Art Messaging to Engage Homeless Young Adults

Substance use is highly prevalent among homeless young adults. In a study of 620 homeless young adults living in the Los Angeles area, more than two thirds reported use of alcohol (68.6%) and marijuana (67.8%) over the previous 3 months,1 and the high rates of amphetamine (35.7%), crack/ cocaine (24.4%), and heroin (14.3%) use were particularly worrisome. Injection drug use was also reported by 41% in another study of 560 homeless young adults.2 Some homeless young adults report that they use drugs to self-medicate, as a way of coping with mental illness, a social connection to peers, and/or escapism from the hardships of living on the streets.3 Art has been shown to be an empowering and engaging Abstract

ances, substance use, and unprotected sexual behaviors are more prevalent among these young adults than among their peers who live with a parent. 6 Interventions designed to help homeless youth and young adults to cope with physical and mental health challenges are highly warranted to prevent these young people from turning to substance abuse as a coping mechanism. The use of artistic media to create prevention messages is one method to provide support to at-risk homeless young adults.
The intent of this study was to elaborate on the evidence to date indicating that homeless young adults are interested in and benefit from art messaging. In particular, we solicited the opinions of homeless young adults as to how they believe the arts can be used to design drug and alcohol use prevention messages that would have relevance to their peers. Future research will be devoted to evaluating the efficacy of drug use prevention messages designed for homeless youth and young adults by their peers.

Use of Art in HeAltH Promotion
Art therapy using creative approaches to explore emotions, thoughts and ideas has been used as a health promotion strategy since 1940, 7 and has been found to improve health status among homeless youth and young adults who experience substantial health disparities. 8 In particular, art therapy has been shown to be effective in the management of drug abuse among women. 9 The use of art as a medium to express thoughts and relay messages is gaining credence as an innovative health strategy to be used with homeless young adults. Homeless youth and young adults in particular report the use of art forms as a way to effectively communicate with their peers. 10 Although little is known about how homeless persons perceive the use of art to communicate the danger of initiating or continuing drug and alcohol use, young homeless participants contend that health care messages delivered in an artistic fashion would be appealing. 11 Art in the form of poetry, music, and dance was used to create a successful anti-drug campaign for Latino youth that resulted in reductions in risky behavior and a desire to serve as peer educators. 12 Music therapy (a form of creative arts) has been shown to promote engagement in therapy among young substance abusers. 13 Rooting anti-risk messages in a culturally familiar form has also been successful in the homeless youth population. In a study conducted with 600 homeless youth in Brazil, researchers found that games, plays, and dance in the national Capoeira form stimulated and internalized necessary HIV/AIDS education within the group, 14 indicating that when the message was delivered in a popular and/or familiar form, it was quite powerful.

metHods design
This qualitative study was designed to gain an understanding of the subjective perceptions and experiences of 24 homeless young adults about ways to utilize the arts in creating powerful messages that could impact future engagement of homeless young adult peers to prevent drug and alcohol use. Qualitative approaches are best suited to understand the complexities of the lives of people as expressed by themselves naturally and within the context of their lives. 15 The design of this study is strongly based upon community-based participatory research (CBPR) paradigm, which relies on community participation for the design, implementation, and assessment of strategies for improving health care within communities. 16 In this study, our community partnership consisted of the director and select staff of a drop-in site for homeless young adults, the research team, and several homeless young adults.
A powerful tool in welcoming the perspectives of the targeted community, CBPR empowers all involved in tailoring intervention strategies. 17 Focus groups are one approach wherein voices of the participants can be clearly heard. In our study, focus groups were used to engage homeless young adults in the formative study, and enable them to communicate their viewpoints and strategies for tailoring effective preventive messages.
role of the Community Partners in the study CBPR approaches were established by first gaining the trust of the director of the community site, who in turn invested the time and energy to identify several young adults who were interested in participating as members of a Community Advisory Board (CAB). In addition, the director, the research team, and the homeless young adults invited by the director, collaborated with the principal investigator and the research team to conceptualize the study. Through these meetings, the concept of art messaging was formulated, which led to the current grant and subsequent funding. 11 The two homeless young adults who participated in the initial meetings with the director and the research team also assisted with the recruitment of other homeless young adults to participate in the CAB, which has guided the researchers in conducting all aspects of the research as described herein. The time period beginning with meetings with the director to the initiation of the CAB sessions was over 9 months. The CAB guided the researchers in recruitment strategies, and discussed ways to gain the trust and interest of the young adults to enhance a willingness to participate in the study.
The CAB also held an integral role in the development of recruitment materials. CAB members informed the timing for focus group interviews in the development of a semistructured interview guide (SSIG; Table 1). The SSIG was used to capture the perspectives of a larger group of homeless young adults about ways to engage their peers via artistic media such as animation, video, drawings, poetry, and so on.
More specifically, in the five CAB sessions held, discussions focused on current drug messaging campaigns and their acceptability for homeless young adults. The CAB collaborated on developing their own substance abuse prevention materials, which featured colorful designs with a collage of words and pictures from printed materials such as magazines. The homeless young adults who participated in the CAB also assisted in the conduct of the focus groups and in helping to interpret findings. Their participation assisted the research staff in understanding the views of homeless young adults upon completion of the focus groups, and with interpretation of the focus group findings as it related to designing the future intervention study and best times for recruitment.

setting and Participants
The qualitative study took place at a homeless drop-in site in Santa Monica that attracts many homeless youth and young adults by providing basic needs and health-related services.
A total of 24 young adults participated in the focus group sessions. Among the 26 who were screened, 2 were not eligible because they never used illegal drugs. These young people were eligible if they were 15 to 25 years of age and self-reported as If you ever had a time when you had a health problem but did not seek care for it, what got in the way?
What has helped you get care when you needed it? Do you think you or your friends would be willing to receive care at the shelter for general health problems? Do you think you or your friends would be willing to receive care at the shelter for drug-related problems?
What are the advantages to receiving this care at the shelter?
What are the disincentives to receiving this care at the shelter?
How can the doctors and nurses at the shelter better enable you to access these services onsite or offsite?
What are the important messages you would like to share with your peers who are homeless regarding the dangers of drug and alcohol use?
What might be the best way to communicate these messages to you or your friends?
What are some ways that you or your friends can help health care providers develop health messages related to the dangers of drug and alcohol use and of HIV/AIDS?
What are the creative ways that would be most appealing to homeless youth to create messages (such as poetry, music, drawing, etc.)?
How can artists and musicians better enable you to develop such messages?
homeless and having used illegal drugs over the last 30 days.
This age group was selected because the literature reveals the majority of this age group has already initiated substance use 18 and therefore may provide insight as to how to prevent their younger peers from initiating drug use.

Content Analysis
The investigator oversaw transcription and content analysis of the focus group recordings. Content analysis was performed by trained research assistants using a set of techniques common to the practice which identify patterns, themes, and categories in recorded language. Content analysis began with a line-by-line coding of all transcribed notes. Through this process, we identified common themes and categories.
Comparisons were made within each focus group and across focus groups until the major themes were saturated and no new major themes arose. 19,20 The results of the content analyses were used to highlight homeless young adults' main perspectives and opinions and will guide future research with this population.
Participatory analysis of the study was achieved by discussing the findings of the focus group sessions with the members of the CAB, which included homeless young adults in an effort to seek their feedback 21 and ensure accurate interpretation of the data. 22 An audit trail was also created by informing the CAB after each analysis session and documenting analytic decisions. The dependability of the data was confirmed by the SSIG, which relied equally on the input of the researchers and the CAB members.

resUlts
The majority of the participants were male (75%) and  In this study, we learned that the intimacy of personal stories and the ability to learn from peers were critically important to homeless young adults. For some, making messages more personal would provide more powerful communication.
Stephenson and Witte 27 found that empathy for other people's life circumstances and the need for personal connection effectively promoted more positive outcomes among homeless young adults attending drug treatment programs. 28 In addition to visual media, music was important to these young adults and could play an important role in future substance abuse prevention campaign by evoking an emotional response. Previous studies reveal that music has served as a common ground and a way to connect on a more personal level and bond with peers among homeless young persons. 29 Although our findings revealed that a variety of styles of music were enjoyed by all ages of our participants, this diverse taste in music is not uncommon, as young adults use music in different ways to satisfy different emotional or developmental Spring 2011 • vol 5.1 needs and to reflect specific issues they are coping with. 30 Our homeless participants also thought creative writing was a way to communicate with other homeless young peers about drug and alcohol use. Poetry and other creative writing serves as a way for others to tap into young adults' inner conflicts and angst. 31

implications for research and Practice
It is hoped that the contributions by these young people to this study will result in more effective and meaningful sub stance abuse prevention messages for them as well as for their younger peers on the cusp of initiating substance use. Our findings also have specific implications for health care providers such as physicians and nurses. Reading and writing poetry has been found to help physicians become more effective providers by enhancing empathy, and compassion. 33 Given the benefits described, it seems possible that physicians could incorporate creative interventions (i.e., poetry, music, art) into the practice of medicine, thereby improving communication with patients. It has been suggested that arts should be integrated into the practice of nursing because creative arts interventions shorten hospital stays and reduce the need for pain medication among patients. 34 We believe that, based on the evidence to date, and the input provided by participants in our study; future studies of the effect of art messaging among homeless young adults are highly warranted.