Running head: INTERVENTIONS ON DECREASING SURVIVAL SEX

Research Proposal:
The Impact of a Health Assessment and Educational Program on Decreasing Survival Sex
Among Young Homeless Females
Jelani Carter, Kylie McCormick, Katelyn Ogle, Lauren Ratiani
Azusa Pacific University

Author Note
Jelani, Kylie, Katelyn, and Lauren are now students at School of Nursing, Azusa Pacific
University. This paper is submitted in partial fulfillment of the requirements for GNRS 508A:
Research and Theory in Advanced Practice Nursing class that is offered by Dr. Azar.
Correspondence concerning this paper should be addressed to Jelani Carter, School of Nursing,
Azusa Pacific University, Azusa, CA 91702. Email: jlcarter12@apu.edu

INTERVENTIONS ON DECREASING SURVIVAL SEX

Abstract
The purpose of this study is to evaluate how a health assessment and educational program
decreases occurrences of survival sex and STD contraction among homeless young women in the
United States. Survival sex is the exchange of sex for food, drugs, money, or shelter. Up to 50%
of homeless females turn to survival sex due to lack of support, poor education, and diminished
job skills. Women engaging in survival sex are at significant risk for reproductive health issues,
ineffective self-management, social isolation, and chronic homelessness. There is a lack of
research regarding the effectiveness of implementing nursing interventions to reduce survival sex
prevalence and improve reproductive health. Penders 1982 Health Promotion Model (HPM) will
guide this study by attempting to predict positive health behaviors. This is a pretest posttest
prospective study with a one-year follow-up assessment. A convenience sample of at least 150
participants ages 15 to 25 will be recruited from downtown Los Angeles streets, drop-in clinics,
and shelters. Regression and t-tests will be used as the analysis technique in this study.
Significant findings can be integrated to establish protocols advocating for harm-reduction and
health promotion in this vulnerable population.
Keywords: Survival sex, homeless young females, health assessment, educational program, STD
rate

INTERVENTIONS ON DECREASING SURVIVAL SEX

The Impact of a Health Assessment and Educational Program on Decreasing Survival Sex
Among Young Homeless Females
Background
Survival sex is the exchange of sex for food, drugs, money, or shelter (Warf et al., 2013).
Anywhere from 10 to 50% of homeless females turn to survival sex due to lack of support, poor
education, and diminished job skills (Warf et al., 2013). Women engaging in survival sex are at
significant risk for reproductive health issues, ineffective self-management, social isolation, and
chronic homelessness (Ensign & Panke, 2002; Walls & Bells, 2011). Sexual risk-taking
behaviors become more prevalent in those who are homeless for greater than one year (Rew,
Grady, Whittaker, & Bowman, 2008). Correlates placing young women at a higher risk for
engaging in survival sex include identifying as African American; identifying as gay, lesbian,
bisexual, and transsexual; use of inhalants or methamphetamine; having a history of attempting
suicide or a family history of severe substance problems; and having tested for HIV (Walls &
Bells, 2011). Drug and alcohol use among the homeless population has been associated with
increased incidences of sexual risk taking behaviors, making it important to explore options to
decrease drug and alcohol use among this vulnerable population (Nyamathi et al., 2012). There is
a significant gap in research regarding the effectiveness of implementing nursing interventions to
reduce survival sex prevalence and improve reproductive health.
Aim
The purpose of this research study is to evaluate how a health assessment and educational
program decreases occurrences of survival sex and STD contraction among homeless young
women in the United States. There is a significant gap in research and literature involving this
population and the correlates and consequences of survival sex. The aim of this research is to

INTERVENTIONS ON DECREASING SURVIVAL SEX

provide tangible health education for young homeless women engaging in survival sex while
simultaneously gathering quantitative data to develop effective strategies to decrease the
occurrences of survival sex in this population.
Research Question and Hypothesis
The research question under study is: do survival sex and STD rates of homeless young
females decrease when implementing a health assessment and educational program? The
hypothesis is that implementing a health assessment and educational program will decrease the
rate of survival sex occurrences and STDs in the young, female, homeless population.
Variables
Independent Variable
The independent variables in this study are a comprehensive health assessment and health
educational program. The health assessment is conceptually defined as a full physical, pap
smear, breast exam and STD/HIV testing. All participants will receive a baseline health
assessment and a one-year follow-up health assessment. Female health educators will lead the
health education program. Individuals participating in the educational program will be split up
into groups of two to ten participants. The health education program is conceptually defined as
eight one-hour weekly nurse-led sessions. Education will include factual information,
demonstrations and open communication on STDs/HIV, safe sex practices, assertive
communication, and homelessness resources and prevention. Each session will allow for an open
discussion addressing how to implement health-promoting strategies into the lives of
participants. The educational intervention will be measured and recorded in the participants file
as received or not received.
Dependent Variable

INTERVENTIONS ON DECREASING SURVIVAL SEX

The dependent variables in this study are the rate of survival sex participation and STD
infection. The conceptual definition of survival sex is the exchange of sex for food, drugs, money
or shelter. It will be measured using the 6-item Survival Sex Questionnaire included in the pretest
and posttest. STD infection is conceptually defined as the presence of any of various diseases or
infections that are transmitted by direct sexual contact such as syphilis, gonorrhea, chlamydia,
genital herpes, hepatitis B, and HIV. It will be measured by the physical examination and
STD/HIV test.
Literature Review
A literature review was conducted to assess the prevalence of survival sex in the young
homeless female population and its correlating factors. Thirteen articles including nine of
quantitative nature and four of qualitative nature were used to evaluate possible reasons for
engaging in this behavior, lifestyle complications related to survival sex, and any interventions
attempted with this specific population.
Survival Sex
Several studies provided data depicting the nature and definition of survival sex. These
studies also included several of the main reasons for homeless young women engaging in
survival sex, and the influences of parents on runaway youth who later turn to survival sex and
other related activities. Watson (2011) conducted a qualitative study to explore female
experiences of homelessness through an examination of survival sex. These vulnerable women
felt they had no resources available to them and had to find individual solutions to their problems
and situations, ultimately leading to survival sex as the resource.
A qualitative study by Warf et al. (2013) examined childhood experiences of homeless
young women with a history of engaging or not engaging in survival sex and described

INTERVENTIONS ON DECREASING SURVIVAL SEX

influences of initial involvement for those engaged. Participants were interviewed with openended questions addressing abuse, system of involvement, mental health, and survival sex. While
no significant differences related to childhood experiences and involvement in survival sex was
found, four main themes related to involvement in survival sex were identified. They include
desperation for basic needs (>50%), friends/peer influences or social norms (33%), coercion
(10%), and drugs (10%).
Correlates of Survival Sex
In 2011, Walls and Bell conducted a multi-city quantitative study examining the
correlates of having engaged in survival sex. They specifically looked at demographic variables,
lifetime drug use, recent drug use, mental health variables, and physical health variables.
Researchers found a high rate of correlation between engaging in survival sex and other health
risk factors. The data collected indicates a need for holistic health education and prevention
strategies when working with this population.
Shannon et al. (2007) investigated HIV prevalence among women engaged in survival
sex work and explored sexual and drug-related vulnerabilities. Findings support a need for
enhanced policy and program initiatives targeting factors that contribute to early initiation into
sex work and subsequent higher rates of HIV infection. Evidence-based strategies are needed to
address the sexual and drug-related vulnerabilities of HIV infection among survival sex
participants.
A quantitative study by Miller et al. (2011) aimed to investigate individual risk patterns
and structural barriers among young female sex workers. The findings of this study highlight the
critical need for targeted structural interventions including access to gender-specific social
housing, safe working spaces, reduction in the amount of harm caused, and addiction treatment

INTERVENTIONS ON DECREASING SURVIVAL SEX

services for youth engaged in survival sex.

Mental health status can be correlated with risky sexual behavior. McCay et al. (2010)
found that the majority of homeless youth report a history of physical assault by an adult (61%)
and high levels of alcohol and/or drug abuse (58.6%). One third of the studys participants
reported being diagnosed with multiple psychiatric disorders, including depression and other
mood disorders. The researchers stressed the urgent need for a better understanding of this
population and the association between mental health and decisions to partake in survival sex.
In 2009, Stein, Milburn, Zane and Rotheram-Borus assessed the effects of parental
relationships with runaway youth. Having a positive relationship with both parents was shown to
have protective factors for adolescents, especially related to psychological distress. A positive
maternal relationship helped protect the adolescents from dangerous survival sex practices.
Ultimately, the longer the adolescents had been homeless the more likely they were to engage in
risky behaviors.
Trauma is another correlate related to participation in survival sex. Hom and Woods
(2013) conducted a qualitative study that focused on the experiences of trauma and its aftermath
in women who have experienced sexual exploitation. The researchers found that many of these
women experienced pre-trafficking abuse and suffered from post-traumatic stress disorder,
depression, low self-esteem and shame, affecting all aspects of their lives. Researchers
determined that survivors of commercial sex need a comprehensive, tailored, holistic approach to
recovery and a nonjudgmental environment for healing.
Health Assessment and Educational Intervention
Several studies addressed the need for multi-dimensional and gender specific approaches
when intervening with this population. In 2012, Nyamathi et al. assessed the implementation of

INTERVENTIONS ON DECREASING SURVIVAL SEX

two community-based programs aimed to decrease the use of drugs and alcohol among homeless
youth. Participants were randomly assigned to the HIV/AIDS and Hepatitis Health Promotion
(HHP) program led by nurses or the Art Messaging (AM) program led by artists. Researchers
suggested that the significant reduction of drug use in the HHP nurse-led program is related to
the integration of open discussion questions and answers on implementing health promotion
strategies in their lives.
Shannon et al. (2010) examined whether the rate of hepatitis C virus (HCV) occurrences
differed in injecting drug-using youths who did and did not report involvement in survival sex.
Within the sample, a significantly high rate of HCV was found in those engaged in survival sex.
Data revealed 50% of participants involved in survival sex were HCV positive at the 18-month
follow-up and 70% at the 36-month follow-up. Shannon et al. suggested that these results show
the critical need for evidence based social and structural HCV reduction and prevention efforts
that target youth involvement in survival sex.
Rew et al. (2008) studied the effects of the duration of homelessness and gender on
personal and social resources, cognitive-perceptual factors, and sexual health behaviors among
homeless youth. They found that participants who had been homeless greater than one year had
greater AIDS knowledge, reported significantly more sexual risk-taking behaviors, and engaged
in fewer safe-sex behaviors than did those who had been homeless less than six months.
Researchers determined that duration of homelessness and gender are important considerations
when planning and developing sexual health interventions for homeless adolescents. Genderspecific interventions should be used when interacting with the homeless adolescent population.
Additionally, Rew, Fouladi, Land and Wong (2007) conducted a gender-specific health
education intervention specifically for homeless adolescents to promote their sexual well-being.

INTERVENTIONS ON DECREASING SURVIVAL SEX

The researchers suggested use of objective behavioral measures and inclusion of more
interaction between group members with discussions about how to manage peer pressure in
future intervention planning.
Ensign and Panke (2002) conducted a qualitative assessment of reproductive healthseeking behaviors, sources of advice, and access to care issues among a sample of clinic-based
homeless adolescent women. Participants reported that they sought health advice from other
women, including their mothers even during homeless, oftentimes first trying self-care
interventions, before going to clinics. They stated that the main barriers to health care were lack
of insurance, confusion over consent, transportation problems, judgment and lack of respect from
providers. The results provide insights into how to improve communication and health care
services for these women.
There is a significant lack of quantitative research that directly evaluates the impact of
nursing interventions and education with this specific population. Because of this insufficiency,
long-term outcomes are not available regarding the issue of survival sex in the young, homeless,
female population.
Theoretical Framework
A modified version of Penders Health Promotion Model (HPM) will be used to guide
this study (See Appendix for Conceptual Map). As stated by Burns and Grove (2011), HPM
identifies individual characteristics and experiences that influence behavior-specific cognitions
and affect to produce behavioral outcomes (p. 235). Behavior-specific cognitions and affects
include perceived benefits of action, perceived barriers to action, perceived self-efficacy,
activity-related affect, interpersonal influences, and situational influences. The HPM assumes
that there are immediate competing demands and preferences that impact health promoting

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behavior. Commitment to a plan of action facilitates the patients ability to have a positive health
outcome. In the modified version of HPM used for this study, the health assessment and
education program have direct influence on the patients commitment to a plan of action and
subsequently to health promoting behavior. The goal is to help facilitate a permanent, positive
lifestyle change for the patient and their environment (Burns & Grove, 2011).
In this study, positive health outcomes are described as decreased participation in
survival sex and increased reproductive health. Current research suggests that there are multiple
reasons a woman would participate in survival sex (Watson, 2011); the HPM provides insight as
to how different behaviors and experiences can influence the engagement in survival sex. The
HPM will utilize partnership between nurses and participants to attain a positive health outcome.
Methodology
Research Design
The design selected is a pretest-posttest prospective design with a comparison group. The
study will be conducted between November 1, 2015 and January 1, 2017 to allow for recruiting
and enrollment. Survival sex questionnaires will be administered and physical exams will be
conducted for all participants. Participants will have access to treatment for STDs through
services at a clinic partner for the duration of the study.
Setting and Location
The settings utilized will be the Los Angeles Christian Health Center (LACHC) and the
Downtown Womens Center (DWC). The health assessment will take place at LACHC and the
educational program will be held at the DWC. These sites were selected based on location to our
accessible population and partnerships with the community.
Sampling Technique

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The target population is homeless young women participating in survival sex in the
United States. The accessible population is homeless women ages 15 to 25 recruited from
downtown Los Angeles streets, drop-in clinics, and shelters. A convenience sample technique
will be used to select participants. Recruited participants will also be asked to encourage friends
to participate in the study. Participants will be randomly assigned into intervention and
comparison groups. The intervention group will receive the health assessment and educational
program and the comparison group will only receive the health assessment.
The inclusion criteria for the study is (a) homeless, defined as not having a permanent
residence for the past 2 months, (b) female (c) ages 15 to 25, (d) and actively engaged in survival
sex within the past month. Participants will be excluded if they do not reach inclusion criteria.
Alpha will be set at 0.05. Effect size is 0.5 (Warf et al., 2013). Power probability is 0.8. A
power analysis for a one-tailed hypothesis was used to determine the minimum sample size (n=
102) with a minimum of 51 participants per intervention and comparison group. Due to the
historically large attrition rate with this vulnerable population (Nyamathi et al., 2012), an
increased sample size of 150 participants will be obtained to limit the threat to internal validity.
Data Collection Measures
All measuring tools will be administered using audio-computer-assisted self-interviewing
(ACASI) technology, providing the respondent with audio interpretation of the questions.
ACASI implementation has been shown to be effective due to the problem with literacy in this
specific population (Nyamathi et al, 2012; Rew et al., 2007; Rew et al., 2008).
Questionnaires. The Survival Sex Questionnaire is 6-item measure developed by researchers
that asks whether subjects have participated in survival sex for money, shelter, food, drugs, and
basic needs. This measure utilizes nominal yes or no questions. Additionally, a ratio question

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will be used to determine how often participants have sex to meet their basic needs. Reliability
and validity values will be tested in this study.
The Safe Sex Behavior Questionnaire (SSBQ) is a 27-item questionnaire adapted by Rew
et al. (2007) that measures safe sex practice among subjects. This measure includes a 4-point
Likert-type response format with items such as, I insist on condom use when I have sexual
intercourse (p. 822). This measuring tool demonstrated to have a Cronbachs alpha of 0.87 and
was considered to have criterion validity by the respective study (Rew et al., 2007).
Additional scales include a 36-item HIV/AIDS Knowledge Questionnaire to assess
participants knowledge of risk factors, transmission, and signs and symptoms. Nominal level
questions are used demonstrating a Cronbachs alpha of 0.82 and was considered to have face
validity by the respective study (Rew et al., 2007). The Assertive Communication Scale (ACS) is
a 5-item 5-point Likert response formatted questionnaire. It measures the subjects efficacy in
communicating assertively about using condoms with sexual partners. Cronbachs alpha was
0.83 and considered to have face validity by the respective study (Rew et al., 2007; Rew et al.,
2008).
Health assessment. The standardized health assessment will include a full physical examination,
pap smear, breast exam and STD/HIV testing. Diagnostic testing will be performed for specific
STDs including syphilis, gonorrhea, chlamydia, genital herpes, hepatitis B, and HIV.
Researchers will develop this biophysiological measure, thus reliability and validity values will
be tested in this study.
Data Collection Procedure
Eligibility and informed consent will be reviewed and obtained prior to the study.
Participants will be randomly assigned into an intervention or a comparison group. Pretest

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questionnaires and health assessment will be given to all participants before the educational
program begins. The participants selected to receive the educational program will be provided
the dates and location of the sessions. Posttest questionnaires and health assessment will be given
to all participants at a one-year follow up. Results will be compared to assess for a decrease in
survival sex occurrence and STD/AIDS infection.
Data Analysis
For the purpose of this study, descriptive statistics will be conducted. T-tests and
regression will be used as the analysis techniques. A paired t-test will be conducted to compare
the results of the pretests and posttests within each group. An independent t-test will compare the
posttest results between the intervention and comparison group. Regression will be utilized to
determine the degree of relationship between the independent and dependent variables.
Threats to Internal and External Validity of the Study
The uncontrolled threats to internal validity are the pretest posttest design,
instrumentation of the health assessment tool, and attrition rate. Also, due to the participants
transient lifestyle, it is expected that contamination of the control group may be experienced
because some participants will be sharing living quarters. This has been an obstacle that other
researchers have experienced while working with this population (Rew et al., 2007). A threat to
external validity is the accuracy of the sample population in relation to the target population.
Another potential threat to the studys external validity is the restricted generalizability due to
convenience sampling.
Ethical Consideration
The research proposal will be submitted and reviewed by the institutional review board
(IRB) for approval obtained from Azusa Pacific University. Research staff will discuss the study

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with potential participants ensuring that all information is fully understood. Next, written consent
will be obtained to enroll in the study. In addition, as part of the consent process, participants
will be informed of their protected rights and privacy and will be instructed that their answers
and all results will be kept confidential in adherence to HIPAA regulations. Participation in the
surveys will be completely voluntary, so subjects will be free to resign from the study at any
time. Subjects may choose to skip any questions with which they are not comfortable, and their
decision as to whether to participate would not influence their eligibility for services. Both the
health assessment and educational intervention carry minimal potential risks to participants.
Furthermore, engagement in this study will be beneficial to the overall health and well-being of
participants.
Implications
Public Health nurses will benefit from this research by developing trusting relationships
with a population that has historically had low access to care and distrust in the healthcare
system. In the clinic setting, significant findings can be integrated to establish protocols
advocating for harm-reduction and health promotion in this vulnerable population.
Through education and development of healthy habits and lifestyles, nurses can instill
empowerment and self-care responsibilities to individuals and groups moving them towards a
larger capacity for self-care and productive living. Participants will be made aware of their
options and resources available to them. Nurses, seen as public health advocates and experts on
health and illness, have a responsibility to educate and promote healthy habits to improve
individual and community well-being. An example of this is nurses linking young homeless
women with available and beneficial resources. By promoting health and changing unhealthy
behaviors, nurses can attain positive health outcomes and optimal well-being.

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Appendix

Modified HPM Conceptual Map

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