Meeting the health care needs of street-involved youth

Question 1

What is the definition of “street-involved youth”?

Answer 1

A quite broad term, accounting for both varying degrees of homelessness and a wide range of at-risk behaviours. The youth who is not necessarily ‘homeless’ but who is exposed to and experiencing the physical, mental, emotional and social risks of street culture

Question 2

What is absolutely homeless?

Answer 2

Youth who live outdoors, in abandoned buildings or use emergency shelters or hostels

Question 3

What is relatively homeless?

Answer 3

Youth who live in unsafe, inadequate or insecure housing, including a hotel or motel room rented by the month, or stay temporarily with friends or relatives (called ‘couch surfing’).

Question 4

What is the 1999 estimate of street youth in Canada?

Answer 4

~150 000

Question 5

What are reasons for becoming street-involved?

Answer 5

1. Poverty
2. Dysfunctional family life
3. Violence
4. Sexual and physical abuse
5. Underlying mental illness
6. Parental drug use
7. Curiosity

Question 6

What are the risks of being street-involved?

Answer 6

1. Lack of money
2. Lack of food
3. Lack of shelter
4. Early initiation of sexual activity
5. Risk of involvement in sex trade or practicing “survival sex”
6. Substance use
7. STI
8. Violence
9. Sexual abuse

Question 7

What are physical health concerns associated with homelessness?

Answer 7

1. Respiratory problems esp. TB and asthma
2. Dental disease
3. Lice
4. Scabies
5. Atopic dermatitis
6. Impetigo
7. Acne
8. Skin infections from MRSA
9. Foot problems
10. Malnutrition
11. Injuries
12. STI

Question 8

What are mental health concerns associated with homelessness?

Answer 8

1. Mood disorders
2. Bipolar disorder
3. Conduct disorder
4. PTSD
5. Attempted suicide
6. Substance abuse

Question 9

What are important questions to ask on history?

Answer 9

1. Do you consider yourself to be homeless or at risk of becoming homeless?
2. Where do you sleep?
3. Where does your daily food come from?
4. Do you feel safe?
5. Do you know one adult that you can depend on?
6. Try to determine child welfare status
7. Determine whether they are currently connected to a social worker
8. Determine significant adults in their life
9. Assess sources of financial support
10. How do you get your money?

Question 10

What are specific questions to ask during the HEEADSSS?

Answer 10

1. History of homelessness, current living situation (ie, shelter or housing program)
2. History of domestic violence
3. History of abuse
4. Learning disorders and attention-deficit hyperactivity disorder
5. At-risk behaviours, notably:
   a) substance use
   b) survival sex
   c) unprotected sexual intercourse or unprotected sex
6. Involvement with the justice system:
   a) arrests
   b) probation
   c) recently incarcerated
7. Mental health history
8. Dental health
9. Immunizations

Question 11

What areas should not be forgotten on physical exam?

Answer 11

Vitals, height, weight and body mass index
1. Vision and hearing screen

2. Skin (feet in particular). Look for needle tracks and evidence of self-harm
3. Respiratory examination for upper respiratory tract infection and asthma
4. Genitourinary examination for signs and symptoms of sexually transmitted infections
5. Sexual maturity rating

Question 12

What are recommendations for HCP to improve services and outcomes for SIY?

Answer 12

1. Recognize SIY as a heterogeneous population with different degrees of street-involvement. Because these youth present in a variety of health care settings, care providers generally need to be more aware of specific issues and risk factors.
2. Be aware of the mature minor protocols and inform youth of their right to confidentiality. Confidentiality issues should always be reviewed before the formal health encounter.
3. Integrate an initial mental health screening should be integrated into various health care settings, focusing on suicide, self-harm and whether the individual is a risk to others.
4. Determine housing and economic status during history-taking. Many youth are reluctant to reveal this information for fear of stigmatization.
5. Ask whether medications can be purchased and used securely.
6. Ask youth whether they can follow through with referrals. Recognize that SIY live unpredictable lives and follow-up may not occur. Try to prioritize:
7. Address the youth’s most immediate concerns at first visit, then explore others at the next visit.
8. Certain examinations, investigations and treatments can be recommended at first visit if follow-up is not assured (ie, with informed consent, diagnose with either a pelvic examination or a urine-based specimen collection for pregnancy, CT and N gonorrheae). Diagnose and treat CT, gonorrhea and other STIs based on Public Health Agency of Canada guidelines:
   a) If HIV, HBV or HCV risk is identified or suspected (eg, due to sexual exposures, abuse or intravenous drug use), screen for HIV at a minimum at initial visit. Early diagnosis can help prevent spread. Also, be sure to discuss transmission of these pathogens at first visit – there may not be another chance.
9. Health care workers should administer applicable vaccines at any available opportunity. Ask all youth about their immunization status. Advise how to access ‘catch-up’ or new vaccines. Better yet, be prepared to provide them ‘on-the-spot’ in any office setting.
10. Advocate for SIY to receive vaccines that are not covered, through alternative funding sources if available.
11. Keep treatment regimens as simple and straightforward as possible. Make follow-up procedures easier by having some walk-in appointments and evening hours.
12. Learn about youth services in your community so that you can make prompt referrals and initiate collaborative care and support.
13. Advocate for better postgraduate interdisciplinary health care training on issues specific to this population.

Question 13

What are recommendations for governments to improve services and outcomes for SIY?

Answer 13

1. Provide universal coverage of vaccines such as the human papillomma virus vaccine, and fund outreach services and mobile medical vans.
2. Respond to the urgent need for integrated adolescent mental health services throughout the continuum of care for SIY.
3. Prioritize societal issues that place youth at risk of running away (ie, through poverty reduction, improved mental health services and family support).
4. Fund specific interventions (ie, evidence-based programs such as the Foyer Model of transitional housing for SIY).
5. Support networking and partnership development within communities, notably among social services, justice and educational organizations, and housing initiatives to work together locally to prevent homelessness by improving social conditions, strengthening communities, and developing age-specific, targeted interventions and care models that work.