Implementing an Evidence-based Alcohol Use and Sexual Risk Intervention in Young Adult Homeless Service Settings

Young adults experiencing homelessness (YAEH) are disproportionately affected by alcohol and other drug (AOD) use and sexual risk behavior, yet drop-in centers serving this population have limited access to brief, evidence-based programs that address both. AWARE is a 4-session group intervention grounded in motivational interviewing (MI) that targets AOD use and sexual risk behavior among 18-25 year olds experiencing homelessness. The program integrates education, skills building, and normative feedback in an interactive group format, incorporating components shown to be effective with homeless youth and other at-risk populations: enhancing protective factors, targeting multiple risk behaviors together, using active learning techniques, reinforcing skills, and delivering information in a non-judgmental manner. Sessions address HIV/STI knowledge and partner risk evaluation (Session 1), identifying and managing triggers for sexual risk behavior (Session 2), weighing the pros and cons of substance use and building strategies to reduce harm (Session 3), and understanding how AOD use affects brain functioning and behavior (Session 4). The brief format and group delivery model were designed to fit the service realities of drop-in centers, where YAEH may engage sporadically and staff capacity is limited.

The study design is a hybrid type 1 effectiveness-implementation study in which we will test the effectiveness of AWARE on young adult health outcomes, while collecting contextual data on implementation and sustainability of the intervention. The effectiveness study will follow a group-randomized design in which young adults receiving services at three drop-in centers will either be in the intervention condition (N = 180) or a services as usual control condition (N = 180). Young adult participants will complete surveys measuring primary and secondary outcomes at baseline, and follow-up surveys at 3- and 6-months post-baseline. The group-randomized trial will have crossover conditions and groups to avoid problems of power reduction and contamination associated with conventional group randomization. The unit of analysis will be the individual, but individuals will be assigned to groups based on where they receive services at a given time. The field period in each condition will be divided into four 22-week phases. The three drop-in centers will alternate serving as the "intervention site" or the "control site," with each center having two intervention phases and two control phases. The first 16 weeks of each phase involves delivering AWARE (intervention sites) or surveying participants at the control sites. Sixteen weeks was chosen to repeat the four-session AWARE program four times, allowing YAEH several opportunities to attend all sessions. The remaining six weeks of each phase is an inactive "wash out" period to allow for the recruitment of a new cohort and reduce the likelihood of contamination across conditions.

In addition to testing effectiveness, this study will assess how consistently and with what quality AWARE is delivered across sites and phases (implementation outcomes), and what organizational and fiscal conditions would support long-term sustainment. Fidelity to the AWARE protocol and MI will be assessed by audio recording sessions and rating them using an adherence checklist. Participant perspectives on intervention quality will be captured at the 3-month follow-up via item measuring therapeutic alliance and MI-consistent facilitator behaviors. Sustainment will be examined through interviews with policy actors and site leaders to identify barriers and facilitators to continued adoption beyond the study period.