Healthcare Access Among Youth Experiencing Homelessness: A Mixed Methods Community Assessment

Background: Youth experiencing homelessness (YEH) have a mortality rate ten times higher than their housed peers with suicide and drug overdose as the leading causes of death (Roy et al, 2004). In addition, YEH experience physical health problems including poor nutrition, dermatologic disorders, respiratory problems, dental disease and sexually transmitted infections (Medlow et al, 2014). Yet, less than 50% of YEH access health care services (Pergamit et al, 2010). Prior research has identified common barriers and facilitators to health service use, but has not examined these from a community perspective, seeking data from multiple stakeholders within a health service ecology. The aim of this study was to understand the service landscape in one community and identify barriers and facilitators to health service.

Methods: We employed a staged mixed methods approach to examine health service use among YEH from the perspectives of multiple stakeholders. First, qualitative data was collected from five focus groups with YEH (n=28) and individual interviews with health providers (n=10) and social service providers (n=7). Then, structured surveys were administered to YEH (n=102), social service casemanagers (n=13), and health providers (n=40). Thematic analysis was conducted to separately analyze focus groups and provider interviews and identify barriers and facilitators, then the principal investigators integrated the results of these analyses. Barriers and facilitators and service use were also examined quantitatively using survey data. Social network maps of youth knowledge and use of different service locations were examined using ucinet software.

Results: Qualitative efforts identified 14 primary health service locations where youth were likely to access health care services including 4 Federally Qualified Health Centers, 7 clinics located in homeless agencies and 3 general care settings -CVS, Walgreens and the emergency room. Network maps showed that YEH service use varied by geographic location, though youth across settings sought care at CVS/Walgreens for various health problems. The youth shelter that provided medical screening as part of intake and provided care on site was linked to the highest levels of service use. Youth and service providers both identified top barriers as cost, transportation, insurance, life stress, and limited knowledge of services. Providers more often identified problems in the system such as lack of trauma informed approaches and lack of flexibility. Youth were more likely than providers to identify weather, being tired, and being in pain as barriers. Mental health and dental care were noted as difficult services to access by YEH and providers.

Implications: Conducting medical screening and follow-up care within homeless serving agencies appears promising but is currently only implemented in one shelter setting. Expanding health service screenings and connections at drop-in centers may facilitate access to a wide range of services, especially mental health and dental care. Partnerships with quick clinics at CVS and Walgreens may ensure access to a network of providers that are located across the city, thereby eliminating transportation and knowledge barriers. Overall, efforts should address top barriers and ensure access to free or at low cost services in locations that reduce transportation and navigation barriers.