Homeless Youth Healthcare Access: Barriers and Solutions

Introduction: The Scale of Youth Homelessness

The estimated number of people in homeless families in 2014 was 216,261, of which nearly 60% were under the age of 18 (Henry et al., 2014, p. 29). The number of unaccompanied homeless children and youth in 2014 was estimated to be just under 200,000 individuals (p. 39). The U.S. Department of Housing and Urban Development (HUD) defines children as any individual under the age of 18, while youth are defined as being between 18 and 24 years of age. Unaccompanied children represent about 70% of this homeless demographic. Combining these numbers results in approximately 78,281 and 263,727 homeless youth and children, respectively, living on the streets and in shelters in the United States in 2014 — representing 13.5% and 45.6%, respectively, of all homeless individuals.

Other estimates suggest that the number of adolescents living on the streets is somewhere between 1.5 and 2 million, which would make this age group the primary homeless demographic populating the streets and shelters of America (Hudson et al., 2010). This demographic tends to be sexually active, affected by substance abuse issues, facing mental health problems, struggling with personal hygiene, and therefore in significant need of medical services. Given the magnitude of this problem, this essay examines the barriers these homeless young adults face when seeking medical care.

Health Risks Facing Homeless Youth

The reasons young adults leave home to live on the streets are numerous and can include parents forcing them out, escape from physical and/or sexual abuse, gender identity discrimination, parental conflict, family homelessness, personal choice, or release from foster care, juvenile justice, or substance abuse treatment centers (HCH Clinicians' Network, 2009; Hudson et al., 2010). These young adults face a number of serious dangers, including sexual and physical abuse, sexual exploitation, prostitution, and drug and alcohol abuse.

In a review by Hudson and colleagues (2010), more than 60% of homeless adolescents responding to a survey reported a history of sexual abuse, 56% reported having injected drugs, and over 12% responded affirmatively to a question about attempted suicide. Homeless youth are consequently susceptible to sexually transmitted diseases, tuberculosis, hepatitis, addiction to drugs and alcohol, and disproportionate rates of mental health problems. The need for access to quality medical services is therefore great among this demographic.

Barriers to Accessing Healthcare

The consequences of inadequate access to care include a greater reliance on emergency services rather than primary care (reviewed by Hudson et al., 2010). Researchers have identified multiple barriers, including an unwillingness to interact with social services or law enforcement, unfamiliarity with how the healthcare system functions, language differences, lack of health insurance, lack of transportation, and a lack of provider respect toward the homeless.

Many of these barriers were validated by a survey of young adults between the ages of 18 and 25 who were living on the streets of Los Angeles (Hudson et al., 2010). The barriers identified by participants included restrictive clinic hours and long wait times. If a homeless youth was willing to wait hours before seeing a clinician, they were often confronted by unpleasant conditions and hostile attitudes from other homeless adults in waiting rooms, only to be treated dismissively by clinicians if their health complaint did not represent a major medical condition such as bipolar disorder or substance abuse. Importantly, Hudson and colleagues (2010) reported that the youth who participated in their study were grateful for older, more experienced homeless youth willing to provide guidance on where to find needed medical services and how to navigate the system.

In an earlier study, researchers asked 20 homeless female youth between the ages of 14 and 23 about their experiences when attempting to access the healthcare system (Ensign & Panke, 2002). A common theme in the data was the need to reorganize clinic waiting and examination rooms to allow family members and friends to accompany clients during visits. Other barriers identified by the women and researchers included a lack of clinician cultural competency — in this context, the ability of clinicians to recognize the sometimes substantial cultural, social, and economic differences between the lives of clinicians and those of the homeless. The women repeatedly mentioned a lack of understanding and the use of negative stereotypes by providers. One example raised by providers involved homeless women who engage in sex work to survive and then seek medical treatment. From an ethical perspective, clinicians have a professional obligation to treat these women with the best care available, without passing judgment on their housing status or involvement in the sex trade.

References

Ensign, J., & Panke, A. (2002). Barriers and bridges to care: Voices of homeless female adolescent youth in Seattle, Washington, USA. Journal of Advanced Nursing, 37(2), 166–172.

HCH Clinicians' Network. (2009). Engaging adolescents who are homeless in care. Helping Hands, 13(5), 1–8. Retrieved from

Henry, M., Cortes, A., Shivji, A., Buck, K., Khadduri, J., & Culhane, D. (2014). Part 1: Point-in-time estimates of homelessness. The 2014 Annual Homeless Assessment Report (AHAR) to Congress. Office of Community Planning and Development, U.S. Department of Housing and Urban Development. Retrieved from

Hudson, A. L., Nyamathi, A., Greengold, B., Stagle, A., Koniak-Griffin, D., Khalilifard, F., et al. (2010). Health-seeking challenges among homeless youth. Nursing Research, 59(3), 212–218.

Stone, C., Trisi, D., Sherman, A., & DeBot, B. (2015, February 20). A guide to statistics on historical trends in income inequality. Center on Budget and Policy Priorities. Retrieved from http://www.cbpp.org/files/11-28-11pov.pdf

Winetrobe, H., Rice, E., Rhoades, H., & Milburn, N. (2015). Health insurance coverage and healthcare utilization among homeless young adults in Venice, CA. Journal of Public Health (Oxford, UK), published online ahead of print January 28, 2015.