Adolescent homelessness is a distressing social problem. Approximately 1.5 to 2 million homeless adolescent persons live on the streets in the United States (Bucher, 2008
); homelessness among young persons is more common than homelessness among older adults (Ensign, 2004
). Young persons often leave their family of origin due to parental conflict; violence between family members; or physical, sexual, or emotional abuse by a family member (Johnson, Rew, & Sternglanz, 2006
; Rosenthal, Mallett, & Myers, 2006
). Consequently, they leave homes of risk to encounter risky living situations on the streets.
Homeless young adults are highly vulnerable to negative health consequences because of the realities of street life, which include substance use, risky sexual behavior, unhygienic living conditions (Ensign & Bell, 2004
), and poor access to health care (Ensign & Panke, 2002
). Homeless young persons also are at risk for sexual and physical abuse (Alexander & Schrauben, 2006
), both of which have been associated with poorer health (Wenzel, Hambarsoomian, D'Amico, Ellison, & Tucker, 2006
). In a survey of homeless adolescents, over 60% of the participants reported a history of sexual abuse, 56.3% had injected drugs, and 12.3% had attempted suicide at least once (Rew, Taylor-Seehafer, & Fitzgerald, 2001
Other negative health consequences experienced by homeless young adults include sexually transmitted infections, poorly controlled chronic mental illness, and lack of immunization for conditions, such as hepatitis A and hepatitis B (Hudson, Nyamathi, & Sweat, 2008
). Homeless young adults also are at increased risk for the development of respiratory disease, thought to be related to exposure to tuberculosis and influenza (Haldenby, Berman, & Forchuk, 2007
). In addition to the mentioned problems, homeless young adults often experience posttraumatic stress disorder, skin disorders (Rew et al., 2001
), foot problems, and lice (Kelly & Caputo, 2007
Homeless persons are more likely to be admitted to the hospital and have increased durations of hospitalization than those of nonhomeless persons due to negative health consequences associated with street living. Despite their high burden of illness, homeless persons have fewer ambulatory care encounters than those of nonhomeless persons (Kushel, Vittinghoff, & Haas, 2001
). Nearly half of all homeless young persons have no regular source of health care (Sneller et al., 2008
There are several reasons homeless young adults may not receive regular health care; these include fear of social service agency notification, fear of legal intervention, lack of familiarity with respect to how to access health care resources, and lack of affordable health insurance (Klein et al., 2000
). Lack of insurance, transportation problems, and lack of respect from providers were some of the barriers to health care identified in a study of the perceptions of homeless women living in Seattle (Ensign & Panke, 2002
). Lack of insurance and lack of a regular source of care have been associated with poor access to health care among homeless women (Lim, Andersen, Leake, Cunningham, & Gelberg, 2002
Carlson, Sugano, Millstein, and Auerswald (2006)
reported that homeless youth and young adults access targeted services depending on their stage of homelessness. When homeless young persons are in stasis or well integrated into street culture, accessing health-related services is not a priority; however, in the stage of disequilibrium, crises are frequent, and it is in crisis mode that the homeless seek mental health, drug abuse, and medical services. Therefore, their perspectives about quality of services might be less than ideal.
In addition to the barriers mentioned earlier, studies to address health care utilization specifically among homeless young adults have revealed other barriers—lack of knowledge regarding use of insurance (for those who have insurance), confidentiality issues, and the perception that health care systems have restrictive rules and regulations–that have been associated with poor service utilization (De Rosa et al., 1999
). Lack of appropriate providers, lack of health care facilities, cultural and spiritual barriers, language barriers, and distrust of health care providers have been identified also as barriers by homeless young persons (Christiani, Hudson, Nyamathi, Mutere, & Sweat, 2008
). In another study, lack of insurance, lack of the ability to pay for services, stigmatization, and the sense of disrespect toward the homeless condition have been identified as barriers to health care delivery (Martins, 2008
). Martins (2008)
suggested that there are two separate, but not equal, health care delivery systems and that a homeless person does not receive the same degree of respect that is given to nonhomeless persons.
The perceptions of how homeless persons view the health care system have not been well studied. In one study, participants reported that when they felt discrimination relative to their homeless status, they were not likely to seek health care (Wen, Hudak, & Hwang, 2007
). These authors concluded that homeless persons' perceptions of discrimination determine whether or not they access a health care system. An ethnic difference exists, such that homeless young persons, who were White, acknowledged homelessness as stigmatizing but did not reject the label of homeless
, unlike African American youth (Hickler & Auerswald, 2009
). White youth and young adults embraced their slovenly appearance, poor hygiene, tattoos, and body piercings. They congregated to form social networks, establish shared identities, and share knowledge regarding street life among themselves. They knew supportive professionals, resources, and services.
Thus far, several barriers faced by homeless persons (in particular, young homeless persons) have been identified. To improve health care access among homeless young adults, it is also important to address factors that might facilitate health care delivery. Barkin, Balkrishnan, Manuel, Andersen, and Gelberg (2003)
showed that the possession of public health insurance improved health care utilization among homeless adolescents and young adults. In another study, the relationship between homelessness and health care access was examined, with the conclusion that strategies to improve health outcomes among emancipated youth should address issues such as lack of health insurance and housing instability (Kushel, Yen, Gee, & Courtney, 2007
). It has been suggested also that Medicaid and the State Children's Health Insurance Program, in conjunction with financing from other public programs, should be used to facilitate health care access to young adults leaving foster care (English, Morreale, & Larsen, 2003
Some other facilitators which may improve health care access for the homeless population include the provision of needle exchange programs, vaccination prevention, and assertive outreach within the community (Wright & Tompkins, 2006
). Behavior-oriented interventions of health promotion using counseling to help homeless adolescents reduce risky behaviors may result in improved health among this group (Flick & Rohnsch, 2007
). There is a growing assertion that improvements should be made with respect to the provision of quality care for the homeless young adults living in the United States (Ensign, 2004
) and that social policy for this group should be implemented at the grass-roots community level (Rew et al., 2001
). One way to achieve high-quality programs designed to improve health care for homeless adults is to solicit these adults' input in program development. The purpose of this article was to gain a further understanding of the perceptions of homeless youth regarding their health-care-seeking behaviors and included the following research questions:
- What are homeless young adults' perspectives on facilitators and barriers to receiving health care?
- How can existing homeless youth and young-adult-centered health care programs be improved?
This study is based on the comprehensive health seeking and coping paradigm (Nyamathi, 1989
). Variables such as demographic factors, situational factors, or personal resources situate and characterize one's environment and how they affect an individual's health-seeking and coping responses. The framework guiding this research concerns a situational factor (homelessness among young adults) and available resources (social support, financial security, and physical and emotional health) and provides some understanding on how homeless young adults might view facilitators and barriers to receiving health care.