and 72% were female. The greatest unmet need voiced by the callers was that of shelter. The National Conference of State Legislatures (2013) reports approximately 75% of the runaway populations are female.
In Rhode Island the most current statistics from The RI Kidscount Factbook (Annie E. Casey Foundation, 2013b) suggest that adolescents and youth ages 18 to 20 had a decrease of approximately 4.5% and 21 to 24 year olds had an increase of approximately 16% for utilization of services for the homeless over the past fiscal year. Since survival is foremost for these individuals, they may engage in behaviors or activities such as forging relationships with men, survival sex and stealing that are necessary for survival and are detrimental to their health and well-being (Aratani, 2009;Edidin et al., 2012;Hodgson et al., 2013;Rew, 1996;Robertson, & Toro, 1999).
Health promotion, maintenance of health and access to health care remains a significant topic of concern for the government as well as health care providers (American Academy of Pediatrics, 2008; Healthy People 2012; United States Interagency Council on Homelessness, 2012). Nurses are focused on the promotion of health especially in areas where there is increased risk of health impairment, a lack of resources to achieve health and with populations who are most vulnerable (Coles, Themessl-Huber, & Freeman, 2012). Patient preferences in regards to care must be considered when providing care to the client. In order to achieve the best care and outcomes for clients it is crucial to acknowledge their strengths and expectations regarding their health. Understanding what youth/adolescents do to maintain and achieve health is an important dimension that has received little attention especially in the female population. (Reid, Berman, & Forchuk, 2005;Rew, 2003;Rew & Horner, 2003;Bender, Thompson, McManus, Lantry, & Flynn, 2007).
Adolescents who have experienced homelessness describe a distrust of health care providers. The literature suggests that these individuals feel that they are not heard, not respected, and are not given the opportunity to communicate their needs or wants to health care providers (Barry, Ensign, & Lippek, 2002;Ensign & Panke, 2002;Haldenby, Berman, & Forchuk, 2007;Reid et al., 2005). Possessing the knowledge and ability to care for themselves is a reported request for these clients (Ensign & Panke). Individuals who are experiencing homelessness possess strengths and abilities, which appear unethical or illegal to the general population but allow for survival in a less than optimal situation. Nurses and other health care providers need to understand how these clients care for themselves and what information is important to them in order to be able to guide these clients towards better health.
Minimal research has been conducted that has identified the self-care attitudes and behaviors exhibited by adolescents who were homeless (Rew, 2003;Rew & Horner, 2003). Barriers to accessing health care have also been described by a number of authors (Ensign & Bell, 2004;Ensign & Panke, 2002;Hudson et al., 2010;Reid et al., 2005;Rew, 2003). Barriers identified by the youth/adolescent include a lack of skills necessary to access health care and the knowledge on how the health care system works. Other barriers include lack of financial resources to purchase care or insurance, a lack of transportation to a health center and a health care atmosphere that is not adolescent/youth centric. Additional barriers include individual's perception of being stigmatized, judged or treated disrespectfully due to their homeless status (Christiani, Hudson, Nyamathi, Mutere, & Sweat, 2008;Ensign & Bell;Ensign & Panke;Farrow, Deisher, Brown, Kulig, & Kipke, 1992;Gerber, 1997;Haldenby et al., 2007;Hudson et al.;Klein et al., 2000;Reid et al.).
Recent literature has begun to explore the importance of obtaining an emic perspective in order to best respond to the health needs of this population. Utilization of positive development for successful navigation to adulthood is also suggested as an approach for mitigating risk with this population (Taylor-Seehafer, 2004). Exploring and building on the strengths of people who are homeless, rather than focusing solely on negative outcomes, illness or limitations has been underscored (Rew & Horner, 2003). Ensign's (2001) research also supports this view stating it is imperative for health care providers to recognize and acknowledge, "young women are the experts about their bodies, health issues and lives" (p. 79).
Homeless youth in the U.S have been identified as a medically underserved and vulnerable population (Ensign, 2004;Oliver, 2013;Rew, 2003). Despite the fact that the numbers of adolescent women who are homeless is on the rise (Annie E. Casey Foundation, 2013a, b;Aratani, 2009; National Alliance to End Homelessness [NAEH], 2013;NCH, 2009a;NCSL, 2013; National Law Center on Homelessness & Poverty [NLCHP], 2012) "there are astonishingly few published studies of homelessness among girls and young women" (Reid et al., 2005, pg. 239). There are even fewer studies that have used narratives to explore how adolescent girls maintained their health while they were homeless. Obtaining information directly from women who experienced homelessness during their adolescence will add to the limited knowledge base.
The research questions for this study were: • What approaches did women use to maintain their health while they experienced homelessness as adolescents?
• What resources did women use during the time they experienced homelessness in adolescence in order to meet their basic needs and to maintain their overall well-being?
• What challenges did the women encounter in meeting their health needs?
• What suggestions do these women have for nurses and other health care providers to assist in meeting the health needs of female adolescents who are homeless?
To examine the above questions, a descriptive approach to inquiry was used.
Semi-structured audiotaped interviews were conducted with women who had experienced homelessness during their adolescence. The interviews were transcribed verbatim and content analysis was used to analyze the data. Nurses and other health care providers will likely encounter adolescents who are homeless. In order to deliver better programs to address the unique needs of the female adolescent population during homelessness, research that is particularly targeted to this population is vital.

Prevalence
Accurate estimates of the prevalence of homelessness in the adolescent population are difficult to determine due to a number of complex factors. Unsheltered youth try to remain unnoticed, hidden and safe. They avoid situations or places, such as shelters and community agencies that have the potential for their minor status, while without a home to be discovered. Additional reasons associated with determining accurate estimates include the ability for these adolescents to be fluid, highly mobile, easily dispersed in the mainstream population and their move in and out of domiciles (Aratani, 2009;Barry et al., 2002;Bender et al., 2007;Dworsky & Courtney, 2009;Edidin et al., 2012;Hyde, 2005;Kidd & Davidson, 2007;Lee, Tyler, & Wright, 2010;Martinez, 2006;Mallett, Rosenthal, Myers, Milburn, & Rotheram-Borus, 2004;National Network for Youth [NN4Y], n.d.a, n.d.b;Ringwalt, Greene, Robertson, & McPheeters, 1998;Robert, Pauzé, & Fournier, 2005;Sanchez, Waller & Greene, 2006;Washington, 2011;Whitbeck, & Hoyt, 1999;. As a result, agencies charged with tracking numbers of individuals who experience homelessness are not able to include those who are not using services, thus leading to an underrepresented estimate of unsheltered individuals. Studies intended at understanding the implications of adolescents experiencing homelessness are frequently aimed at targeted cities and may not generalize to all populations especially in urban areas. The 2011 United States Census reports a total population of approximately 311 million adolescents living in the United States. Of this 311 million the largest subpopulation is adolescents ages 20 to 24, which is estimated at 22 million followed by ages 15 to 19 estimated at slightly fewer than 22 million (US Census Bureau, 2010). Healthy People 2020 estimate that adolescents between the ages of 10 to 24 comprise 21% of the United States population (Healthy People, 2012). Prevailing estimates of youths who experience homelessness range from 1.6 to 2 million children (Molino, 2007;NAEH, 2013;NCFH, 2009;NCH, 2008;National Runaway Safeline, 2013). Of this population an estimated 6 to 40% report being lesbian, gay, transexual, or bisexual [LGTB] (Cochran, Stewart, Ginzler, & Cauce, 2002;Corliss, Goodenow, Nichols, & Austin, 2011;NAEH, 2013;. In addition, aproximately 6 to 22% of young women report being pregnant (Feldmann & Middleman, 2003;NN4Y, nd, b;NCH, 2008;Thompson, Bender, Lewis, & Watkins, 2008). The Center for American Progress suggests in the youth homeless population LGTB population is the largest group with a greater number of individuals who are male (Hein, 2011). Females account for the largest population of runaway and homelessness at aproximately 75% (NCSL, 2013 (O'Neill, 2013).
Unfortunately these statistics from all of the various agencies do not provide a comprehensive picture since the data are gathered from shelters that do not take into account those individuals who may be homeless and not using available services. This is especially true of homelessness in rural areas.
The Conference on Mayors report (2012) for the city of Providence did not report statistics for unaccompanied youth. However the report does suggest an expected increase in unaccompanied individuals for the upcoming year. According to the RI Kids Count Fact Book (Annie E. Casey Foundation, 2013b), one shelter in Rhode Island reported an increase of unaccompanied youth accessing basic services as well as using adult emergency shelters for 2011. The 2013 RI Kids Count Fact Book reports an increase in children who are living in single-parent families and in poverty.
Due to the "hidden" nature of adolescents all statistics and reported numbers for this population may be greatly underrepresented. According to the NAEH (2011NAEH ( , 2013, which examined the State of Homelessness in 35% of communities, reported that homeless youth did not exist in their communities. However, estimates of approximately 50,000 youth are on the "streets" living in areas not suitable for habitation. Furthermore these estimates are considered to be expanding (NAEH, 2012;Son, 2002). National trends noted in the Annual Report on Homelessness in America from 2010 to 2011 indicates an increase of 5.8% of poor single-person households and a 9.4% increase in poor households living doubled up. Since the age parameter for a single adult is not mentioned, this figure may include individuals who are ages 18 to 25.
Public agencies that provide services to individuals who experience homelessness are given the task of keeping count of the numbers. significantly. An ammendment to the strategic plan in 2012 includes strategies to improve accessing comprehensive statistics on the scope of youth homessness as well as exploring evidence based practices to respond to the issue of youth homelessness (USICH, 2012).

Definition of Adolescents/Youth
Additional factors contributing to the difficulty gathering demographic data is related to the various descriptors used to define adolescent/youth as well as homelessness. These terms are not well defined and vary across studies. Age parameters for youth vary depending on the source used to define adolescent or youth.
Some of the terms used to describe adolescents or youths experiencing homelessness include unaccompanied youth, runaways, throwaway/castaways, pushed-out, and street children. These terms vary in their definition and age parameters and may not accurately describe the population of youth who remain unsheltered (Aratani, 2009;Edidin et al., 2011;Farrow et al., 1992;Hagedorn & Ekegren, 2002;Son, 2002;Robertson & Toro, 1999;Toro, Lesperance, & Braciszewski, 2011;Washington, 2011 Some sources use growth and development or achievement of economic independence as parameters for this stage (Garzon & Dunn, 2013). Additionally adolescence can be sub-divided into categories of early, middle, or late adolescence or into two categories of early and late with age parameters as well as specific developmental milestones within each category (Ammerman et al., 2004;Newman & Newman, 2012;Saewyc, 2011). For this study the terms adolescent and /youth were used interchangeably including individuals between the ages of 10 and 24.

Adolescence: A Time of Rapid Developmental Changes and Transition
Adolescence is a time of rapid developmental changes in the physical, cognitive, and social-emotional domains (Saewyc, 2011). Physical growth is marked by the onset of puberty resulting in an ability to reproduce as well as achievement of adult physical proportions. Due to these rapid changes, adolescents often feel awkward or uncomfortable with their bodies. The brain is continuing to develop in adolescence, which affect their decisionmaking and problem solving abilities. Newer research suggests that higher cognitive functioning at the pre-frontal cortex may not be fully mature until the mid-twenties (Giedd, 2008;Giedd et al., 2012). Their actions are guided more by the amygdala and less by the frontal cortex. The amygdala is responsible for instinctual reactions that include fear and aggression. The frontal cortex controls reasoning and helps us think before taking action. Based on the stage of brain development, adolescents are more likely to act on impulse, and engage in dangerous behaviors. They are less likely to pause and consider consequences of their actions and modify their behaviors that may be inappropriate or dangerous. Adolescents rely more on emotion vs. logical thinking (limbic) in decision-making. Around age 15, adolescents and adults make similar decisions when presented with a hypothetical situation. However in an actual situation adolescent rely more on emotion. Since adolescence is a time of experimentation, risktaking is more likely to occur (Chamberlain & Johnson, 2011;Giedd, 2008;Giedd et al., 2012;DHHS, n.d.).
Although adolescence is characterized as a time of risk taking behaviors, some risk is needed to prepare the adolescent for future challenges. Unnecessary risks may lead to poor health choices, leading to chronic health conditions or death. Since higher brain functions related to planning, forming strategies, problem solving and foreseeing consequences of behavior is not fully mature until later in adolescence, support and guidance should be considered as an important component during the child's transitions to adulthood. An adolescent who experiences homelessness without the needed support has a greater propensity for future risks and poorer health outcomes (Beharry, 2012;Boivin et al., 2005;Edidin et al., 2012;Farrow et al., 1992;Feldmann & Middleman, 2003;Haldenby et al., 2007;Hagedorn & Ekegren, 2002;Healthy People 2012;Rew, 2008).
Knowledge, skills and habits used throughout one's life are established during this period of development. Any alteration to healthy habits, unhealthy choices, and high risk will have disproportionate influence on the economic productivity and health of persons (Reyna, Chapman, Dougherty, & Confrey, 2012). Therefore, an inability or alteration in adolescents reaching their full potential will impact the future of the nation. Burt (2002) argues that investing in adolescents especially those at risk increases future prospects for the individual as well as economic forecasts for the larger society. Adolescents experiencing homelessness are a population at risk and without interventions to support the "normal" developmental processes.
As adolescents are moving toward increasing independence, they are struggling with developing their sense of identity. Trying on new roles and making commitments to defined sets of values and goals is typical in this stage of development. On the other side of the spectrum is not being able to achieve identity, which can lead to psychosocial issues (Newman & Newman, 2012). Newman and Newman (2012) identified two stages of adolescence as early (12 to 18) and late (18 to 24). Early adolescence is described as focusing on having group identity versus feeling a sense of alienation. Developing one's identity begins with aligning with group identity. Questions that can lead to internal conflicts include: "Who am I in relation to the group?" "Does membership in this group fit or not fit with my values, needs, or goals?" A positive resolution to this developmental crisis occurs when adolescents are able to discover one or more groups that meet their need to be connected, to belong and to express their "social selves" (Newman & Newman).
Successful resolution of group identity leads to consideration of individual identity. In light of the many challenges adolescents face, homelessness has the potential for interfering with identity formation.
Additional considerations in early adolescence include romantic and sexual relationships including dating, first intercourse, and early discovery of sexual orientation. For some adolescents the discovery of their gender identity is a reason for family discord and expulsion from the home. A disproportionate number of lesbian, gay, transsexual, and bisexual are noted in the adolescent homeless population with a greater level of negative outcomes related to risk and violence (Abramovich, 2012;Rew, 1996;Rew, Whittaker, Taylor-Seehafer & Smith, 2005;Van Leeuwen et al., 2005;.
Later adolescence is concerned with autonomy, career choice, and establishing an internal compass for morality and gender identity. Several studies point out that in order to survive, the use of survival sex, especially in the female and gay population is used to meet their basic needs of food, shelter, and protection as well as an opportunity to earn money (Greene, Ennett, & Ringwalt, 1997;Ray, 2006;Rew et al., 2005;Rice et al, 2013;Tyler & Johnson, 2006;. As a result, the first sexual encounter for some adolescents experiencing homelessness may be that of rape (Ensign & Bell, 2004;Coates & McKenzie-Mohr, 2010;. Transitioning through the stages of adolescence allows for development into a healthy functioning adult. Disruption, as in the experiences and consequences of homelessness may impede the individual's ability to navigate through the stage of adolescence with subsequent bearing on adult functioning (Ammerman et al., 2004)

Homelessness Defined
There is no one definition of homelessness in the literature. At the federal level, definitions of homelessness may vary somewhat from agency to agency, but overall the prevalent theme in the definition is an individual who is without a fixed, regular, and adequate nighttime residence or is living in a place not meant for human habitation. Legal definitions of homelessness are provided through the McKinney-Vento Act and through federal agencies primarily that of HUD. Homelessness refers to individuals who lack a fixed, regular, and adequate nighttime residence and includes: (i) Children and youth who are sharing the housing of other persons due to the loss of housing, economic hardship, or a similar reason; are living in motels, hotels, trailer parks, or camping grounds due to the lack of alternative adequate accommodations; are living in emergency or transitional shelters; are abandoned in hospitals; or are awaiting foster care placement; (ii) Children and youth who have a primary nighttime residence that is a public or private place not designed for or ordinarily used as a regular sleeping accommodation for human beings.
(iii) Children and youths who are living in cars, parks, public spaces, abandoned buildings, substandard housing, bus or train stations or similar settings (National Health Care for the Homeless Council, n.d.; Legal Information Institute [LII], n.d.) Adding to the mix is from the perspective of the population themselves since their perception of homelessness does not fit the definition and therefore those individuals may not identity with the term of homeless. How long an individual is homeless also has an impact on the reporting estimates for individual's experiencing homelessness. No consistent time limit is described in the definition of homelessness.
Time can be as short as hours, days, or longer. The period of time can be intermittent or the individual remains lost to streets or experiences death (Edidin et al., 2012, Hodgson et al., 2013. For many youth, the time without shelter is short. Youth either return home often temporarily, go into foster care or to a transitional youth facility.
For others the period of time is transient. For the purpose of this study the length of time for homelessness is defined as 24 hours or longer.
In a longitudinal study by Milburn et al. (2007), the rate and timing of youth who experienced homelessness as a result of running away from home and the length of time away from home in a population of youth in Los Angeles, California, and Melbourne, Australia were examined. The findings suggest that youth who become homeless generally returned home and remained at home within two years. Sanchez et al. (2006) suggest that youth who runaway typically return home within a one to twomonth period and their experience is different from those who remain unsheltered.

Who Runs
Reasons for leaving home are variable and complex. Although economics has a role in homelessness, the greatest predictable risk for youth homelessness arises from dysfunctional family functioning (Chamberlain & Johnson, 2011;Collins & Barker, 2009;Ensign & Bell, 2004;Finfgeld-Connett, 2010;Farrow et al., 1992;Haldenby et al., 2007;Martijn, & Sharpe, 2006;Reid et al., 2005;Rew, 2003;Rew, Taylor-Seehafer, Thomas & Yockey, 2001;Sanchez et al., 2006;Tyler, 2006;Tyler, Hagewen, & Melander, 2011;Tyler & Schmitz, 2013 profiles of runaway youth supported findings from previous studies that implicate disrupted family functioning and family structure as a strong predictor, but also noted geographic differences (Sanchez et al., 2006). Youth in the South were least likely to run away followed by the Midwest and Northeast with Western youth most likely to run away. Implications for these findings were not explained but the authors suggested futher evaluation to examine these results.
In some cases, youth were forced from their homes or abandoned due to family conflict related to sexual orientation, drug abuse (Greene et al., 1997;Hein, 2011;Hyde, 2005;Tyler, 2006) or financial constraints that led to loss of domicile (NAEH, 2011;NCH, 2009 Krinsky (2010) discusses that in American society, financial independence is most often not achieved until aproximately age 26. Therefore it is not surprising that youth who age out of foster care join the ranks of homeless, incarcerated or unemployed due to the lack of education, family support and needed social skills to navigate life.
Additional pathways to homelessness include running from foster care due to the desire to reconnect with family of origin or due to environments that are not tolerable (Hickler & Auerswald, 2009;Nesmith, 2006;Perez & Romo, 2011;Robertson & Toro, 1999;Tyler, 2006). African American youth who were experiencing homelessness in San Francisco reported failure of social services as a consequence of their homelessness; although they frequently maintained kinship ties with family members while on the streets (Hickler & Auerswald).

Culture of Homelessness
Challenges related to experiencing homelessness as well as the ability to survive has been reported in the literature. Some of the literature suggests that survival is linked to the culture in which the individual is living, as well as internal and external strengths. The experience of homelessness is not uniform. Perception and meaning of homelessness is related to the individual's experiences, gender, ethnicity, age as well as other factors. Culture implies a shared belief system, norms, values and social structure. The American Heritage New Dictionary of Cultural Literacy online (2013) defines culture as "The sum of attitudes, customs, and beliefs that distinguishes one group of people from another. Culture is transmitted, through language, material objects, ritual, institutions, and art, from one generation to the next".
Homeless adolescents belong to a unique culture that shares specific dress, attitudes, beliefs, and language (Barry et al., 2002;Ensign & Panke, 2002;Oliveira & Burke, 2009). Culture is specific to geographical areas and findings may not be generalized to other geographical areas. Females experiencing homelessness share a way of life that involves gender specific issues. Females are at greater risk for violence, sexual exploitation, pregnancy, as well as a greater need for health care, safety needs and coping with experiences of living (Ensign & Panke). Several studies have attempted to describe the culture of adolescents who experience homelessness (Hickler & Auerswald, 2009;Oliveira & Burke). However a minimal amount of literature explores the culture of adolescent females who are homeless. Characteristics of this "culture" are similar across studies and relate to the risks of homelessness and non-traditional strategies used in daily living, but also indicate positive behaviors and supports that allow for survival. Peer support, connection to a "street family," and "non-homeless friends" (Bender, Ferguson, Thompson, Komlo, & Pollio, 2010;Ferguson, Bender, Thompson, Xie & Pollio; are examples of supports necessary to survival.

Consequences of Homelessness for Adolescents
The impact of experiencing homelessness is significant to a population in which development of cognitive, psychosocial, and physical growth is a major focus.
Homelessness leads to disruption of development, health, emotional and social well being resulting in the risk for loss of future potential. As a developmental stage, adolescence has been noted to be a time of growth physically, emotionally, and cognitively especially with decision-making ability and future planning.
Adolescents without the needed social supports become highly vulnerable due to perceptions that exist regarding the age at which a child can care for him or herself.
Homelessness adds to the vulnerability of these children. In order to survive, they will become involved with high-risk activities to meet their basic needs.   and violence (Heerde & Hemphill, 2013;Kipke, Simon, Montgomery, Unger & Iversen, 1997;Oliveira & Burke, 2009).

Food Security
Adolescence is a time of rapid physical growth in which adequate nutrition is needed in order to meet the body's needs. In the general population adolescents are noted to have poor eating habits and often lack the needed vitamins, iron, magnesium, zinc, and calcium for proper growth (Saewyc, 2011). Adolescents experiencing homelessness, may be overweight due to the availability of foods that come from fast food places, soup kitchens, or food banks where the use of canned or processed nonperishable foods are offered (Franklin et al., 2012;Richards, Smith, & Eggert, 2013).
Lack of proper nutrition has the potential to lead to poor health outcomes including the inability for wounds to heal and decreased immunity. Additionally, the nutritional soundness of affordable foods are often assoicated with high amounts of salt and fats (Beharry, 2012;Dachner, & Tarasuk, 2013).
A lack of money to purchase food and non-participation in food assistance programs is notable in this population. Although governmental assistance in food stamps known as Supplemental Nutrition Assistance Program (SNAP) is available, certain conditions must be met. Some form of documentation that proves identity such as a drivers license, school identification card or birth certificate must be presented to obtain food stamps. Some programs have started computer access for adolescents who are homeless to upload their personal documents such as birth certificates, driver's license number and social security number for free. Proof of income is not always needed. However in some states application to work or training programs must occur Two other studies examining food aquistion and food insecurity took place in Canada. Antoniades and Tarasuk (1998) used a survey to examine the experiences of a group of 88 youth who were experiencing homelessness in Toronto. Results indicated that experiences of hunger were associated with the type of accomodations the individuals were living in. Participants who were associated with a shelter or rooming house experienced less hunger compared to those who were on the street. Concern as to where to obtain food and having enough food was reported in two-thirds of the sample. Although measurement of body mass index did not show a significant relationship with hunger, assessment of nutritional soundness was not included as a component of the study. Dachner and Tarasuk (2002) used ethnographic methods including semistuctured interviews to examine food insecurity and daily survival of life of homeless youth on the streets of Toronto. Food aquisition was a daily concern for these youth and the constraints of their situation greatly impacted the ability to purchase food and the quality of food that was affordable. Food in this situation was a "precious commodity" that was carefully guarded and shared.

Mental Health and Social Issues
A significant amount of literature reports an association of risk for mental health issues and homelessness. Mental health, exposure to violence or trauma is an area of concern and risk for this population. Risks such as exposure to violence and vicitmization have the potential of leading to homelessness. Hodgson et al. (2013) conducted a systematic review of the psychopathology for "young people" who experienced homelessness. "Psychopathology" was frequently present prior to being homeless. However the experiences of homelessness exacerbated the psychopathology.
Homeless youth are more likely to experience physical and/or sexual abuse than those who are not homeless either as a witness or as a victim (Aratani, 2009;Edidin et al., 2012;Kipke et al., 1997;Mallett et al., 2005;. Exposure and victimization related to violence continues during the periods of homelessness (Aratani, 2009;Rew, 2008;Rew, 1996;Reid et al., 2005; Steinman, Cauce, Cochron, Tyler, Gervais, & Davidson, 2013). Rates of exposure to violence was found to be somewhat equal between males and females in a study by Kipke et al. (1997). In this study, exposure to violence in a sample of 432 homeless youths in Los Angeles California was explored and rates of exposure were noted to be high. Sexual assault and fear of being hurt by being stabbed, shot or beaten were found to be more associated with females than males.
(HRSA, 2010). However both genders reported exposure to violence at fairly equal rates. Individuals who are lesbian, transgender, gay or bisexual [LTGB] are at greater risk for vicitmization as compared to individuals who are heterosexual. Since it is estimated nearly half of the homeless adolescent population is LGTB, a greater proportion of this population individuals are at risk for victimization (Aratani, 2009;Cochran et al., 2002;Hein, 2011;Tyler, 2008;Whitbeck, Chen, Hoyt, Tyler, & Johnson, 2004).
Exposure and victimization as well as stressors of experiencing homelessness is highly associated with substance abuse including alcohol, marijuana, or injectable drugs and risk of suicide. In some instances substance abuse is a cause of expulsion or volunatarily leaving home. However stessors of living on the street and trying to survive is often the catalyst for the onset of substance use. A significant subset of literature related to substance abuse and homlessness is dedicated to this problem in the context of adolescence. Studies examining the issue of substance abuse, consequences of substance abuse, and interventions to alleviate or minimize the risk of substance abuse are present (Bousman et al., 2005;Feng et al., 2013;Gomez, Thompson & Barczyk, 2010;McMorris et al., 2002;Nyamathi et al., 2010;Slesnick & Meade, 2001).
Suicide rates are notably higher in adolescents experiencing homelessness (Boivin et al., 2005;Ganz & Sher, 2012;Robertson & Toro, 1999;Thompson et al., 2012). In a narrative study by Kidd and Kral (2002), it was suggested that adolescents engaging with trading sex and prostitution had a high degree of suicide attempts with approximately three-quarters of the sample reporting they had attemped to commit suicide. Additional reasons for high suicide rates in the adolescent population expeiencing homelessness is associated with underlying mental illness exacerbated by the situation.
Experiences of abuse and exposure to violence leads to increased distrust of adults thus distrust of agencies that are managed by adults and decreased use of available mental health services (Collins & Barker, 2009;Kozloff et al., 2013;Rew, 1996Rew, , 2003. Unaccompanied youth are at greater risk for mental health problems such as post-traumatic stress disorder (PTSD) and conduct disorders (Bender et al., 2010;Bender et al., 2013).  examined the development of symptoms of mental illness in a cohort of homeless adolescents from several midwestern cities compared with a cohort of housed adolescents from the same area. Findings indicated homeless adolescent females were five times more likely to have symptomology consistent with post-traumatic stress disorder [PTSD]. Alumi of foster care who experinced homelessness were noted to have higher rates of individuals with symptoms of PTSD (White et al., 2011). Gender differences were noted in rates and symptomatology of PTSD as well as self-harm and suicide attempts for adolescents expeiencing homlessness. Females were found to have higher rates of PTSD as well as greater self-harming behaviors and attempted suicides as compared to males (Gwadz, 2007;Moskowitz, Stein & Lightfoot, 2012). Other prevailing disorders reported by a number of authors include depression, and conduct disorders. (Edidin et al., 2012;Hoddgson et al., 2013;Slesnick & Prestopnik, 2008;Stewart et al., 2004).

Physical Health
Women experiencing homelessness have been identified as being highly vulnerable and a "sub-culture" who are medically underserved (Ensign & Panke, 2002;Haldenby et al., 2007). Adolescent females are at greater risk for being victimized and for experiencing health disparities (Haldenby et al.;Hoyt, Ryan, & Cauce, 1999;Lee et al., 2010). Adolescents experiencing homelessness have the same health care needs as those who are housed. However, due to the consequences of homelessness, and a lack of access of physical care, health promotion and disease prevention, many adolescents will potentially have health problems that are more problematic and difficult to treat (Dawson & Jackson, 2013;Klein et al., 2000, NHCHC, n.d.). Additionally, the lack of food and shelter also have an impact on health resulting in malnutrition, sleep deprivation and conditions resulting from exposure to wet, cold, or heat (Beharry, 2012;Reid et al., 2005;Rew, 1996). In addition to the typical preventable issues, Rew (1996) outlined health risks along with the contextual factors for adolescents experiencing homelessness into four domains: physical, psycholgical, social and spiritual. Additional consideration was suggested for culturally and holistic care of the adolescent when planning health services.
Minimal literature was found exploring spirituality and in this case is related more to hope, care, and meaning rather than a deity or organized religion. It is an area that has minimal literature however it is at times discussed briefly in context to other research questions or concepts especially in regards to resilience and strenghts (Bender et al., 2007;Williams & Lindsey, 2005).
Adolescent health care includes immunizations, screenings, and assessments.
Depending on the age when homelessness occurs, protection for certain diseases through immunizations, as well as screenings for preventable health issues will be impacted. Protection through immunization is primarily for meningitis, tetnus, diptheria, acellular pertussis (Tdap), hepatitis A, and human papillomavirus vaccine (HPV). Screenings and risk assessments generally done during adolescence include blood pressure screening, hemoglobin and heatocrit levels, dylipidemia screening, sexually transmitted infections (STI) screening, hearing and vision screenings, drug and alcohol assessments, as well as assessment of the behavior and psychosocial aspects (AAP, n.d.; US Preventative Services Task Force, n.d.).

Strategies Used by Adolescents Experiencing Homelessness
Survival is by far the most important need for the individual expeiencing homlessness (Bender et al., 2007;Ferguson et al., 2011;Rew, 2003;Robertson & Toro, 1999 (Kidd & Davidson, 2007;Rew, 2003;Rew & Horner, 2003;Robertson & Toro, 1999). Bender et al. (2007) explored strengths in a population of homeless adolescents and described personal strengths or attributes with a corresponding skill set which allowed for survival. Key attributes included responsibility for self, aspirations and goals, maturity, positive attitude, and trust.
These findings suggest that survival is dependent on an individual's ability to develop street smarts such as learning the "rules." discerning who to trust, and adapting to the "culture" of the streets. However external resources such as peer supports and societal resources were often identified by the participants prior to identification of the individual's internal strengths. In some cases adolescents experiencing homelessness changed their behaviors and successfully exited homelessness as a result of increased maturity, observing the demise of others, or as a result of being responsible for another person or dog (Rew & Horner, 2003).
Knowledge of resources and peer networking are key components of strength.
Those who perceive themselves as resilient,were less likely to engage in risky behaviors regardless of their disconnection from their nuclear family . Once basic needs were met, attention to health, wellness, health promotion and disease prevention could be addressed.

Barriers to Accessing Health Care
Experiencing homelessness leads to a disruption in the attainment of health care. Homeless adolescents typically seek health care when absolutly necessary.
Consequently, delay in accessing care may lead to a chronic condition or disability.
Limitations in accessing health care is a recurrent theme in the literature. Factors such as lack of transportation, health insurance, monies to pay for services, inability to provide consent due to age, a lack of knowledge regarding how the health care system functions, and lack of knowledge regarding health promotion, or disease prevention such as adequate immunization affects the adolescents ability to access adequate health care (Dawson & Jackson, 2013;Doroshenko, Hatchette, Halperin, MacDonald & Graham, 2012;Hudson et al., 2010). Additional factors include fear of discovery, health care providers being uncaring and unempathic as well as perceived feelings of discrimination and stigmatization (Darkwah et al., 2012;Ensign & Bell, 2004;Ensign & Panke, 2002;Gerber, 1997;Oliver, 2013;Reid et al., 2005).
There are only a few studies that have examined adolescents' experiences during homelessness regarding health and strategies they used to take care their basic health needs (Ensign & Panke, 2002;Reid et al., 2005;Rew, 2003). In the area of women's health, issues related to reproductive health are highly explored. However an emic perspective of how adolescent females cared for themselves, how they accessed information or sought advice to maintain their health is lacking.

Summary
Recommendations from various studies suggest approaching holistic care of the adolescent experiencing homelessness from a positive strenghts approach (Bender et al., 2007;Lindsey, Kurtz, Jarvis, Williams & Nackerud, 2000;Rew, 2008;Rew & Horner, 2003). Focusing on the resourcefullness and current strengths of the individual builds confidence and trust between the individual and providers.

Methodology
The experiences of women who were homeless during their adolescence were the focus of this study. The specific research questions were: • What approaches did women use to maintain their health while they experienced homelessness as adolescents?
• What resources did women use during the time they experienced homelessness in adolescence in order to meet their basic needs and to maintain their overall well-being?
• What challenges did the women encounter in meeting their health needs?
• What suggestions do these women have for nurses and other health care providers to assist in meeting the health needs of female adolescents who are homeless?
A qualitative descriptive design combined with semi-structured interactive interviewing was used for this study. Qualitative descriptive studies produce findings that are close to the data and seek to understand experiences of individuals (Denzin & Lincoln, 2011;Sandelowski, 2000Sandelowski, , 2010. Recounting of personal experiences of events, which are significant to the individual, allows for the building of knowledge, which in turn informs recipients of information. Health care providers as well as society as a whole can develop a greater understanding of "what is going on" (Marecek, 2003;Marecek, Fine, & Kidder, 1997;Morse, 2011;Speziale & Carpenter, 2007). With this type of inquiry, knowledge is constructed from the rich descriptions provided by participants (Parse, 2001). Consequently recollections, insights and understanding of events can contribute to construction of theory. Although there are a variety of methods to elicit information from participants, the research question and sample drives the best method to reach the who, what, and when of an experience (Richards & Morse, 2007;Sandelowski, 2000).

Participants and Setting
Upon approval from the University of Rhode Island Institutional Review Board (Appendix A), a purposive convenience sample was recruited for this study to explore the experiences of young adult women who were homeless when they were adolescents (unsheltered). The sample consisted of 9 women between the ages of 23 to 39 with a mean age of 28.8 years. Three of the women were above the age of 30 and the remaining women were in the range of 23 to 28 years. Selection criteria included: the ability to read and understand English, experienced homelessness for a period of time during adolescence and a willingness to participate in a 1 to 2 hour interview.
Potential research participants were recruited from a residential facility for young women in a northeastern city. The administrator of the program at this facility presented an introduction to the proposed study during group meetings and asked the women who were interested to self-identify. At that time an appointment with the researcher was scheduled for an interview.

Data Collection
Prior to data collection, an explanation of the purpose of the research study as well as the risks and benefits were discussed with each participant individually.
Participants were made aware that the researcher applied for a Certificate of Confidentially (Lutz, Shelton, Robrecht, Hatton, & Beckett, 2000). Consent for participation in the study was obtained after the participant had time to ask questions from the researcher.

Demographics
After informed consent was obtained (Appendix B), the participants were asked to complete a demographic form (Appendix C), which included their age, race/ethnicity, education, length of time they were not housed, medical and psychiatric history, and medications. Participants were asked if they had health insurance and a primary care provider. The question of race and ethnicity was changed to include only race after the first interview was completed due to the participant's confusion regarding differences between race and ethnicity.

Semi-structured Interview
For this study a semi-structured open-ended interview was used for data collection (Appendix D). An interview guide assisted this researcher to remain on target, and provide some sequencing and guidance without interfering with the flow of the participant's reflections and descriptions (Polit & Beck, 2008;Seidman, 2006).
The interview questions were based on the research questions and the literature review. This type of interview allowed the participants to respond to the interview questions in their own words and at their own pace. To ensure that the interview guide contained appropriate wording that was culturally sensitive, age appropriate and nonjudgmental, faculty members who have expertise with this population and the director of the program reviewed the content from the interview guide. Adjustment to the language used was not needed.

Ethical Considerations
Since women with a past history of homelessness can be considered a vulnerable group, the researcher must be very sensitive to issues of informed consent and confidentiality. In addition, questions related to homelessness and experiences during that period of time could potentially raise emotional reactions. Therefore the researcher limited the interview length to no more than 2 hours, allowed for flexibility in the structure of the interview, scheduled the interview in a conference room in the facility which was a "safe" and private place, and identified a referral source within the agency for management of psychological distress if that occurred, (Draucker, Martsolf & Poole, 2009;Kavanaugh & Ayres, 1998).
Allotment of at least one and one-half to two hours per interview was reserved.
Interviews were audiotaped using a digital voice-recorder and participants chose a pseudonym at the onset of the interview that was used during the interview. Interviews were scheduled in the late afternoon at 1 p.m. and 3 p.m. in order to accommodate the participants' schedule of activities. Assessment of the participants' level of comfort was carefully monitored during the interviews. Process consent (Usher & Arthur, 1998) was used and participants were frequently asked if they wished to continue as well as reminding them that they could stop at any time, or take a break if needed.
A twenty-five dollar gift certificate was given to the participants at the completion of the interview in appreciation for their time and participation, which surprised them. They were extremely grateful for this gift.
Due to the sensitive nature of the study, all transcribed audiotapes, notes, consent and demographic forms were kept in a locked box. The listing of names with an assigned pseudonym were recorded on a different piece of paper and kept separate from the rest of the study data. A code number and pseudonym identified the interviews. Pseudonyms were self-selected by the participant. The study records including the audiotapes were shared with only two additional researchers who were dissertation committee members. At the end of the research, all audiotapes will be destroyed and study materials will be kept in the researcher's office and destroyed after three years.
Sharing one's experiences can have positive or negative outcomes for the participant. However, the literature does note that participants can benefit from participating in interviews (Corbin & Morse, 2003;Hutchinson, Wilson & Wilson, 1994;Riessman, 1993). In the process of interviewing study participants have described feeling a sense of relief in expressing personal feelings and can benefit from having their experiences validated (Hutchinson et al.,; Riessman). Since researchers are co-participants in the data collection process, journaling was done by the researcher at the end of each interview to allow for personal reflection on the interview and to document any concerns or issues that occurred during the interview process.

Data Analysis
Analysis proceeded from the researcher listening to the interview tapes prior to transcription to begin the immersion process and to obtain a sense of the whole. Tapes of the interviews were then transcribed verbatim through a transcription company that specializes in all forms of transcription including medical transcription. Transcribers who handled the transcription were fully aware of the sensitivity and confidentiality of the materials. No identifiable materials were included in the process of transcription.
Any potential identifiers were removed prior to transcription. Transcripts were then read several times to allow for immersion in the data and increase familiarity with each participant.
Qualitative content analysis (QCA) was used to analyze the transcripts.
Qualitative content analysis (QCA) is considered to be an excellent choice for qualitative descriptive studies and is frequently used in nursing research (Hsieh & Shannon, 2005;Sandelowski, 2000Sandelowski, , 2010Schilling, 2006). This method is a systematic process that is flexible with the intent of reducing large amounts of data (Schreier, 2012;Taylor & Renner, 2003). In essence the data in context was analyzed without jumping to rash conclusions. Krippendorff (2013) defines qualitative content analysis as a "research technique for making replicable and valid inferences from texts (or other meaningful matter) to the contexts of their use" (p. 24). Qualitative content analysis does not attempt to separate the analyst from findings and seeks to "recognize meanings" as described by the participant, but also the meanings that are imbedded between the "lines." Referred to as manifest and latent meanings, analysts seek to hear what has been said (manifest) and what has not been said (latent) (Krippendorff, 2013). Graneheim and Lundman (2004) assert that the researcher should decide whether analysis should focus on what is explicitly being verbalized which is the "visible and obvious" (manifest content) and analysis of the "underlying meaning" (latent content).
The authors suggest that a decision should be made on one or the other due to depth and level of abstraction; however interpretation from both perspectives is possible (Sandelowski, 2000).
As an analytic process, qualitative content analysis has some fluidity in the approach. Several authors describe a "model" or stepwise approach when using qualitative content analysis (Graneheim & Lundman, 2004;Krippendorff, 2013;Schreier, 2012). Similar in approach, each author emphasizes a systematic approach in which the analyst examines the data, draws inferences, condenses or summarizes data, and categorizes data to identify themes and patterns emerging from the data.
For this study the conventional approach to content analysis described by Hsieh and Shannon (2005) was used. After the transcripts were read as a whole several times, the data was read carefully word for word, sentence-by-sentence. Codes were then derived by highlighting key words in the text that captured the participants' thoughts. Initial impressions by the researcher were also documented. As this detailed process continued, labels for codes began to emerge that were reflective of more than one key thought. The codes were then sorted and grouped into categories based on how the codes were related. Direct quotes were then taken from the transcribed interviews to support the categories and provide descriptions using the participants' own words.

Trustworthiness
As with any research method, attention to details of trustworthiness and validity are essential. How validity is described varies depending on which text is used. However the basic premise is to assure in some manner that the fit of the chosen methodology is consistent with the research questions and management of the data is appropriate to the method. In addition, the researcher should be able to account for each step of the process from beginning to dissemination of findings. Lincoln and Guba (1985) identified a number of criteria that can be used to establish trustworthiness of qualitative data and discussed activities that can be employed to address the criteria. To increase the probability that the findings were credible, prolonged engagement was used initially to establish trust in the organization. Time was spent meeting with the director of the facility and observing how the women participated in their day-to-day lives.
A peer researcher with knowledge of the process and area explored the material with the researcher looking for errors in the process, bias, omissions, noncongruency as well as any other concerns related to the findings (Polit & Beck, 2008).
Peer debriefing was also utilized throughout the study to explore the process of data collection and discuss the effect of hearing painful stories on the researcher. Informal member checking occurred during the interviews. Comments made during the interviews by the participants were often reflected back to ensure accuracy or clarify any questions the researcher had.
The committee chair and this researcher independently coded the data and then met to discuss the codes until full agreement was reached. Very few differences in coding actually occurred. The two researchers then worked as a team to develop the categories. Thick description in the form of quotes from the text was used to provide descriptions of the participants' experiences during their period of homelessness.
Finally an audit trail of records occurred throughout the research process. All data including the researcher's journals was made available to the chair and members of the dissertation committee.
Attention to high researcher standards in conduct, transparency, thoughtful interpretation of data, and representation of findings was the goal for this researcher.
Regardless of which framework a researcher uses to assure validity it will be how a researcher demonstrated their accountability to the data and process that will ultimately determine trustworthiness (Graneheim & Lundman, 2004).

Chapter IV Findings
The results of this study are descriptions of the experiences of women during their period (s) of homelessness. The data was collected through semi-structured interviews. The purpose of the analysis was to address the following research questions: • What approaches did women use to maintain their health while they experienced homelessness as adolescents?
• What resources did women use during the time they experienced homelessness in adolescence in order to meet their basic needs and to maintain their overall well-being?
• What challenges did the women encounter in meeting their health needs?
• What suggestions do these women have for nurses and other health care providers to assist in meeting the health needs of female adolescents who are homeless?
The study sample was comprised of nine women who have been given fictitious names. The complete transcription of each audiotaped interview was initially treated as a whole and read several times prior to conducting manifest and latent content analysis. Nine women between the ages of 23 to 39 (mean 28.8) participated in this study. Despite efforts to obtain a diverse population, all women were Caucasian (Table 1). Typically there is quite a diverse population in this setting. However, at the time of this study, the population was more homogenous. Length of time the individual experienced homelessness, amount of time homeless, as well as where the women originally came from did have some diversity. As a result of the analytic process, six categories were identified and two themes emerged. The categories are listed as (1) hunger; (2) staying safe, warm and rested; (3) keeping clean; (4) resourcefulness; (5) challenges encountered; (6) insights and recommendations. The two themes that emerged were (1) survival takes precedence; and (2) remaining invisible.

Discussion of Categories
It was striking to see the creativity and resourcefulness that these women used to address issues resulting from their homelessness. Although resourcefulness is one of the major categories, there are rich examples of resourcefulness that are also integrated in the other five categories.
Hunger. Accessing food was considered a priority, but access to food was not always possible. Eating three meals a day or even one meal per day could be difficult.
For several of the women, getting something to eat was their greatest challenge while experiencing homelessness. One woman stated that there were times "I went like a week without eating." Another woman reported that she would ask for food from strangers "like if I'm hungry I'll go and ask somebody, Can you help me with food?" . . . "Whatever I need I'll get." "I just tried finding food here and there." Jade (age 32) and Sydney (age 26) similarly reported not having enough to eat; maintaining weight and nourishment were their greatest challenges while experiencing homelessness.
Kelli (age 28) clearly became emotional when thinking about her hunger and how bad if felt to be that hungry. "There were times I went like a week without eating." "Hunger is bad. I lost a lot of weight." (Kelli).
Most of the women described reliance on friends for a hot meal. If they were unable to access food from friends many of the women reported that they would not eat. Reliance on friends also involved taking food from their friends' homes for use later on. One woman actually returned to their home during the day when the parent was at work to take food from her kitchen. "A lot of time at night I would go into their food pantry and put stuff in a bag . . . I really didn't make good food choice . . . the more fattening stuff would keep me full longer" (Sydney, age 26).
Several of the women worked as waitresses and accessed food at their employment. "Working as a waitress . . . well, we had food you know. Eating well, that is a basic thing" (Lita, age 26). Another woman used her welfare to buy food at fast food places.
As for selection of food the women discussed getting whatever they could.
Attention to a balanced diet was not possible, however, one participant did express a desire to choose food that would keep her full for longer periods of time and would be higher in calories to maintain her weight. Another reported that if she could request food she would ask for foods such as peanut butter, bread and fruit in a can. This participant also wished that someone had taught her what types of foods to ask for that would be beneficial for someone who had limited resources.
It is important to note that these women reported not being aware of food pantries, soup kitchens, or other resources that might be available to them for food. A few suggested that even if they had known about a food pantry they may not have used this resource due to a sense of embarrassment and a desire to keep the homelessness hidden. Those who were still in school during this period of time reported that they would not seek free hot meals since the paperwork for this benefit had to be completed by a parent. Once again, due to the fear of exposure or "someone finding out" that they were not living at home but were experiencing homelessness prevented these individuals from accessing meals at school.
Staying safe, warm, and rested. Managing personal safety was a critical concern for these women. While others expressed careful selection of the surroundings, exposure to violence varied depending on the location the participant was living as well as whom the participant was with. Being homeless with someone they trusted provided a perceived sense of protection and security.
Other strategies included projecting an image that suggested no fear as verbalized by Kelli "trying to make myself appear bigger than I was . . . I acted like I was tougher . . ." For some women, the environment in which they were homeless was perceived as not "violent" or "unsafe place," indicating that the community in which they were living did not have a reputation as an unsafe city. For others, the places that were quiet and isolated were frightening and felt unsafe.

"I tried to stay away from the quiet, like the quiet kind of scared me. I wouldn't um, I wouldn't want to be where there wasn't a lot of light or there wasn't a lot of noise because I felt like that maybe, you know, that was a bad thing." (Sydney, age 26)
Some participants had experienced violence in the form of rape and abuse. Joy (age 31) described situations in which she had a gun and knife pulled on her as well as having been beaten.
Accessing shelter was another key priority especially during colder times of the year. "I just remember trying to have a lot of blankets . . . and you know, our body heat on each other at night" (Kay, age 23). Age was a barrier that the women discussed. In order to rent an apartment or even get a hotel room the individual needed to be over 18. One woman would find a man and have him rent her a room. Another woman used her skills as a graphic artist to change her age on her ID so that she could rent an apartment. The majority of women described "couch surfing" or sleeping over at a friend's home. "I couldn't believe it came to this . . . I was sleeping in cars" (Kay). Others slept in abandoned buildings, or in a tent outside. "I found this sober house on Craigslist and ended up staying there for two months….I asked someone of the street to use a cell phone (Kay). Sydney (age 26) described: ". . . trying to find people her own age and I'd say, 'HI, I'd like to be your friend. Can you take me home?' Some of them had parents who were alcoholics or drug addicts and we would stay in the basement. Sometimes I had to hide in the closet so the parents wouldn't see me".
Another participant spoke of a strategy she used especially for the cold winter months. She would pay the first month's rent and then wait to be evicted. Since it took several months for that to occur she would be sheltered for some time.
For the women who experienced homelessness as transient periods, the type of shelter would vary and could change. One woman replied, "I always found shelter. I never just slept in the rain or anything. You just become crafty." One woman lived on a fishing boat for shelter. Another worked as a housekeeper for a motel so that she could benefit from a free room. In addition to friends, many of the women discussed using men to provide shelter. The same woman who discussed being crafty also described a strategy she used when she was "sick" of trying to find shelter and would "conveniently fall in love" (Joy, age 31).

"I would start like going out with a boy and move in with them but I really…Like I liked them but I didn't really like them-like them. So I had a place to live but it wasn't mine . . ."
Several of the women described "using men" for shelter. Although it is possible that these women provided sex for shelter, it was not verbalized as such during the interviews. The majority of women reported that they were not aware of shelters especially those who were very young at the time of their initial homelessness.
Those who became aware of the availability of shelters reported that they would not use them even if they had been aware of their existence due to concerns of personal safety. For the few women who were at the younger side of adolescence were fearful of being exposed and returned to their family or foster family. For these women the possibility of returning to their homes was worse than being on the street.
The majority of the women verbalized "friends" as a source of shelter. What is interesting to note is the façade of a "normal sleepover." Lynn (age 28) and Sarah (age 27) spoke of staying with their best friend for a period of time. Sydney (age 26) ran from her foster placement and spoke of relying on "friends" or acquaintances for shelter and resources. "I did a lot of couch surfing to different people's houses and stuff (Gabrielle, age 39)." Sydney also described how she would find places to stay: Although the ability to shower was not a daily occurrence, oral hygiene as in brushing one's teeth was something that each woman discussed as important to them. Most of the women brushed at least once a day and a few others tried to brush several times a day. Using public bathrooms provided a place and running water to brush. For another participant a bottle of water and a toothbrush allowed her to brush anywhere as she could spit on the ground. When asked why brushing teeth were important, the women reported that they felt clean and it was a way to keep up outward appearances. For others, brushing their teeth was related to keeping healthy and not having to see a dentist. "Yeah, I did shower whenever I got the chance, I did brush my teeth whenever I got the-I kept up outer appearance . . ." (Sydney, age 26).
Most of the women spoke of relying on their "friends" to meet some of their basic needs. However the term friends were not fully explored in this study. The women did use the term friends to describe individuals they knew well, or to describe someone who they had recently met on the street. The term friend was used to describe the people who they "hung out with and shared drugs with." For several of the women, friends were primarily a source for shelter. Kelli (age 28) describes being at a friend's home and being offered the opportunity to shower. ". . . as far as taking showers and things . . . sometimes some friends' moms would even offer it." Strategies for bathing included using a friend's shower when "sleeping over" or "couch surfing." Others described meeting their hygienic needs by using bathrooms at fast food restaurants, gas stations, or wherever a public bathroom could be used that the individual could lock for privacy. A practice several participants called "taking a bird bath." One participant described how during the summer a swim in the ocean or fresh water lake provided a sense of feeling clean.

"Because it was um, summer time and warmer, I often just went swimming you know. Like in the ocean or… and I felt not clean but you know like salt is kind of a purifier…So I'd kind of wash up and jump in the -you know there's a fresh water place around that area too that I would go you know." (Lita, age 26)
Another participant described how standing out in the rain provided a means to "shower" as well as launder the clothing she was wearing at the time. Several of the women discussed carrying a small bag with toiletries so that when the opportunity arose they could take advantage of meeting their hygienic needs.
Others would "borrow from friends, "steal" from stores or would scavenge for items such as toilet paper, soap, feminine and oral hygiene care products in friend's homes or in public restrooms. "Tampons, definitely that was a commodity" (Sydney, 26).
"Borrowing" from friends was an important strategy for most of the women, however one of the women spoke about not taking anything from a friend's home since from her perspective this type of practice could jeopardize her ability to seek shelter from these friends.

Resourcefulness.
All of the women who participated in the study described friends as a primary resource in their ability to survive. It was their friends who gave them a place to sleep, an opportunity to shower, food to eat, clothing and support. It was also "friends" that supported drug use or initiated an introduction to drug use.
Regardless friends or peers were considered highly important to these women.
When faced with an illness, injury, or health issue, slightly more than half of the women surveyed (n = 5) described that they had gone or would go to a pharmacy and consult with the pharmacist in order to seek information about medication as well as information on managing simple illnesses or injuries. Other sources of information were sought through a kin connection or through friends. Most of the women didn't consider accessing the library for information regarding health. A few did see the library as a source for information, but not directly related to health. One woman reported that she would go into the library to get out of the cold, but not to seek information. None of the women who participated in this study considered that the library had free access to computers. Getting information to remain healthy was not a priority. As one participant, Kelli (28) noted, "that was, like, the last concern." For some of the women (n = 3) although they did not maintain a routine connection with family, during times of crisis or in need of advice the women would reach out to kin. For other women (n = 5) advice or information was sought from on older friend, peers, or a friend's mother. "My girlfriends basically or their mothers . . . she was like a second mother to me" (Sarah, age 27). Several (n = 3) of the women described maintaining a close relationship with a friend whom they relied upon for advice, support, and shelter.
"I found someone that was older than me that also seemed to have an issue with drugs. Someone who seemed put together. Someone that didn't have any issue probably would not help somebody. I mean honestly that's just the way it is." (Sydney, 26) Joy (age 31) reports having a lot of people "that cared about" her, but were unhappy with the choices she had made. She spoke of having several friends who she could ask for advice; however she preferred to seek advice and information from older adults such as her boss and his wife. Having worked for the restaurant for a long time, she describes her boss of "kind of like my dad in a way." She also describes seeking advice at times from people whom she had developed a relationship with whom she referred to as her "regulars" at the restaurant where she was employed.
Although school personnel were not individuals that these women sought for advice or support, the school environment was considered an important resource for a couple of these women. For others (n = 3) accessing dental and gynecological care were a challenge.
The majority of the women (n = 8) reported that they did not access routine health care, nor did they think about their health especially because of the turmoil of experiencing homelessness. Only one participant reported that she did not think she had ever abandoned routine health care. Statements such as "I did not care about health" or "I did not think about health" were verbalized. Kay (age 23) replied with,

"I just really didn't have time to think about my health. It was really just like a chaotic time. You know."
Several women (n = 2) reported that their substance abuse problem began during the period of time they were experiencing homelessness. Another couple of women (n = 2) described their substance abuse as resulting from prescribed medication for anxiety and pain. One woman's experience with substance abuse was not introduced until her 30's which is outside of the age parameter for this study, however the woman did describe using alcohol during the period of time she was experiencing homelessness. For the remaining women (n = 4) who participated in the study, substance use and alcohol use occurred prior to experiencing homelessness. A lack of health insurance was also considered a challenge in managing health for those who were concerned about health. Not having health insurance or the financial capital to pay for health care was a barrier for the majority of the women.
Although several of the women continued to have coverage through their parent, even when they were experiencing homelessness. Their routine health care was sporadic.
One woman reported that she did not think she gave up on routine care. For another she reported that she kept up on her gynecological care. For Gabrielle (age 39), a lack of insurance or money to obtain her medication for her depression was reported as her greatest health challenge. Without health insurance she was unable to buy the medication and would go without which contributed to an increase in her mental health issues.
An individual's state of mind and how they she/he about themselves can be considered a barrier and challenge in maintaining health. For these women their sense of self and self-esteem was impacted by their experiences of homelessness. Although for some, events, which occurred prior to their experience of homelessness such as, abuse, exposure to violence, and addiction continued to impact them. All but one of the women expressed a poor or negative sense of self during this period of homelessness. Kelli (age 28) stated she did not know how she felt about herself since she was "just too busy . . . trying to stay alive" (Kelli).
Descriptors the women used to describe how they felt about themselves included being embarrassed, and feeling "less than." The women expressed concern that there was not enough information about what is available is out there on the streets. All participants discussed the need for information on how to stay healthy and, resources they could access. Many of the women suggested that information was not clearly available so providing information was the most frequently reported suggestion.
When asked about availability of resources or personal knowledge of resources all of the women reported that they were not aware of what types of resources or information was available to them. For a few women (n = 2) how to find information was considered a barrier. Additionally, a few of the women reported that not only were they not aware of resources or information, but no one reached out to them. Jade (age 32) suggested that health providers provide a list of different help resources, such as a packet of ". . . resources and stuff to help them." Educational classes, especially free classes about that "stuff," should be provided during the day so that individuals who are in need can attend. Classes that relate to topics of importance to this population would also provide a vehicle in which to distribute information or packets of resources to those who wanted the information.
For a few women (n = 3) information about nutrition, selection of foods that are the best for someone who is experiencing homelessness as well as where to find resources was considered critical information that health providers relay. Another suggested that providers ask if the individual had a safe place to go.
". . . I don't think I ever got asked up until just recently. Like now I think one of the main questions they have is do you have somewhere safe to go." (Kelli, age 28) The idea of providing appropriate resource information was somewhat universal among the women; however, suggestions on how to disseminate the information varied. For the majority of the women (n = 8), remaining anonymous was more important than the information. Suggestions on how to accomplish this were asked of the participants and the women had some direction for health care providers. Some respondents (n = 2) suggested a phone line that could be accessed; another person thought that a phone line might not be accessible to all since many of the individuals experiencing homelessness had limited or no access to a phone.
Several of the women (n = 2) suggested when trying to reach the adolescent population especially those experiencing homelessness, information needed to be accessible, but it had to be left out or accessed through a center or van that did not require the individual to give an identifying information. "It needs to be anonymous." Anonymity was important when seeking resources, as many of the women recall not wanting to be exposed and returned to a difficult situation or into state care.

Discussion of Themes
The two themes that emerged from the data were found throughout six of the interviews. As Morse (2008) states, the themes provide a "meaningful" essence that runs through the data . . . sometimes in the background and sometimes in the foreground" (p. 727). Staying alive was the main focus, however as a result of their attempts to survive, the choices each woman made led to significant consequences such as addiction, trauma, violence, and mental health issues. Concern for health, health promotion and meeting health needs were not at the forefront for these women. Other than meeting one's basic needs of food, shelter, safety, and hygiene, health care was not a high concern.
However, for one woman, finding places to maintain hygiene in being able to "clean up" was voiced as a high priority. This woman considered herself a "survivor" and frankly stated "whatever I need, I'll get . . . Like, I'm not one to suffer or go without anything" (Jade, age 32).
If health services were needed some of the women (n = 4) reported use of the emergency department or "would wait it out." Use of the emergency department or Paying to see a health care provider was a barrier to most of the women.
Although several of the women (n = 3) during the period of time they were homeless did have some type of health insurance or worked, accessing routine health care was not considered a priority. As Kellie (age 28) spoke of going for health care she stated that she ". . . would have to be dying . . ." and that health care was ". . . like the last concern." From her perspective, shelter was her first concern and then food; everything else was secondary.
Some of the women had been pregnant prior to being homeless, and for some pregnancy was the point at which they returned to their family, ending their homelessness. It was interesting to note that when the women became pregnant they did seek routine pre-natal care and received health insurance for themselves and their child. Retrospectively, some of the women spoke of how they wished they had taken better care of themselves and their health especially now that they are mothers and wish to be healthy so that they can be present for their children. Joy (age 31) expressed concern about the school nurse telling her mother about the advice she sought especially with sexual activity and drug use. "I would have never said that to the school nurse. They would tell on me." The remaining women either dropped out of school or had experienced homelessness after leaving school.
Only one woman actually felt "comfort" with her school nurse. She sought her advice, but would not disclose to the nurse her state of homelessness for fear of being returned to foster care.

Summary
In summary, this study revealed that survival and maintaining their invisibility as homeless overshadowed the ability of these women to focus on their health as a priority during their periods of homelessness. It is also important to consider that in normal adolescence there is component of the personal fable: "everyone is looking at me or knows what I am thinking" (Garzon & Dunn, 2013). In spite of this reality, these participants were incredibly resourceful and used a number of creative strategies to address their basic needs confronting them on a daily basis. As was expected, they encountered numerous challenges in meeting their health needs and gave insightful recommendations for nurses and other health care providers who can have an important impact on female adolescents who may be homeless in the future.

Conclusion and Implications
This study explored women's experiences related to their health during periods of homelessness when they were adolescents. The research questions for this study were: • What approaches did women use to maintain their health while they experienced homelessness as adolescents?
• What resources did women use during the time they experienced homelessness in adolescence in order to meet their basic needs and to maintain their overall well-being?
• What challenges did the women encounter in meeting their health needs?
• What suggestions do these women have for nurses and other health care providers to assist in meeting the health needs of female adolescents who are homeless?

Main Findings
Chapter one provided an introduction of the persistent problem of homelessness in the adolescent population. The literature review in chapter two revealed a focus on chronic homelessness. In contrast the participants in this study experienced homelessness intermittently with a duration lasting one week to several months over a period of fourteen years.
Difficulty in obtaining accurate estimates of the prevalence of homelessness in this population and the lack of a consistent definition of adolescence and homelessness makes it difficult to generalize research findings. The literature that is related to adolescence and homelessness includes both genders. What was striking in the literature review was the extremely limited information specific to adolescent females who are homeless. Given the unique needs of the female population, a call for research to increase our understanding of the experiences of adolescents obtained from an emic perspective was underscored.
The participants in this study shared some commonalities. All had experienced some period of homelessness and all were mothers at the time of the interview.
Additionally all of the women could be considered as having had family dysfunction either due to substance abuse or other type of abuse. The majority of the women (n = 8) also had completed their education, had some college courses or had a GED and was in recovery for substance abuse.
The circumstances leading to the participants' homelessness were varied and consistent with the literature (Hyde, 2005;Mallett et al., 2005;Reid et al., 2005;Tyler, 2006;van den Bree et al., 2009). For six women, the decision to leave home was due to family discord, physical abuse, and/or substance abuse; two were kicked out from their home; one was removed from her family and placed in foser care and ran away from foster care. Once away from home all of these women described desperation in trying to maintain their existence. They used a number of approaches and resources to attempt to meet their basic needs. Similar to the findings from Bender et al. (2007), the importance of non-homeless friends was critical to this population in accessing resources to provide for shelter and hygiene. Four participants described using strategies such as stealing to obtain food and meet hygienic needs and falsifying documents to obtain shelter. Kidd and Davidson (2007) reported similar findings in their qualitative study on homeless youth in Toronto and New York.
Several studies examining homeless youth regarding their experiences of illness and health care reported that during times of illness, females were more likely to ask a friend to accompany them to provide support and protection (Ensign & Bell, 2004;Ensign & Panke, 2002). Females during times of illness reported increased feelings of vulnerability and concerns for their safety. One of the few studies that explored the lives of homeless young women living on the streets in Canada did not report the idea of reliance on friends as a source of support. In all of these studies "friends' is not defined. Participants from one study reported that friendship was not a term they used lightly and trust of another person was not easily given (Bender et al., 2007).
Sex as a survival strategy, described in the literature by a number of authors (Bender et al., 2007;Edidin et al., 2012;Ensign, 2001;Greene, et al., 1997;Rew & Horner, 2003;Rice et al., 2013;Tyler & Johnson, 2006; was suggested by four participants. However none of the participants overtly described prostitution but rather using men, or conveniently falling in love as strategies to meet their needs for shelter. Although these behaviors are not consistent with pro-social norms, they do reflect resourcefulness and attempts to survive. Unlike what has been mentioned in a few studies (Bender et al., 2007;Oliver, 2013;Rew & Horner, 2003; Rice, Monro, Barman-Adhikari, & Young, 2010) these participants did not use the library to access information either through the computer or in print. In fact a few stated that they would not think about the library as a resource; nor did they realize libraries had available computers for use. One participant believed she would be "asked to leave if she entered into a library" and another felt that the "library was only a place for nerds." Unlike some of the literature that addresses panhandling, use of shelters (Ensign & Gittelshohn, 1998) and food kitchens by adolescents who are homeless these participants did not engage in these activities. When asked about resources such as shelters and food kitchens, the participants reported not having knowledge of such resources. According to Bender et al. (2007) youth reported that shelters were safe and adequate. Being on the streets and forming peer connections with other homeless youths also allowed them to learn about these available resources. Although several of the participants did speak of being with a group of other homeless youth and relying on them for information, they were seeking guidance to meet day to day needs from other women they considered to be experienced and knowledgeable.
Consequences of homelessness described by these women were also consistent with the findings of numerous authors. Issues such as rape, sexually transmitted diseases and substance abuse were noted (Edidin et al., 2012;Hodgson et al., 2013;Robertson & Toro, 1999). The majority of the participants discussed mental health issues or exacerbation of previous mental health disorders such as anxiety, depression, and post-traumatic stress; this finding is also consistent with the literature (Edidin et al.;Gwadz et al., 2007). Although eight of the women did not have a diagnosis of depression prior to experiencing homelessness, two thought the symptoms had been present for years but never confirmed. Events occurring during the experience of homelessness and for a couple of the women prior to experiencing homelessness were thought to have contributed to their post-traumatic stress disorders. Edidin et al. (2012) suggests there are higher levels of post-traumatic stress disorders in the homeless population of both genders. Gwadz et al. (2007) reported that PTSD was more common for females and that depression and anxiety was a comorbidity associated with PTSD. Consequences of experiencing homelessness impacted the participants in multiple ways. For some the trauma of certain events experienced during that period of time such as rape, beatings, and exposure to violence, and dependence on others for survival had a serious effect on their mental health. Five participants used a number of approaches to conceal they were homeless.
Appearance was an important concern to the women, which enabled them to "maintain their secret." Although there are references to this population as being "hidden" in the literature, not many studies explicitly reported attempts by homeless individuals to keep their homelessness hidden.
One striking finding in this study was the emphasis on their oral hygiene by all participants. They went to great efforts to keeping their teeth clean. The literature suggests that many youth suffer from poor oral hygiene and consequently are at greater risk for caries and gum disease, however limited data is available on this finding (Boivin et al., 2005;Feldman & Middleman, 2003). In fact little research has addressed oral health in adolescent/youth that are homeless. Previous research has explored accessing health care as well as perceived quality of health care received by this population (Dawson & Jackson, 2013;Ensign, 2001;Ensign & Bell, 2004;Ensign 2007;Hudson et al., 2010;Reid et al., 2005;Rew, 2003 Klein et al., 2000;Reid et al.).
The challenges these participants countered in meeting their health needs was consistent with the literature. The women described a lack of financial capital to pay for health care or for medication. Several women reported that it would be pointless to seek health care since they could not afford to pay for medication. Additional reasons cited in the literature relate to the perception that there is no need to access healthcare, as they do not have any health problems (Dawson & Jackson, 2013;Edidin et al., 2012). None of the women who participated in the study suggested that they considered themselves unhealthy during that period of time.
As stated earlier, these participants were not aware of available resources or how to find out about them. There were many available resources in this community at the time when these women were homeless including food pantries in churches, shelters, and free health clinics. It is concerning that these participants were not successful in finding what they needed to improve their situation. Albeit some of the "hot" lines are new and may not have existed during the period of time they were homeless. Some authors have discussed the presence of a community of homeless peers who are sources of information needed for survival on the streets (Bender et al., 2007). Other studies suggest that perception of support and available materials is limited and not always easily accessible (Haldenby et al., 2007;Pergamit & Ernst, 2010). When the participants needed advice regarding health issues, they reached out to a family member, an adult parent figure, or an older woman on the street for support and guidance. This finding is also consistent with the work of Ensign and Gittelsohn (1998) and Ensign and Panke (2002).
One of the greatest contributions of this study is the insightful recommendations these participants provided for nurses and other health care providers. The women were very articulate and willing to participate in this discussion with the hope of helping other adolescents in the future. They identified the need for information about the location of food pantries and youth centric shelters as well as where this information should be placed. Bus stations, pharmacies, Walmart or other low budget shopping stores in the community and even schools were identified as key locations. A well-advertised hotline that provided information but did not require the adolescents' name was noted to be very important. One participant recommended the availability of short classes addressing life skills, nutrition and basic health needs offered in an outreach center.
The need to remain anonymous even when obtaining information, health care and resources was underscored by several participants. The fear of being identified as an adolescent who is unsheltered was the primary barrier to accessing any assistance.
Several participants stressed the need for health providers to assume a nonchalant approach whereby adolescents would not feel pressured to divulge their situation.
Last, health care providers need to reach out to this population with a sincere and nonjudgmental attitude when the do encounter individuals who are homeless.
Providers should include a homeless assessment along with their abuse assessment with each encounter. One participant believed they would be more comfortable accessing health care if a van was available.

Limitations
There are a number of limitations in this study. The sample size was small, lacked ethnic diversity and was confined to one geographical area. All of the participants had time constraints when planning for the interview. Four participants had one child with them during their interview and three had to leave to pick up their children, which was distracting at times.

Implications
Knowledge development. The findings of this study raise number of potential areas for future research. As a next step, this researcher plans on compiling a list of resources including shelters, food pantries, and free health clinics that will be given to adolescents who present as homeless in this community. They will then be asked to give feedback regarding their knowledge of these resources and where they obtained this information. Research related to the use of technology with this generation of adolescence is another area warranting future research.
Nursing education and practice. Nurses and nurse practitioners are in a pivotal position to reach out to this population in emergency departments and primary care settings. Based on recommendations from the American Academy of Pediatrics (2008), providers need to include an assessment for the risk of homelessness with each client encounter. Information about resources for adolescents who are homeless can also be placed in practice settings. A health facility for this population needs to be youth centric. The 45th Street Clinic (Barry et al., 2002), a walk-in free clinic for adolescents, in Seattle can serve as a model. This clinic is open two days a week in the evening and provides care for adolescents, ages 12 to 23. The adolescent's strengths and skills are explored and their need for independence is acknowledged. Since these youth are considered emancipated, they are not required to present identification and can use their street names. Paper work has been adapted to be user friendly by this population. Hygiene packets could be placed in a central location so that with each encounter the clients could serve themselves without having to ask for items.
School nurses are another important resource that can be tapped. As the study implies, keeping the issue hidden or secret is a strategy used by the adolescent female to avoid exposure. However several did state that if someone reached out to them, they might have broken their silence.
Collaboration with pharmacists in the community to strategically place information related to health, use of alternative therapies, and indications for over the counter medication will also be important. Considering the importance of dental care, providing small bags, which contain essential necessary items such as a toothbrush, toothpaste, and mouthwash, should be considered. Additional resources such as tampons strategically placed in bathrooms at schools, hospital EDs, and in primary care centers will address some of the needs identified by these participants.

Informed Consent
The University of Rhode Island College of Nursing White Hall 313 Kingston, RI

Exploring the Health of Women
Who Experienced Homelessness During Adolescence

CONSENT FORM FOR RESEARCH
You have been invited to take part in a research project described below. The researcher will explain the project to you in detail. You should feel free to ask questions. If you have more questions later, Ginette Ferszt PhD, (401-874-5345) or Claire Creamer PhD(c), RN, (401-456-9597) the person(s) mainly responsible for this study will discuss them with you. You must be at least 18 to 45 years old to be in this research project.

Description of the project:
My name is Claire Creamer and I am a working on a research study in nursing at the University of Rhode Island. For my research I am interested in learning about how you took care of your health while you did not have a place to sleep at night. With this information I hope to be able to help nurses and other professionals to improve the health of others.

What will be done:
If you decide to take part in this study here is what will happen. If you agree to take part you will sign a consent form and then participate in an audiotaped interview, which will last about 1 ½ to 2 hours. The interview will take place at a location that is agreed upon by the interviewer and yourself. The interviews will focus on how you took care of your health, how you got health information, and what suggestions you have for nurses and other professionals.

Risks or discomfort:
There are some risks involved in participating in this study. You may experience some emotional discomfort when discussing your experiences of homelessness. If this occurs we will stop the interview immediately and if you want to see a counselor, a referral will be made to a counselor in your agency.

Benefits of this study:
There are no direct benefits to you personally for participating in this study, however your stories and experiences will help nurses and other professionals to improve health of others.

Confidentiality:
The only people who will have access to the information you provide, including your audiotapes, will be the researchers. For the study you will be asked to choose a name of your choice that will be used during the audiotaped interview. All of the records will be kept in a locked box in a locked office located in room 313, White Hall, University of Rhode Island.
There are some limits to confidentiality. This study is confidential. The researcher will emphasize that study is confidential. However if you state that you will harm yourself or another person, or that a child, an elderly or disabled individual is being abused or neglected that information will be reported to the appropriate agency.
We have applied for a Certificate of Confidentiality which will protect the investigators from being forced to disclose identifying information on research participants in any civil, criminal, administrative, legislative, or other proceeding, whether at the federal, state, or local level.

Decision to quit at any time:
The decision to take part in this study is up to you. You do not have to participate. Whether you choose to participate or not will have no influence on the current services you are receiving. If you decide to take part in the study, you may quit at any time.

Rights and Complaints:
If you are not satisfied with the way this study is performed, you may discuss your complaints with Ginette Ferszt PhD ( Mental health history:

Appendix D Proposed Interview Questions
My name is Claire Creamer and I am interested in learning about how you took care of your health during a time when you were without shelter. As the expert, what you experienced will help nurses and other professional to better serve other people in the future.
For each of the following questions I will ask you, I want you to think back to when you were a teenager and you did not have a regular place to stay.
In that time period what kinds of things did you do to take care of your health?
When you look back what do you think was your biggest health issue?
During that time, were you able to stay safe?
What was your biggest challenge?
When you were hurt or feeling ill what did you do?
Were there any free clinics available to you? If so, did you use the clinic?
During that time was there a particular person(s) who you could go to for help, advice and/or support?
Were you able to find or get information to help you stay healthy?
Is there anything about keeping healthy that you wish someone had told you?
How did you feel about your-self as a person during that time?
If there was one thing that you would want nurses and other health care providers to know what would that be.