- Email: [email protected]
Homeless and runaway youths’ access to health care
JOURNAL OF ADOLESCENT HEALTH 2000;27:331–339
ORIGINAL ARTICLE
Homeless and Runaway Youths’ Access to Health Care JONATHAN D. KLEIN, M.D., M.P.H., AMIE HALL WOODS, KAREN M. WILSON, M.P.H., MOISES PROSPERO, JODY GREENE, M.S., AND CHRIS RINGWALT, Dr.P.H.
Purpose: To describe use of health services and selfreported access to regular and emergency care by homeless adolescents and street youth. Methods: Interviewer-administered surveys addressed use of health services, availability of sources of care for emergencies, and types of care sources used. An abbreviated version of the questionnaire used for youth in shelters was used for street youth. A nationally representative sample of 640 sheltered youth and a purposive sample of 600 street youth aged 12–21 years were interviewed. All data were collected in 1992. Results: Half of street youth and 36% of sheltered youth did not have a regular source of health care (p < .05). One-fourth of street youth and 18% of sheltered youth also reported serious health problems within the past year (p < .05). Street youth were more likely than sheltered youth to have used emergency treatment (36% vs. 29%; p < .05) and alcohol- or drug-related emergency treatment (25% vs. 13%; p < .05). Sheltered youth with a regular source of care were more likely to use nonemergency sites than those without a source of primary care (46% vs. 20%; p < .001). Few sheltered or street youth perceived shelter clinics, clinics for runaway youth, or free youth clinics to be available to meet their emergency care needs. Conclusions: Significant numbers of homeless youth did not have a regular source of health care. Those who
From the Division of Adolescent Medicine, University of Rochester (J.D.K., A.H.W., K.M.W., M.P.), Rochester, New York; and the Research Triangle Institute (J.G., C.R.), Research Triangle Park, North Carolina Address correspondence to: Jonathan D. Klein, M.D., M.P.H., Strong Children’s Research Center, Division of Adolescent Medicine, Box 690, Department of Pediatrics, 601 Elmwood Avenue, Rochester, NY 14642. E-mail: [email protected]. Manuscript accepted March 23, 2000.
had a regular source of care were more likely to have continuity between routine and emergency care. Integration of health services with other agencies serving youth in shelters or on the street may improve access to care for those without a routine source of care and provide better continuity for these high-risk youth. © Society for Adolescent Medicine, 2000 KEY WORDS: Accessibility Continuity of care Gender differences Health services Homeless youth
The National Network for Runaway and Homeless Youth estimates that 1.3 million youth have run away or are homeless on the streets of America (1). Homeless and runaway adolescents are at high risk for injuries, physical abuse, suicide, and homicide. Each year approximately 5000 runaway and homeless children die from assault, illness, and suicide (2), and an estimated 125,000 –200,000 adolescents engage in “survival sex,” exchanging sexual acts for money, food, drugs, shelter, or protection (3). Runaway and homeless youth are more likely than their domiciled counterparts to engage in risky sexual behavior, increasing their chances of becoming pregnant or contracting human immunodeficiency virus (HIV) and other sexually transmitted diseases. Homelessness for teens often precedes and/or contributes to an increased risk of sexual abuse, which is associated with higher rates of unprotected sex, drug and alcohol abuse, and more sexual partners (4).
© Society for Adolescent Medicine, 2000 Published by Elsevier Science Inc., 655 Avenue of the Americas, New York, NY 10010
1054-139X/00/$–see front matter PII S1054-139X(00)00146-4
332
KLEIN ET AL.
Increasing threats to physical and psychological safety contribute to a myriad of emotional and psychosocial problems, including depression and suicidality (3). Adolescent homelessness is a growing problem among our nations’ youth. In a representative household sample of 6496 adolescents surveyed in 1992 and 1993, 7.6% of youth reported spending at least one night in a youth or adult shelter, a public place, outside or in an abandoned building, underground, or with a stranger, regardless of sociodemographic or geographic factors (5). The prevalence of dysfunctional living situations extended across the cultural and financial spectrum. Despite runaway and homeless youths’ high level of risk and increased need for health services, many factors may influence their decision not to seek care. In addition to their distrust of authority, issues of confidentiality, cost, and their status as minors may prevent homeless and runaway youth from using available care (6). Although 75% of runaway and homeless youth stay in or near the communities in which they were raised, most are not familiar with local health resources (7). In hospital settings, adolescents are likely to be asked for a permanent address, health insurance information, and parental permission for treatment. Accordingly, homeless youth may fear social service agency notification or legal intervention. Affordability, denial of need, delay in seeking care, and lack of adequate follow-up all complicate the management of health problems. Contact with shelter services, in contrast, may lead to mandated examinations by Social Service departments, justice agencies, or shelter policy. Although an integrated service model is often portrayed as the ideal, health care targeted to homeless youth rarely addresses the full range of youths’ social, educational, vocational, and legal needs (7). Relatively little is known about runaway or homeless youths’ access to care. In this study, we describe use of health services and self-reported access to regular and emergency care by unaccompanied homeless adolescents in shelters, and by street youth.
Methods Data for this study were collected as part of a study of runaway and homeless youths’ substance use and drug prevention and treatment needs conducted for the U.S. Department of Health and Human Services Administration on Children, Youth, and Families. A nationally representative cluster sample of adolescents in federally and nonfederally funded shelters
JOURNAL OF ADOLESCENT HEALTH Vol. 27, No. 5
and the first ever multicity sample of street youth were interviewed in 1992 (8). For the shelter sample, 25 primary sampling units were selected from 125 geographic areas used as part of the 1991 National Household Survey on Drug Abuse (NHSDA). Primary sampling units for that study were constructed and then sampled in proportion to their population of youth. A census of youth shelters was developed in each area as previously described. A second stage sample of 30 shelters was then selected from the 82 shelters available. After accounting for refusals and confirming eligibility, the final sample included 23 shelters (77%). These shelters were all located in metropolitan areas and were distributed across 17 of the primary sampling units. The use of multistage sampling techniques ensured that both federally and nonfederally funded shelters were represented, and that this sample reflected a range of geographic regions and levels of population density. Of 840 youth sampled from shelters, 660 met criteria to be included in the shelter sample (defined as youth who have spent at least one night in a youth or adult shelter, without the permission of parents or legal guardians), and 640 (97%) of these eligible youth completed the survey. Youth were sampled from shelters in proportions calculated to result in equal numbers of interviews in both smaller and larger shelters, to result in more accurate point estimates in weighted analysis. An intervieweradministered questionnaire was completed by all youth in the shelter sample. All respondents were between the ages of 12 and 21 years (mean, 16.6). Interviews were also conducted with 600 street youth aged 12–21 years (mean, 17.9) in 10 cities using a purposive sampling strategy. Ten cities were selected from the 25 primary sampling units from the shelter survey known to have a high number of street youth, and outreach workers from local homeless youth services agencies assisted field investigators in identifying sites where homeless street youth were likely to congregate. Street youth were defined as youth who have spent at least one night away from home without the permission of parents or legal guardians in an improvised shelter, on the street, or in the home of a stranger. An abbreviated version of the questionnaire used for sheltered youth was used with street youth owing to physical safety concerns of the interviewers and because of the higher likelihood of interruptions. Although screening information for street youth was not recorded, few eligible youth refused to participate. Before completion of the survey, field investigators obtained informed
November 2000
consent from participating youth and emphasized the confidentiality of the interview. Both questionnaires asked about health services use, availability of sources of care for emergencies, types of care sources used, and history of having had a serious health problem. Teens’ responses to “Do you have a regular doctor or other health care provider, or a place you go to regularly for health care?” were used to define the presence of a regular health care source. In addition, sheltered youth were asked to describe the type of regular care source given if responding affirmatively to this question. Adolescents were also asked to differentiate between regular and emergency care. An emergency source of care was defined as care that would address an immediate health need. The questionnaire used for sheltered youth also addressed availability of a regular source of care and most recent contact with that care source. Questionnaires were tested, and face and content validity established as previously described (8). Interviewing procedures were designed to enhance the privacy of responses, with respondents recording sensitive responses (e.g., drug use) on answer sheets rather than responding verbally to the interviewers. Each street youth was given $10 in fast-food coupons for a completed interview; sheltered youth were offered snacks and soda for their participation. Incentives for the two sample groups differed because of the disparity in the environment in which the survey was administered (i.e., an indoor, often more stable environment for sheltered youth, and a variable environment for street youth, such as a coffee shop or other safe place.) Because the shelter-only data were chosen to provide representative national estimates, these data were weighted for analysis. The street data were not weighted, as a purposive sampling design was used and the sample was not designed to be nationally representative. However, the abbreviated questionnaire used with street youth matched that used with sheltered youth. Comparisons between the two groups are presented, as these adolescents represent different parts of the spectrum of unaccompanied homeless youth. Initial shelter weights were computed as the product of two factors: the weight associated with where the shelter was located, and the probability that the shelter would be selected within each primary sampling area (8). These weights were adjusted for shelter and youth eligibility and nonresponse. Teens were considered to have had a serious health problem if they answered “yes” to the question, “In the past 12 months, when you spent the night away from
HOMELESS AND RUNAWAY YOUTHS’ HEALTH CARE
333
home, did you have any serious health problems?”. Data for comparison of sheltered and street youth were analyzed using a comparison of proportions. Yates’ correction Chi-square tests were used for comparison of proportions in the sample of street youth, and SAS was used for frequencies and Cochran–Mantel–Haenszel Chi-square statistics (9). This study protocol was approved by the Research Subject Review Board at the Research Triangle Institute.
Results Demographics, Access and Health Status Half of the sheltered youth were female and 40% of the street youth were female (Table 1). White adolescents comprised one-third of the sheltered youth and half of the street youth, whereas African-American and Hispanic youth were more common in shelters than on the street. Adolescents living in shelters were more likely than adolescents living on the street to have a regular source of health care, and to report having had a medical checkup or health examination in the previous 2 years (Table 1). Thirty-six percent of street youth and 29% of sheltered youth had been treated in the emergency department in the previous year, and street youth were more likely than sheltered youth to report that the stay was related to drug or alcohol use. Street youth were also more likely than sheltered youth to report having had a serious health problem in the previous year. The most common source of emergency care cited by both groups was the emergency department (Table 1). Sheltered youth were twice as likely as street youth to use hospital outpatient clinics and more likely to use shelter clinics for emergency care. Fifteen percent of both the street and sheltered youth reported going to a doctor’s office for emergency care. None of the sheltered youth and only 0.5% of the street youth reported using mobile health vans for emergency care. Effect of Having a Regular Source of Care Sheltered youth who did not have a source of routine care were more likely to report seeking emergency care at a hospital emergency department than those with a routine source of health care (Table 2). Teens with a regular source of care were more likely to report seeking emergency care at a doctor’s office or hospital outpatient clinics. These findings suggest that sheltered youth with a source of routine care are more
334
KLEIN ET AL.
JOURNAL OF ADOLESCENT HEALTH Vol. 27, No. 5
Table 1. Demographics and Health Services Use of Sample of Homeless Adolescents (%) Street Youth (n ⫽ 600) Gender Female Male Race/ethnicity White African-American Hispanic Asian Native American Other Health services use Have regular source of care Have regular checkup or health exam within past 2 years Seen in ED in previous year Seen in ED for drugs/alcohol Had serious health problems within past year Source of emergency care Doctor’s office Community health center Hospital outpatient clinic Hospital emergency department Public health department School health clinic Clinic for runaway youth Free youth clinic Shelter clinic Mobile health van Health maintenance organization Other
Sheltered Youth (n ⫽ 640)
p ⱕ.001
40 60
57 43
53.4 29.2 3.9 2 4 7.4
34.4 46.1 8.8 1.9 3.4 5
50 84 36 25 25
63.7 93 29 13 18
ⱕ.05 ⱕ.05 ⱕ.05 ⱕ.05 ⱕ.05
15 8 8 33 6 0.9 2 8 8 0.5 2 10
15 6 15 29 5 0.6 0.6 3 13 0 2 11
.94 .20 ⱕ.001 .15 .52 .78 ⱕ.05 ⱕ.0005 ⱕ.05 23 .85 .63
ⱕ.001
ED ⫽ emergency department.
likely to have continuity between routine and emergency care than sheltered youth without routine sources of care (street youth were not asked to identify their regular sources of care).
Access by Gender for Sheltered Youth Whereas white adolescents were equally represented among both female and male sheltered teens, Afri-
Table 2. Sources of Emergency Care for Sheltered Youth Who Do and Do Not Identify Routine Health Care Sources* (Weighted %)
Source
Have Regular Care (%) (n ⫽ 396)
Do Not Have Regular Care (%) (n ⫽ 244)
p
Doctor’s office Community health center Hospital outpatient clinic Hospital emergency department Public health department Family planning clinic Clinic for runaway youth Free youth clinic Shelter clinic Other
27.3 6.8 19 20.2 4.9 0.2 0.5 4.2 8.4 8.1
9.4 7.5 10.5 35.3 8 0.4 2.4 3.1 11.2 10.8
ⱕ.001 .48 ⱕ.001 ⱕ.001 ⱕ.001 .33 ⱕ.001 .13 ⱕ.01 .02
* Routine health care source ⫽ respondent’s answer to “Do you have a regular doctor or other health care provider, or a place you go to regularly for health care?”
November 2000
HOMELESS AND RUNAWAY YOUTHS’ HEALTH CARE
335
Table 3. Nationally Representative Sample of Sheltered Youth, by Gender and Age (Weighted %) Variable Race/ethnicity White African-American Native American Asian/Pacific Islander Hispanic Other Health Excellent Good Fair Poor Last checkup in past year 1–2 years ago 2⫹ years ago Never Don’t remember Have regular source of health care Usual source of care (n ⫽ 396) Doctor’s office Community health center Hospital outpatient clinic Emergency department Public health clinic Clinic for runaways Free youth clinic Shelter clinic Family Planning clinic Other Last time received care at usual source Past 30 days 1–5 months ago 1–2 years ago More than 2 years ago Don’t remember Source of emergency care Doctor’s office Community health center Hospital outpatient clinic Emergency department Public health clinic Clinic for runaways Free youth clinic Shelter clinic Other Emergency department stay in past 12 months Related to drug/alcohol use Overnight hospital stay in past year Serious health problems in past year Ever had a venereal disease Been tested for AIDS
Total (%)
Male (%)
Female (%)
37.4 42.3 4.1 2.1 9.1 5.0
39.4 35.8 6.0 3.7 9.4 5.7
36.0 46.6 2.9 1.0 9.0 4.5
31.5 42.6 22.6 3.0
36.6 42.4 18.6 2.2
28.3 42.8 25.2 3.5
84.7 6.5 1.9 1.4 5.5 63.7
86.2 5.5 1.5 1.4 5.5 56.2
83.7 7.2 2.1 1.4 5.6 68.6
36.7 14.1 20.0 1.6 7.4 1.9 4.0 6.4 1.6 6.3
33.4 8.2 15.2 3.8 4.4 3.5 6.4 12.9 0.7 11.7
38.4 17.3 22.6 0.4 9.0 1.1 2.7 2.9 2.1 3.4
40.1 37.0 6.8 1.6 3.5
35.0 38.7 6.0 3.4 3.0
43.5 36.7 7.3 0.7 3.8
20.8 6.9 15.8 25.1 5.8 1.2 3.6 9.2 9.0 25.6 14.3 22.6 17.0 10.4 51.9
15.7 3.7 16.9 28.0 4.5 1.2 4.2 13.9 11.9 24.1 19.1 16.8 15.3 7.4 55.0
24.8 9.3 15.5 24.0 6.9 1.1 3.3 6.4 7.3 26.7 11.5 26.5 18.1 12.3 49.9
p
Age ⱕ17 yrs (%)
Age ⬎17 yrs (%)
39.4 38.0 4.9 1.7 10.1 5.8
33.5 50.1 2.5 2.8 7.3 3.4
32.2 40.1 23.7 3.3
30.4 46.5 20.8 2.1
81.5 7.7 2.4 1.6 6.9 67.7
92.6 4.6 0.8 1.1 0.9 56.1
43.4 18.3 17.6 1.3 8.5 0.34 1.3 0.8 0.7 7.7
20.9 4.5 25.7 2.3 4.8 5.6 10.3 19.3 3.7 2.8
32.8 43.1 8.6 1.1 3.7
58.2 24.4 2.9 3.0 0
28.4 9.8 15.2 20.4 6.4 0.8 2.2 3.9 12.1 15.6 18.6 18.1 12.5 8.7 36.1
8.2 2.1 17.6 35.0 5.1 1.9 6.4 19.4 3.9 44.8 11.2 31.4 25.6 13.8 82.6
ⱕ.001
ⱕ.05
ⱕ.001
ⱕ.05
ⱕ.001
.14
ⱕ.001 ⱕ.05 ⱕ.001 ⱕ.001 ⱕ.001 ⱕ.001 ⱕ.001 ⱕ.001 ⱕ.001 ⱕ.01 ⱕ.001 ⱕ.001
ⱕ.001 ⱕ.001 .26 ⱕ.01 ⱕ.005 .97 .19 ⱕ.001 ⱕ.001 .09 ⱕ.005 ⱕ.001 ⱕ.05 ⱕ.001 ⱕ.05
p
ⱕ.001 ⱕ.001 ⱕ.001 ⱕ.001 .06 ⱕ.005 ⱕ.001 ⱕ.001 ⱕ.001 ⱕ.001 ⱕ.001 ⱕ.001
ⱕ.001 ⱕ.001 .07 ⱕ.001 .14 ⱕ.005 ⱕ.001 ⱕ.001 ⱕ.001 ⱕ.001 ⱕ.001 ⱕ.001 ⱕ.001 ⱕ.001 ⱕ.001
yrs ⫽ years.
can-American females significantly outnumbered their male counterparts (Table 3). The largest percentage of the sheltered youth reported that their health was good (42.6%), compared with 31.5% who
reported excellent health and 22.6% who reported fair health. Girls were less likely than boys to rate their health as excellent and more likely to rate their health as fair than were boys (Table 3).
336
KLEIN ET AL.
Eighty-five percent of sheltered youth report having had a checkup within the previous year. A high percentage of both genders reported having a checkup. Sixty-four percent of the adolescents in the shelter-only sample reported having a regular source of health care; the most common provider of which was a doctor’s office (36.7%). Other usual sources of care reported by the shelter sample were: hospital outpatient clinics (20%), community health centers (14.1%), public health clinics (7.4%), shelter clinics (6.4%), other sources of care (6.3%), free youth clinics (4%), clinics for runaway youth (1.9%), family planning clinics (1.6%), and emergency departments (1.6%). Female adolescents living in shelters were more likely than males to report having a usual source of health care. Whereas doctor’s offices were the most commonly cited source of regular care for both genders, females were more likely than males to use a community health center or a hospital outpatient clinic as their regular care source. In contrast, males were more likely than females to use a shelter clinic as a regular source of care (Table 3). Among sheltered youth with a regular source of care, 40.1% reported that they had received care at their usual source within the previous 30 days. Females were more likely than males to report having received care at their usual source within the previous 30 days, but both males and females were equally likely to have received care within the previous year. Girls were also more likely than boys to report that when they needed emergency care they would use a doctor’s office or a community health center, but less likely to report that their source of emergency care was an emergency department. One-quarter of sheltered adolescents had used the emergency department while away from home in the previous year, with males and females reporting this behavior in similar proportions. Males, however, were more likely to report that their stay was due to drug or alcohol use. Over one-fifth of all sheltered adolescents reported an overnight hospital stay in the past year, but girls were more likely than boys to report this type of overnight stay. Seventeen percent of sheltered teens reported having had serious health problems in the previous year, although females were more likely than males to report such problems in this time frame. Access by Age for Sheltered Youth Whereas the ratio of boys to girls was similar for sheltered adolescents over 17 years of age, more sheltered adolescents who were aged 17 years and
JOURNAL OF ADOLESCENT HEALTH Vol. 27, No. 5
under were female. In addition, whereas white and African-American adolescents were equally represented among those aged 17 years and under, half of those over 17 years of age were African-American and only one-third were white (Table 3). Although almost all older sheltered adolescents reported having had a checkup in the previous year, fewer younger teens reported this. Nonetheless, younger adolescents were more likely to report having a regular source of health care, and that source was more likely to be a doctor’s office. The most frequently cited usual source of care for the older sheltered youth was a hospital outpatient clinic. Older sheltered youth were also more likely to report having received care at their usual source within the past 30 days. For younger sheltered youth the most common source of emergency care was a doctor’s office. Conversely, the most common source of emergency care for older sheltered youth was the emergency department. One-fifth of older sheltered youth reported using shelter clinics for emergency care, whereas only 4% of those in the younger age group did. Older sheltered adolescents were much more likely to report having been treated in the emergency department while they were away from home than younger teens, but younger adolescents were more likely to report that their emergency department stay was due to drug or alcohol use. Older sheltered youth were also more likely to have stayed in the hospital overnight while away from home, and were more likely to report having experienced serious health problems in the previous year.
Discussion This study is the first to assess access to health care for a representative sample of adolescents in shelters and a large multicity sample on the street. Not surprisingly, half of street youth and over one-third of sheltered youth did not have a source of routine health care. In comparison, based on parental report, only 15% of adolescents aged 11–17 years in a nationally representative sample of households did not have a source of routine health care (10). However, a significant proportion of street and shelter youth in this study did identify a source of routine care. In addition, street youth reported having used care in the past year at a similar rate, and sheltered youth reported using care at a rate higher than that of domiciled adolescents (11). Street youth consistently reported having more
November 2000
serious health problems than sheltered youth, as well as high rates of emergency department visits related to alcohol or drug use. In addition, our findings are similar to those reported in a recent study of health status and access to care among a shelter-based sample of street and system youth (youth involved in an institutional or foster care system) in Baltimore. In that study, Ensign and Santelli found similar rates of emergency department usage, and as in our analysis, street youth in that study were also more likely to have used the emergency department in the past year in connection to their higher rates of injuries and substance abuse (12). Although fewer street youth than sheltered youth in our study reported having a clinician visit within the past 2 years, those rates are nearly as high and do not differ significantly from those reported by nationally representative samples of in-school adolescents (11). Because the length of time away from home may vary owing to the transience and turmoil of homelessness, it is possible that youth self-report may reflect services provided while domiciled or during an interruption of street life. In addition, we could not determine from our survey the proportion of visits that were triggered by mandated examinations in shelter settings. Nonetheless, although fewer adolescents had regular sources of care than reported having had a checkup, the proportions with regular care utilization and with emergency department and other care use, were both high. The results of our study demonstrate the importance of linking health services to programs seeking to meet the needs of homeless adolescents. In a study of youth in an outreach program in one shelter, 19% of adolescents reported that medical needs were their main concern (13). Similarly, 57% of youth in another shelter sample had received health care services within the previous month, and one-quarter of these youth identified several barriers to their access to care (14). Those studies were limited in that they addressed the needs of adolescents in a single geographic area and identified youth already seeking health care. Two previous studies illustrate the disparity between youth shelter agencies’ perceived lack of emphasis on health care delivery and the needs of this high-risk population. In a U.S. General Accounting Office study of interventions for high-risk youth, health services were not identified by program officials as important elements of their program’s success (15). However, despite this lack of prioritization of health needs by programs designed to assess the needs of youth at risk, as many as 25% of homeless
HOMELESS AND RUNAWAY YOUTHS’ HEALTH CARE
337
and runaway youth were reported as having received medical services directly or through referral, in a national study of homeless youth seeking services from shelters (16). Those services included family planning, psychiatric, and psychological services. It is not clear whether those services included preventive care or whether the services were part of, or linked with, shelter services. Furthermore, among the runaway and homeless youth studied, only 3% received treatment or referral for drug and alcohol abuse, although 22% reported such problems (16). In contrast, a recent Los Angeles study found that 71% of homeless youth had an alcohol and/or illicit drug abuse disorder, according to DSM-III criteria (17). Continuity of care also declined sharply upon most youths’ departure from shelters; in one study, almost half (46%) of homeless youth were not scheduled to receive any follow-up services, and only 10% of homeless and 8% of runway youth were scheduled to receive follow-up medical care (16). The young women in our shelter sample were more likely than the young men to report having and using a usual source of health care. They were also more likely to have had a serious health problem or to have reported worse health status than were males. Whereas previous studies have shown females to be more at risk and to report greater fear of being assaulted with a knife or sexually assaulted, no significant differences existed in the amount of physical violence with or without other weapons to which males and females were exposed to on the street (18). In addition, no gender difference was found among a sample of runaway youth in Minnesota when asked about barriers that they perceived when attempting to obtain health care (14). Although the younger adolescents in our study were less likely to have had a checkup in the previous year, older adolescents were less likely to have a usual source of care. Older adolescents were also more likely to have had serious health problems and to have used an emergency department in the previous year. These findings are supported by a recent study of HIV-risk behavior in a street-based sample of homeless and runaway youth in New York City, which found that whereas older age segments of youth were more likely to be at high risk, they were also least likely to be in contact with prevention services (19). Many homeless and runaway youth participate in lifestyles that lead to serious health problems (1–5). Owing to their precarious or nonexistent housing status, homeless youth are at high risk for exposure to violence as both witnesses and victims (18) and make frequent emergency room visits. Our study
338
KLEIN ET AL.
indicated that homeless youth with a source of routine health care are more likely to perceive greater accessibility of emergency care, are more likely to report continuity between routine and emergency care, and are more likely to use non-emergency sites for their care. In contrast, homeless youth without routine health care sources are more likely to identify hospital emergency departments than primary care, continuity sites as their major source of emergency care. Emergency departments tend to be unable to provide continuous care or assist with regard to adolescents’ living situations. Homeless adolescents also may seek care for reasons relating to violence or mental health, which may precipitate use of the emergency department. Although we do not know to what extent utilization by these youth is due to these factors, about one-quarter of the homeless adolescents in our study had been treated in the emergency department in the past year. Traditionally, emergency departments have been shown to function as a safety net, providing care and addressing needs of indigent and otherwise underserved populations (20). High levels of emergency department use have been correlated not only with an inverse relationship to primary care access (21), but also with the provision of almshouse needs: food, transitory shelter, and brief contact with those who provide temporary relief from the stresses of homelessness and its comorbidities. Furthermore, these services are largely undocumented or underreported within the emergency services use literature, as they are frequently offered informally by nurses or other nonphysician personnel (22). Addressing high levels of emergency department use from the dual perspective of both the difficulty in accessing primary care and the provision of basic needs may shed light on the reasons behind what has previously been identified as inappropriate use of this care site. Special free clinics, shelter clinics, and runaway youth programs are used by only 12% of sheltered youth for routine health care. These findings suggest that many youth for whom these programs are designed may not be using them. We do not know from this study whether failure to identify these services is due to program availability, insufficient outreach, street adolescents’ distrust of institutions, difficulty in finding or traveling to care sites, or other barriers. Nonetheless, understanding the reasons for these low levels of utilization will be important to better reach these high-risk youth with the services designed for them. Most cities still have relatively few special services for homeless youth (6). Our study has several limitations. It relies on
JOURNAL OF ADOLESCENT HEALTH Vol. 27, No. 5
adolescents’ self-report and recall of the services they have used, and our data collection was constrained by the circumstances and environment required to interact with and question street and sheltered youth. Our sample of street youth may be biased by this selection process because youth were recruited by outreach workers and introduced to the field interviewers. Thus, youth living in vehicles, abandoned buildings, or other facilities and who were less visible to, or simply avoided, outreach workers were beyond the reach of this study. Fear of disclosure or of legal sanctions may have resulted in underreporting of adolescents’ behaviors. In addition, adolescents may have varied in how they describe particular health facilities. For example, a street teen might have identified a site as a runaway clinic, whereas a young person living in a shelter may have labeled the same site a shelter clinic, both cases reflecting their perceptions of the linkages between these programs. In addition, although we sampled adolescents from shelters in a representative manner, crossover may exist between youth in shelters and street youth, who may in fact be the same individuals defined at different points in time. Owing to the possibility of inclusion in either group, youth on the street may reflect back to sheltermandated experiences in their self-report of frequency and sources of care. Shelters may also differ in their definitions, purposes, and allowances for length of stay, and by whether they are mandated to provide medical care. We did not obtain information describing the presence of onsite or program-linked health services at these shelters. Furthermore, although the shelters that we selected in metropolitan areas provided the necessary access to street and sheltered youth, this factor limits our findings to those youth residing in urban areas, and may not be applicable to homeless youth in rural areas. The sample of shelters that chose to participate may also have been biased in ways we were not able to detect. In addition, these results from 1992 may not be generalizable to homeless or sheltered youth in 2000, as both the population and available services may have changed in a variety of ways. Although these issues cannot be fully resolved from our study, they highlight the importance of linking integrated services to use of care, especially in emergency departments and other acute health care or shelter settings. Runaway and homeless adolescents are at risk for serious physical, psychological, and emotional problems. Although it is believed that homeless youth tend to have few treatment options available (6), many at-risk adolescents have contacts with both
November 2000
routine and emergency health care. Youth on the street may experience a series of destabilizing events leading to exit from street life or a reestablishment of life on the street (23). To the degree that chronic and acute health issues lead to destabilization, appropriate service linkages may assist these at-risk youth in their exit from the street. Furthermore, although homeless youth studied in some areas have verbalized the presence of barriers to care, the service utilization patterns of those youth are strongly associated with use of the shelter system (24). Effective outreach programs, including the provision of both direct services and information to homeless youth populations, may help reduce the barriers they face in obtaining health care. Further exploration into the availability and integration of incentives to obtaining primary care, such as the use of complementary or alternative medicine by homeless youth, may encourage youth to seek out sources of primary care (25). In addition, increasing emergency and outpatient provider awareness of both homelessness in adolescence and its biologic, social, and emotional comorbidities may be useful in improving access to health care for homeless and runaway youth. Integration of effective health services with shelter, street, and health, safety, and social services also may help promote better continuity of care for homeless youth. Finally, ongoing surveillance of the needs of homeless adolescents will be needed to develop and improve policies addressing homeless and runaway teens’ access to care. This study was funded in part by a grant from the National Institute on Drug Abuse (Grant DA08849), the Administration on Children, Youth and Families (Contract 105-90-1703), and by the Strong Children’s Research Center Summer Student Research Program (National Heart Lung and Blood Institute Grant T35HL07754). Dr. Klein is also supported by a Robert Wood Johnson Faculty Scholars Award. This study was presented in part at the Society for Adolescent Medicine annual meeting, Los Angeles, California, March 18, 1999.
References 1. Sherman DJ. The neglected health care needs of street youth. Public Health Rep 1992;107:433– 40. 2. National Runaway Switchboard Runaway Curriculum. Information packet. Chicago, IL, 1992. 3. Hersch P. Coming of age on the city streets. Psychol Today 1988;22:28 –37. 4. Rotheram-Borus MJ, Mahler KA, Koopman C, Langabeer K. Sexual abuse history and associated multiple risk behavior in adolescent runaways. Am J Orthopsych 1996;66:390 – 400. 5. Ringwalt CL, Greene JM, Robertson M, McPheeters M. The prevalence of homelessness among adolescents in the United States. Am J Public Health 1998;88:1325–9.
HOMELESS AND RUNAWAY YOUTHS’ HEALTH CARE
339
6. Morey MA, Friedman LS. Health care needs of homeless adolescents. Curr Opin Pediatrics 1993;5:395–9. 7. Farrow MD, Deisher RW, Brown R, et al. Health and health needs of homeless and runaway youth. J Adolesc Health 1992;13:717–26. 8. Greene JM, Ennet ST, Ringwalt CL. Substance use among runaway and homeless youth in three national samples. Am J Public Health 1997;87:229 –35. 9. SAS Institute, Inc. SAS/STAT User’s Guide, Version 6, 4th ed. Cary, NC: SAS Institute, Inc., 1989. 10. Hedberg VA, Byrd RS, Klein JD, et al. The role of community health centers in providing preventive care to adolescents. Arch Pediatr Adolesc Med 1996;150:603– 8. 11. Klein JD, Wilson KM, McNulty M, et al. Access to medical care for adolescents: Results from the 1997 Commonwealth Fund survey of the health of adolescent girls. J Adolesc Health 1999;25:120 –30. 12. Ensign J, Santelli J. Shelter-based homeless youth. Arch Pediatr Adolesc Med 1997;151:817–23. 13. Saltonstall MB. Bridge over troubled waters/runaways and youth on the streets of Boston: One agency’s response. Boston: Boston Globe Foundation, 1984. 14. Geber GM. Barriers to health care for street youth. J Adolesc Health 1997;21:287–90. 15. United States General Accounting Office Report to the Chairman, Subcommittee on Oversight of Government Management, Committee on Governmental Affairs, U.S. Senate. Residential care: Some high-risk youth benefit, but more study needed. January 1994, GAO/HEHS-94-56. 16. United States General Accounting Office Report to the Honorable Paul Simon, U.S. Senate. Homelessness: Homeless and runaway youth receiving services at federally funded shelters. December 1989, GAO/HRD-90-45. 17. Kipke M, Montgomery S, Simon T, Iverson E. “Substance abuse” disorders among runaway and homeless youth. Subst Use Misuse 1997;32:969 – 86. 18. Kipke M, Simon T, Montgomery S, et al. Homeless youth and their exposure to and involvement in violence while living on the streets. J Adolesc Health 1997;20:360 –7. 19. Clatts MC, Davis WR, Sotheran JL, Atillasoy A. Correlates and distribution of HIV risk behaviors among homeless youths in New York City: Implications for prevention and policy. Child Welfare 1998;77:195–207. 20. Iserson KV, Kastre TY. Are emergency departments really a “safety net” for the medically indigent? Am J Emerg Med 1996;14:1–5. 21. Grumbach K, Keane D, Bindman A. Primary care and public emergency department overcrowding. Am J Public Health 1993;83:372– 8. 22. Malone R. Whither the almshouse? Overutilization and the role of the emergency department. J Health Politics Policy Law 1998;23:795– 832. 23. Auerswald C, Eyre S. Initiation into and extrication from life on the streets: A qualitative study of youth. J Adolesc Health 1999;24:89. 24. De Rosa CJ, Montgomery SB, Kipke MD, et al. Service utilization among homeless and runaway youth in Los Angeles, California: Rates and reasons. J Adolesc Health 1999;24:449 – 58. 25. Breuner CC. Alternative medicine use by homeless youth. Arch Pediatr Adolesc Med 1998;152:1071–5.
ORIGINAL ARTICLE
Homeless and Runaway Youths’ Access to Health Care JONATHAN D. KLEIN, M.D., M.P.H., AMIE HALL WOODS, KAREN M. WILSON, M.P.H., MOISES PROSPERO, JODY GREENE, M.S., AND CHRIS RINGWALT, Dr.P.H.
Purpose: To describe use of health services and selfreported access to regular and emergency care by homeless adolescents and street youth. Methods: Interviewer-administered surveys addressed use of health services, availability of sources of care for emergencies, and types of care sources used. An abbreviated version of the questionnaire used for youth in shelters was used for street youth. A nationally representative sample of 640 sheltered youth and a purposive sample of 600 street youth aged 12–21 years were interviewed. All data were collected in 1992. Results: Half of street youth and 36% of sheltered youth did not have a regular source of health care (p < .05). One-fourth of street youth and 18% of sheltered youth also reported serious health problems within the past year (p < .05). Street youth were more likely than sheltered youth to have used emergency treatment (36% vs. 29%; p < .05) and alcohol- or drug-related emergency treatment (25% vs. 13%; p < .05). Sheltered youth with a regular source of care were more likely to use nonemergency sites than those without a source of primary care (46% vs. 20%; p < .001). Few sheltered or street youth perceived shelter clinics, clinics for runaway youth, or free youth clinics to be available to meet their emergency care needs. Conclusions: Significant numbers of homeless youth did not have a regular source of health care. Those who
From the Division of Adolescent Medicine, University of Rochester (J.D.K., A.H.W., K.M.W., M.P.), Rochester, New York; and the Research Triangle Institute (J.G., C.R.), Research Triangle Park, North Carolina Address correspondence to: Jonathan D. Klein, M.D., M.P.H., Strong Children’s Research Center, Division of Adolescent Medicine, Box 690, Department of Pediatrics, 601 Elmwood Avenue, Rochester, NY 14642. E-mail: [email protected]. Manuscript accepted March 23, 2000.
had a regular source of care were more likely to have continuity between routine and emergency care. Integration of health services with other agencies serving youth in shelters or on the street may improve access to care for those without a routine source of care and provide better continuity for these high-risk youth. © Society for Adolescent Medicine, 2000 KEY WORDS: Accessibility Continuity of care Gender differences Health services Homeless youth
The National Network for Runaway and Homeless Youth estimates that 1.3 million youth have run away or are homeless on the streets of America (1). Homeless and runaway adolescents are at high risk for injuries, physical abuse, suicide, and homicide. Each year approximately 5000 runaway and homeless children die from assault, illness, and suicide (2), and an estimated 125,000 –200,000 adolescents engage in “survival sex,” exchanging sexual acts for money, food, drugs, shelter, or protection (3). Runaway and homeless youth are more likely than their domiciled counterparts to engage in risky sexual behavior, increasing their chances of becoming pregnant or contracting human immunodeficiency virus (HIV) and other sexually transmitted diseases. Homelessness for teens often precedes and/or contributes to an increased risk of sexual abuse, which is associated with higher rates of unprotected sex, drug and alcohol abuse, and more sexual partners (4).
© Society for Adolescent Medicine, 2000 Published by Elsevier Science Inc., 655 Avenue of the Americas, New York, NY 10010
1054-139X/00/$–see front matter PII S1054-139X(00)00146-4
332
KLEIN ET AL.
Increasing threats to physical and psychological safety contribute to a myriad of emotional and psychosocial problems, including depression and suicidality (3). Adolescent homelessness is a growing problem among our nations’ youth. In a representative household sample of 6496 adolescents surveyed in 1992 and 1993, 7.6% of youth reported spending at least one night in a youth or adult shelter, a public place, outside or in an abandoned building, underground, or with a stranger, regardless of sociodemographic or geographic factors (5). The prevalence of dysfunctional living situations extended across the cultural and financial spectrum. Despite runaway and homeless youths’ high level of risk and increased need for health services, many factors may influence their decision not to seek care. In addition to their distrust of authority, issues of confidentiality, cost, and their status as minors may prevent homeless and runaway youth from using available care (6). Although 75% of runaway and homeless youth stay in or near the communities in which they were raised, most are not familiar with local health resources (7). In hospital settings, adolescents are likely to be asked for a permanent address, health insurance information, and parental permission for treatment. Accordingly, homeless youth may fear social service agency notification or legal intervention. Affordability, denial of need, delay in seeking care, and lack of adequate follow-up all complicate the management of health problems. Contact with shelter services, in contrast, may lead to mandated examinations by Social Service departments, justice agencies, or shelter policy. Although an integrated service model is often portrayed as the ideal, health care targeted to homeless youth rarely addresses the full range of youths’ social, educational, vocational, and legal needs (7). Relatively little is known about runaway or homeless youths’ access to care. In this study, we describe use of health services and self-reported access to regular and emergency care by unaccompanied homeless adolescents in shelters, and by street youth.
Methods Data for this study were collected as part of a study of runaway and homeless youths’ substance use and drug prevention and treatment needs conducted for the U.S. Department of Health and Human Services Administration on Children, Youth, and Families. A nationally representative cluster sample of adolescents in federally and nonfederally funded shelters
JOURNAL OF ADOLESCENT HEALTH Vol. 27, No. 5
and the first ever multicity sample of street youth were interviewed in 1992 (8). For the shelter sample, 25 primary sampling units were selected from 125 geographic areas used as part of the 1991 National Household Survey on Drug Abuse (NHSDA). Primary sampling units for that study were constructed and then sampled in proportion to their population of youth. A census of youth shelters was developed in each area as previously described. A second stage sample of 30 shelters was then selected from the 82 shelters available. After accounting for refusals and confirming eligibility, the final sample included 23 shelters (77%). These shelters were all located in metropolitan areas and were distributed across 17 of the primary sampling units. The use of multistage sampling techniques ensured that both federally and nonfederally funded shelters were represented, and that this sample reflected a range of geographic regions and levels of population density. Of 840 youth sampled from shelters, 660 met criteria to be included in the shelter sample (defined as youth who have spent at least one night in a youth or adult shelter, without the permission of parents or legal guardians), and 640 (97%) of these eligible youth completed the survey. Youth were sampled from shelters in proportions calculated to result in equal numbers of interviews in both smaller and larger shelters, to result in more accurate point estimates in weighted analysis. An intervieweradministered questionnaire was completed by all youth in the shelter sample. All respondents were between the ages of 12 and 21 years (mean, 16.6). Interviews were also conducted with 600 street youth aged 12–21 years (mean, 17.9) in 10 cities using a purposive sampling strategy. Ten cities were selected from the 25 primary sampling units from the shelter survey known to have a high number of street youth, and outreach workers from local homeless youth services agencies assisted field investigators in identifying sites where homeless street youth were likely to congregate. Street youth were defined as youth who have spent at least one night away from home without the permission of parents or legal guardians in an improvised shelter, on the street, or in the home of a stranger. An abbreviated version of the questionnaire used for sheltered youth was used with street youth owing to physical safety concerns of the interviewers and because of the higher likelihood of interruptions. Although screening information for street youth was not recorded, few eligible youth refused to participate. Before completion of the survey, field investigators obtained informed
November 2000
consent from participating youth and emphasized the confidentiality of the interview. Both questionnaires asked about health services use, availability of sources of care for emergencies, types of care sources used, and history of having had a serious health problem. Teens’ responses to “Do you have a regular doctor or other health care provider, or a place you go to regularly for health care?” were used to define the presence of a regular health care source. In addition, sheltered youth were asked to describe the type of regular care source given if responding affirmatively to this question. Adolescents were also asked to differentiate between regular and emergency care. An emergency source of care was defined as care that would address an immediate health need. The questionnaire used for sheltered youth also addressed availability of a regular source of care and most recent contact with that care source. Questionnaires were tested, and face and content validity established as previously described (8). Interviewing procedures were designed to enhance the privacy of responses, with respondents recording sensitive responses (e.g., drug use) on answer sheets rather than responding verbally to the interviewers. Each street youth was given $10 in fast-food coupons for a completed interview; sheltered youth were offered snacks and soda for their participation. Incentives for the two sample groups differed because of the disparity in the environment in which the survey was administered (i.e., an indoor, often more stable environment for sheltered youth, and a variable environment for street youth, such as a coffee shop or other safe place.) Because the shelter-only data were chosen to provide representative national estimates, these data were weighted for analysis. The street data were not weighted, as a purposive sampling design was used and the sample was not designed to be nationally representative. However, the abbreviated questionnaire used with street youth matched that used with sheltered youth. Comparisons between the two groups are presented, as these adolescents represent different parts of the spectrum of unaccompanied homeless youth. Initial shelter weights were computed as the product of two factors: the weight associated with where the shelter was located, and the probability that the shelter would be selected within each primary sampling area (8). These weights were adjusted for shelter and youth eligibility and nonresponse. Teens were considered to have had a serious health problem if they answered “yes” to the question, “In the past 12 months, when you spent the night away from
HOMELESS AND RUNAWAY YOUTHS’ HEALTH CARE
333
home, did you have any serious health problems?”. Data for comparison of sheltered and street youth were analyzed using a comparison of proportions. Yates’ correction Chi-square tests were used for comparison of proportions in the sample of street youth, and SAS was used for frequencies and Cochran–Mantel–Haenszel Chi-square statistics (9). This study protocol was approved by the Research Subject Review Board at the Research Triangle Institute.
Results Demographics, Access and Health Status Half of the sheltered youth were female and 40% of the street youth were female (Table 1). White adolescents comprised one-third of the sheltered youth and half of the street youth, whereas African-American and Hispanic youth were more common in shelters than on the street. Adolescents living in shelters were more likely than adolescents living on the street to have a regular source of health care, and to report having had a medical checkup or health examination in the previous 2 years (Table 1). Thirty-six percent of street youth and 29% of sheltered youth had been treated in the emergency department in the previous year, and street youth were more likely than sheltered youth to report that the stay was related to drug or alcohol use. Street youth were also more likely than sheltered youth to report having had a serious health problem in the previous year. The most common source of emergency care cited by both groups was the emergency department (Table 1). Sheltered youth were twice as likely as street youth to use hospital outpatient clinics and more likely to use shelter clinics for emergency care. Fifteen percent of both the street and sheltered youth reported going to a doctor’s office for emergency care. None of the sheltered youth and only 0.5% of the street youth reported using mobile health vans for emergency care. Effect of Having a Regular Source of Care Sheltered youth who did not have a source of routine care were more likely to report seeking emergency care at a hospital emergency department than those with a routine source of health care (Table 2). Teens with a regular source of care were more likely to report seeking emergency care at a doctor’s office or hospital outpatient clinics. These findings suggest that sheltered youth with a source of routine care are more
334
KLEIN ET AL.
JOURNAL OF ADOLESCENT HEALTH Vol. 27, No. 5
Table 1. Demographics and Health Services Use of Sample of Homeless Adolescents (%) Street Youth (n ⫽ 600) Gender Female Male Race/ethnicity White African-American Hispanic Asian Native American Other Health services use Have regular source of care Have regular checkup or health exam within past 2 years Seen in ED in previous year Seen in ED for drugs/alcohol Had serious health problems within past year Source of emergency care Doctor’s office Community health center Hospital outpatient clinic Hospital emergency department Public health department School health clinic Clinic for runaway youth Free youth clinic Shelter clinic Mobile health van Health maintenance organization Other
Sheltered Youth (n ⫽ 640)
p ⱕ.001
40 60
57 43
53.4 29.2 3.9 2 4 7.4
34.4 46.1 8.8 1.9 3.4 5
50 84 36 25 25
63.7 93 29 13 18
ⱕ.05 ⱕ.05 ⱕ.05 ⱕ.05 ⱕ.05
15 8 8 33 6 0.9 2 8 8 0.5 2 10
15 6 15 29 5 0.6 0.6 3 13 0 2 11
.94 .20 ⱕ.001 .15 .52 .78 ⱕ.05 ⱕ.0005 ⱕ.05 23 .85 .63
ⱕ.001
ED ⫽ emergency department.
likely to have continuity between routine and emergency care than sheltered youth without routine sources of care (street youth were not asked to identify their regular sources of care).
Access by Gender for Sheltered Youth Whereas white adolescents were equally represented among both female and male sheltered teens, Afri-
Table 2. Sources of Emergency Care for Sheltered Youth Who Do and Do Not Identify Routine Health Care Sources* (Weighted %)
Source
Have Regular Care (%) (n ⫽ 396)
Do Not Have Regular Care (%) (n ⫽ 244)
p
Doctor’s office Community health center Hospital outpatient clinic Hospital emergency department Public health department Family planning clinic Clinic for runaway youth Free youth clinic Shelter clinic Other
27.3 6.8 19 20.2 4.9 0.2 0.5 4.2 8.4 8.1
9.4 7.5 10.5 35.3 8 0.4 2.4 3.1 11.2 10.8
ⱕ.001 .48 ⱕ.001 ⱕ.001 ⱕ.001 .33 ⱕ.001 .13 ⱕ.01 .02
* Routine health care source ⫽ respondent’s answer to “Do you have a regular doctor or other health care provider, or a place you go to regularly for health care?”
November 2000
HOMELESS AND RUNAWAY YOUTHS’ HEALTH CARE
335
Table 3. Nationally Representative Sample of Sheltered Youth, by Gender and Age (Weighted %) Variable Race/ethnicity White African-American Native American Asian/Pacific Islander Hispanic Other Health Excellent Good Fair Poor Last checkup in past year 1–2 years ago 2⫹ years ago Never Don’t remember Have regular source of health care Usual source of care (n ⫽ 396) Doctor’s office Community health center Hospital outpatient clinic Emergency department Public health clinic Clinic for runaways Free youth clinic Shelter clinic Family Planning clinic Other Last time received care at usual source Past 30 days 1–5 months ago 1–2 years ago More than 2 years ago Don’t remember Source of emergency care Doctor’s office Community health center Hospital outpatient clinic Emergency department Public health clinic Clinic for runaways Free youth clinic Shelter clinic Other Emergency department stay in past 12 months Related to drug/alcohol use Overnight hospital stay in past year Serious health problems in past year Ever had a venereal disease Been tested for AIDS
Total (%)
Male (%)
Female (%)
37.4 42.3 4.1 2.1 9.1 5.0
39.4 35.8 6.0 3.7 9.4 5.7
36.0 46.6 2.9 1.0 9.0 4.5
31.5 42.6 22.6 3.0
36.6 42.4 18.6 2.2
28.3 42.8 25.2 3.5
84.7 6.5 1.9 1.4 5.5 63.7
86.2 5.5 1.5 1.4 5.5 56.2
83.7 7.2 2.1 1.4 5.6 68.6
36.7 14.1 20.0 1.6 7.4 1.9 4.0 6.4 1.6 6.3
33.4 8.2 15.2 3.8 4.4 3.5 6.4 12.9 0.7 11.7
38.4 17.3 22.6 0.4 9.0 1.1 2.7 2.9 2.1 3.4
40.1 37.0 6.8 1.6 3.5
35.0 38.7 6.0 3.4 3.0
43.5 36.7 7.3 0.7 3.8
20.8 6.9 15.8 25.1 5.8 1.2 3.6 9.2 9.0 25.6 14.3 22.6 17.0 10.4 51.9
15.7 3.7 16.9 28.0 4.5 1.2 4.2 13.9 11.9 24.1 19.1 16.8 15.3 7.4 55.0
24.8 9.3 15.5 24.0 6.9 1.1 3.3 6.4 7.3 26.7 11.5 26.5 18.1 12.3 49.9
p
Age ⱕ17 yrs (%)
Age ⬎17 yrs (%)
39.4 38.0 4.9 1.7 10.1 5.8
33.5 50.1 2.5 2.8 7.3 3.4
32.2 40.1 23.7 3.3
30.4 46.5 20.8 2.1
81.5 7.7 2.4 1.6 6.9 67.7
92.6 4.6 0.8 1.1 0.9 56.1
43.4 18.3 17.6 1.3 8.5 0.34 1.3 0.8 0.7 7.7
20.9 4.5 25.7 2.3 4.8 5.6 10.3 19.3 3.7 2.8
32.8 43.1 8.6 1.1 3.7
58.2 24.4 2.9 3.0 0
28.4 9.8 15.2 20.4 6.4 0.8 2.2 3.9 12.1 15.6 18.6 18.1 12.5 8.7 36.1
8.2 2.1 17.6 35.0 5.1 1.9 6.4 19.4 3.9 44.8 11.2 31.4 25.6 13.8 82.6
ⱕ.001
ⱕ.05
ⱕ.001
ⱕ.05
ⱕ.001
.14
ⱕ.001 ⱕ.05 ⱕ.001 ⱕ.001 ⱕ.001 ⱕ.001 ⱕ.001 ⱕ.001 ⱕ.001 ⱕ.01 ⱕ.001 ⱕ.001
ⱕ.001 ⱕ.001 .26 ⱕ.01 ⱕ.005 .97 .19 ⱕ.001 ⱕ.001 .09 ⱕ.005 ⱕ.001 ⱕ.05 ⱕ.001 ⱕ.05
p
ⱕ.001 ⱕ.001 ⱕ.001 ⱕ.001 .06 ⱕ.005 ⱕ.001 ⱕ.001 ⱕ.001 ⱕ.001 ⱕ.001 ⱕ.001
ⱕ.001 ⱕ.001 .07 ⱕ.001 .14 ⱕ.005 ⱕ.001 ⱕ.001 ⱕ.001 ⱕ.001 ⱕ.001 ⱕ.001 ⱕ.001 ⱕ.001 ⱕ.001
yrs ⫽ years.
can-American females significantly outnumbered their male counterparts (Table 3). The largest percentage of the sheltered youth reported that their health was good (42.6%), compared with 31.5% who
reported excellent health and 22.6% who reported fair health. Girls were less likely than boys to rate their health as excellent and more likely to rate their health as fair than were boys (Table 3).
336
KLEIN ET AL.
Eighty-five percent of sheltered youth report having had a checkup within the previous year. A high percentage of both genders reported having a checkup. Sixty-four percent of the adolescents in the shelter-only sample reported having a regular source of health care; the most common provider of which was a doctor’s office (36.7%). Other usual sources of care reported by the shelter sample were: hospital outpatient clinics (20%), community health centers (14.1%), public health clinics (7.4%), shelter clinics (6.4%), other sources of care (6.3%), free youth clinics (4%), clinics for runaway youth (1.9%), family planning clinics (1.6%), and emergency departments (1.6%). Female adolescents living in shelters were more likely than males to report having a usual source of health care. Whereas doctor’s offices were the most commonly cited source of regular care for both genders, females were more likely than males to use a community health center or a hospital outpatient clinic as their regular care source. In contrast, males were more likely than females to use a shelter clinic as a regular source of care (Table 3). Among sheltered youth with a regular source of care, 40.1% reported that they had received care at their usual source within the previous 30 days. Females were more likely than males to report having received care at their usual source within the previous 30 days, but both males and females were equally likely to have received care within the previous year. Girls were also more likely than boys to report that when they needed emergency care they would use a doctor’s office or a community health center, but less likely to report that their source of emergency care was an emergency department. One-quarter of sheltered adolescents had used the emergency department while away from home in the previous year, with males and females reporting this behavior in similar proportions. Males, however, were more likely to report that their stay was due to drug or alcohol use. Over one-fifth of all sheltered adolescents reported an overnight hospital stay in the past year, but girls were more likely than boys to report this type of overnight stay. Seventeen percent of sheltered teens reported having had serious health problems in the previous year, although females were more likely than males to report such problems in this time frame. Access by Age for Sheltered Youth Whereas the ratio of boys to girls was similar for sheltered adolescents over 17 years of age, more sheltered adolescents who were aged 17 years and
JOURNAL OF ADOLESCENT HEALTH Vol. 27, No. 5
under were female. In addition, whereas white and African-American adolescents were equally represented among those aged 17 years and under, half of those over 17 years of age were African-American and only one-third were white (Table 3). Although almost all older sheltered adolescents reported having had a checkup in the previous year, fewer younger teens reported this. Nonetheless, younger adolescents were more likely to report having a regular source of health care, and that source was more likely to be a doctor’s office. The most frequently cited usual source of care for the older sheltered youth was a hospital outpatient clinic. Older sheltered youth were also more likely to report having received care at their usual source within the past 30 days. For younger sheltered youth the most common source of emergency care was a doctor’s office. Conversely, the most common source of emergency care for older sheltered youth was the emergency department. One-fifth of older sheltered youth reported using shelter clinics for emergency care, whereas only 4% of those in the younger age group did. Older sheltered adolescents were much more likely to report having been treated in the emergency department while they were away from home than younger teens, but younger adolescents were more likely to report that their emergency department stay was due to drug or alcohol use. Older sheltered youth were also more likely to have stayed in the hospital overnight while away from home, and were more likely to report having experienced serious health problems in the previous year.
Discussion This study is the first to assess access to health care for a representative sample of adolescents in shelters and a large multicity sample on the street. Not surprisingly, half of street youth and over one-third of sheltered youth did not have a source of routine health care. In comparison, based on parental report, only 15% of adolescents aged 11–17 years in a nationally representative sample of households did not have a source of routine health care (10). However, a significant proportion of street and shelter youth in this study did identify a source of routine care. In addition, street youth reported having used care in the past year at a similar rate, and sheltered youth reported using care at a rate higher than that of domiciled adolescents (11). Street youth consistently reported having more
November 2000
serious health problems than sheltered youth, as well as high rates of emergency department visits related to alcohol or drug use. In addition, our findings are similar to those reported in a recent study of health status and access to care among a shelter-based sample of street and system youth (youth involved in an institutional or foster care system) in Baltimore. In that study, Ensign and Santelli found similar rates of emergency department usage, and as in our analysis, street youth in that study were also more likely to have used the emergency department in the past year in connection to their higher rates of injuries and substance abuse (12). Although fewer street youth than sheltered youth in our study reported having a clinician visit within the past 2 years, those rates are nearly as high and do not differ significantly from those reported by nationally representative samples of in-school adolescents (11). Because the length of time away from home may vary owing to the transience and turmoil of homelessness, it is possible that youth self-report may reflect services provided while domiciled or during an interruption of street life. In addition, we could not determine from our survey the proportion of visits that were triggered by mandated examinations in shelter settings. Nonetheless, although fewer adolescents had regular sources of care than reported having had a checkup, the proportions with regular care utilization and with emergency department and other care use, were both high. The results of our study demonstrate the importance of linking health services to programs seeking to meet the needs of homeless adolescents. In a study of youth in an outreach program in one shelter, 19% of adolescents reported that medical needs were their main concern (13). Similarly, 57% of youth in another shelter sample had received health care services within the previous month, and one-quarter of these youth identified several barriers to their access to care (14). Those studies were limited in that they addressed the needs of adolescents in a single geographic area and identified youth already seeking health care. Two previous studies illustrate the disparity between youth shelter agencies’ perceived lack of emphasis on health care delivery and the needs of this high-risk population. In a U.S. General Accounting Office study of interventions for high-risk youth, health services were not identified by program officials as important elements of their program’s success (15). However, despite this lack of prioritization of health needs by programs designed to assess the needs of youth at risk, as many as 25% of homeless
HOMELESS AND RUNAWAY YOUTHS’ HEALTH CARE
337
and runaway youth were reported as having received medical services directly or through referral, in a national study of homeless youth seeking services from shelters (16). Those services included family planning, psychiatric, and psychological services. It is not clear whether those services included preventive care or whether the services were part of, or linked with, shelter services. Furthermore, among the runaway and homeless youth studied, only 3% received treatment or referral for drug and alcohol abuse, although 22% reported such problems (16). In contrast, a recent Los Angeles study found that 71% of homeless youth had an alcohol and/or illicit drug abuse disorder, according to DSM-III criteria (17). Continuity of care also declined sharply upon most youths’ departure from shelters; in one study, almost half (46%) of homeless youth were not scheduled to receive any follow-up services, and only 10% of homeless and 8% of runway youth were scheduled to receive follow-up medical care (16). The young women in our shelter sample were more likely than the young men to report having and using a usual source of health care. They were also more likely to have had a serious health problem or to have reported worse health status than were males. Whereas previous studies have shown females to be more at risk and to report greater fear of being assaulted with a knife or sexually assaulted, no significant differences existed in the amount of physical violence with or without other weapons to which males and females were exposed to on the street (18). In addition, no gender difference was found among a sample of runaway youth in Minnesota when asked about barriers that they perceived when attempting to obtain health care (14). Although the younger adolescents in our study were less likely to have had a checkup in the previous year, older adolescents were less likely to have a usual source of care. Older adolescents were also more likely to have had serious health problems and to have used an emergency department in the previous year. These findings are supported by a recent study of HIV-risk behavior in a street-based sample of homeless and runaway youth in New York City, which found that whereas older age segments of youth were more likely to be at high risk, they were also least likely to be in contact with prevention services (19). Many homeless and runaway youth participate in lifestyles that lead to serious health problems (1–5). Owing to their precarious or nonexistent housing status, homeless youth are at high risk for exposure to violence as both witnesses and victims (18) and make frequent emergency room visits. Our study
338
KLEIN ET AL.
indicated that homeless youth with a source of routine health care are more likely to perceive greater accessibility of emergency care, are more likely to report continuity between routine and emergency care, and are more likely to use non-emergency sites for their care. In contrast, homeless youth without routine health care sources are more likely to identify hospital emergency departments than primary care, continuity sites as their major source of emergency care. Emergency departments tend to be unable to provide continuous care or assist with regard to adolescents’ living situations. Homeless adolescents also may seek care for reasons relating to violence or mental health, which may precipitate use of the emergency department. Although we do not know to what extent utilization by these youth is due to these factors, about one-quarter of the homeless adolescents in our study had been treated in the emergency department in the past year. Traditionally, emergency departments have been shown to function as a safety net, providing care and addressing needs of indigent and otherwise underserved populations (20). High levels of emergency department use have been correlated not only with an inverse relationship to primary care access (21), but also with the provision of almshouse needs: food, transitory shelter, and brief contact with those who provide temporary relief from the stresses of homelessness and its comorbidities. Furthermore, these services are largely undocumented or underreported within the emergency services use literature, as they are frequently offered informally by nurses or other nonphysician personnel (22). Addressing high levels of emergency department use from the dual perspective of both the difficulty in accessing primary care and the provision of basic needs may shed light on the reasons behind what has previously been identified as inappropriate use of this care site. Special free clinics, shelter clinics, and runaway youth programs are used by only 12% of sheltered youth for routine health care. These findings suggest that many youth for whom these programs are designed may not be using them. We do not know from this study whether failure to identify these services is due to program availability, insufficient outreach, street adolescents’ distrust of institutions, difficulty in finding or traveling to care sites, or other barriers. Nonetheless, understanding the reasons for these low levels of utilization will be important to better reach these high-risk youth with the services designed for them. Most cities still have relatively few special services for homeless youth (6). Our study has several limitations. It relies on
JOURNAL OF ADOLESCENT HEALTH Vol. 27, No. 5
adolescents’ self-report and recall of the services they have used, and our data collection was constrained by the circumstances and environment required to interact with and question street and sheltered youth. Our sample of street youth may be biased by this selection process because youth were recruited by outreach workers and introduced to the field interviewers. Thus, youth living in vehicles, abandoned buildings, or other facilities and who were less visible to, or simply avoided, outreach workers were beyond the reach of this study. Fear of disclosure or of legal sanctions may have resulted in underreporting of adolescents’ behaviors. In addition, adolescents may have varied in how they describe particular health facilities. For example, a street teen might have identified a site as a runaway clinic, whereas a young person living in a shelter may have labeled the same site a shelter clinic, both cases reflecting their perceptions of the linkages between these programs. In addition, although we sampled adolescents from shelters in a representative manner, crossover may exist between youth in shelters and street youth, who may in fact be the same individuals defined at different points in time. Owing to the possibility of inclusion in either group, youth on the street may reflect back to sheltermandated experiences in their self-report of frequency and sources of care. Shelters may also differ in their definitions, purposes, and allowances for length of stay, and by whether they are mandated to provide medical care. We did not obtain information describing the presence of onsite or program-linked health services at these shelters. Furthermore, although the shelters that we selected in metropolitan areas provided the necessary access to street and sheltered youth, this factor limits our findings to those youth residing in urban areas, and may not be applicable to homeless youth in rural areas. The sample of shelters that chose to participate may also have been biased in ways we were not able to detect. In addition, these results from 1992 may not be generalizable to homeless or sheltered youth in 2000, as both the population and available services may have changed in a variety of ways. Although these issues cannot be fully resolved from our study, they highlight the importance of linking integrated services to use of care, especially in emergency departments and other acute health care or shelter settings. Runaway and homeless adolescents are at risk for serious physical, psychological, and emotional problems. Although it is believed that homeless youth tend to have few treatment options available (6), many at-risk adolescents have contacts with both
November 2000
routine and emergency health care. Youth on the street may experience a series of destabilizing events leading to exit from street life or a reestablishment of life on the street (23). To the degree that chronic and acute health issues lead to destabilization, appropriate service linkages may assist these at-risk youth in their exit from the street. Furthermore, although homeless youth studied in some areas have verbalized the presence of barriers to care, the service utilization patterns of those youth are strongly associated with use of the shelter system (24). Effective outreach programs, including the provision of both direct services and information to homeless youth populations, may help reduce the barriers they face in obtaining health care. Further exploration into the availability and integration of incentives to obtaining primary care, such as the use of complementary or alternative medicine by homeless youth, may encourage youth to seek out sources of primary care (25). In addition, increasing emergency and outpatient provider awareness of both homelessness in adolescence and its biologic, social, and emotional comorbidities may be useful in improving access to health care for homeless and runaway youth. Integration of effective health services with shelter, street, and health, safety, and social services also may help promote better continuity of care for homeless youth. Finally, ongoing surveillance of the needs of homeless adolescents will be needed to develop and improve policies addressing homeless and runaway teens’ access to care. This study was funded in part by a grant from the National Institute on Drug Abuse (Grant DA08849), the Administration on Children, Youth and Families (Contract 105-90-1703), and by the Strong Children’s Research Center Summer Student Research Program (National Heart Lung and Blood Institute Grant T35HL07754). Dr. Klein is also supported by a Robert Wood Johnson Faculty Scholars Award. This study was presented in part at the Society for Adolescent Medicine annual meeting, Los Angeles, California, March 18, 1999.
References 1. Sherman DJ. The neglected health care needs of street youth. Public Health Rep 1992;107:433– 40. 2. National Runaway Switchboard Runaway Curriculum. Information packet. Chicago, IL, 1992. 3. Hersch P. Coming of age on the city streets. Psychol Today 1988;22:28 –37. 4. Rotheram-Borus MJ, Mahler KA, Koopman C, Langabeer K. Sexual abuse history and associated multiple risk behavior in adolescent runaways. Am J Orthopsych 1996;66:390 – 400. 5. Ringwalt CL, Greene JM, Robertson M, McPheeters M. The prevalence of homelessness among adolescents in the United States. Am J Public Health 1998;88:1325–9.
HOMELESS AND RUNAWAY YOUTHS’ HEALTH CARE
339
6. Morey MA, Friedman LS. Health care needs of homeless adolescents. Curr Opin Pediatrics 1993;5:395–9. 7. Farrow MD, Deisher RW, Brown R, et al. Health and health needs of homeless and runaway youth. J Adolesc Health 1992;13:717–26. 8. Greene JM, Ennet ST, Ringwalt CL. Substance use among runaway and homeless youth in three national samples. Am J Public Health 1997;87:229 –35. 9. SAS Institute, Inc. SAS/STAT User’s Guide, Version 6, 4th ed. Cary, NC: SAS Institute, Inc., 1989. 10. Hedberg VA, Byrd RS, Klein JD, et al. The role of community health centers in providing preventive care to adolescents. Arch Pediatr Adolesc Med 1996;150:603– 8. 11. Klein JD, Wilson KM, McNulty M, et al. Access to medical care for adolescents: Results from the 1997 Commonwealth Fund survey of the health of adolescent girls. J Adolesc Health 1999;25:120 –30. 12. Ensign J, Santelli J. Shelter-based homeless youth. Arch Pediatr Adolesc Med 1997;151:817–23. 13. Saltonstall MB. Bridge over troubled waters/runaways and youth on the streets of Boston: One agency’s response. Boston: Boston Globe Foundation, 1984. 14. Geber GM. Barriers to health care for street youth. J Adolesc Health 1997;21:287–90. 15. United States General Accounting Office Report to the Chairman, Subcommittee on Oversight of Government Management, Committee on Governmental Affairs, U.S. Senate. Residential care: Some high-risk youth benefit, but more study needed. January 1994, GAO/HEHS-94-56. 16. United States General Accounting Office Report to the Honorable Paul Simon, U.S. Senate. Homelessness: Homeless and runaway youth receiving services at federally funded shelters. December 1989, GAO/HRD-90-45. 17. Kipke M, Montgomery S, Simon T, Iverson E. “Substance abuse” disorders among runaway and homeless youth. Subst Use Misuse 1997;32:969 – 86. 18. Kipke M, Simon T, Montgomery S, et al. Homeless youth and their exposure to and involvement in violence while living on the streets. J Adolesc Health 1997;20:360 –7. 19. Clatts MC, Davis WR, Sotheran JL, Atillasoy A. Correlates and distribution of HIV risk behaviors among homeless youths in New York City: Implications for prevention and policy. Child Welfare 1998;77:195–207. 20. Iserson KV, Kastre TY. Are emergency departments really a “safety net” for the medically indigent? Am J Emerg Med 1996;14:1–5. 21. Grumbach K, Keane D, Bindman A. Primary care and public emergency department overcrowding. Am J Public Health 1993;83:372– 8. 22. Malone R. Whither the almshouse? Overutilization and the role of the emergency department. J Health Politics Policy Law 1998;23:795– 832. 23. Auerswald C, Eyre S. Initiation into and extrication from life on the streets: A qualitative study of youth. J Adolesc Health 1999;24:89. 24. De Rosa CJ, Montgomery SB, Kipke MD, et al. Service utilization among homeless and runaway youth in Los Angeles, California: Rates and reasons. J Adolesc Health 1999;24:449 – 58. 25. Breuner CC. Alternative medicine use by homeless youth. Arch Pediatr Adolesc Med 1998;152:1071–5.