The vulnerability of young homeless people
Authors: Jessica A Heerde, George C Patton
Journal: The Lancet Public Health (2020)

Growing inequality and greater austerity in social policies have had profound effects on health and wellbeing in many countries. One devastating consequence that further compounds inequality is homelessness—which continues to rise globally. The prevalence of youth homelessness is particularly concerning, given its disruptive effects on education, transition to employment, and establishing a stable and nurturing social network. Homeless young people face a high mortality as a result of multimorbidities from mental health problems, injury, violence, communicable and non-communicable diseases, and substance abuse.1Aldridge RW Story A Hwang SW et al.Morbidity and mortality in homeless individuals, prisoners, sex workers, and individuals with substance use disorders in high-income countries: a systematic review and meta-analysis.Lancet. 2018; 391: 241-250Summary Full Text Full Text PDF PubMed Scopus (347) Google Scholar, 2Edidin JP Ganim Z Hunter SJ Karnik NS The mental and physical health of homeless youth: a literature review.Child Psychiatry Hum Dev. 2012; 43: 354-375Crossref PubMed Scopus (256) Google Scholar Research into the injustice of youth homelessness is hindered by the difficulty in gaining sound information on a population group who are difficult to sample, engage, and trace, either in descriptive or intervention studies.3Heerde JA Bailey JA Toumbourou JW Rowland B Catalano RF Longitudinal associations between early-mid adolescent risk and protective factors and young adult homelessness in Australia and the United States.Prev Sci. 2020; 21: 557-567Crossref Scopus (9) Google Scholar, 4van den Bree MB Shelton K Bonner A Moss S Thomas H Taylor PJ A longitudinal population-based study of factors in adolescence predicting homelessness in young adulthood.J Adolesc Health. 2009; 45: 571-578Summary Full Text Full Text PDF PubMed Scopus (71) Google Scholar In this context, Sandra Nilsson and colleagues5Nilsson SF Nordentoft M Fazel S Laursen TM Homelessness and police-recorded crime victimisation: a nationwide, register-based cohort study.Lancet Public Health. 2020; 5: e333-e341Summary Full Text Full Text PDF PubMed Scopus (8) Google Scholar have used new strategies of data linkage to bridge part of this research gap. In their study, published in The Lancet Public Health, they retrospectively examined associations between homeless shelter contact and police-recorded crime victimisation using population-level linked administrative records in Denmark. They effectively tracked 1 182 749 individuals aged 15–35 years across 9 831 776 person-years, among which 184 813 people had at least one crime victimisation incident and 4286 individuals (22 240 person-years) had at least one homeless shelter contact. Rates of victimisation were high among people with homeless shelter contact (cumulative probabilities 23% [95% CI 21–26] in females and 16% [15–18] in males within 5 years of first contact). Additionally, compared with the general population, rates of violent victimisation were significantly increased among people with homeless shelter contact (incidence rate ratio 7·2 [95% CI 6·3–8·2] in females and 3·6 [3·2–4·0] in males), and risk was further increased in people who also had a psychiatric diagnosis. The findings illustrate the potential of data-linkage studies to document the health and health risks of a disadvantaged group who would otherwise be difficult to study. Their novel methods still have limitations, acknowledged by the authors, with the primary outcome of victimisation unlikely to be fully ascertained and the sampling only capturing that portion of the homeless population accessing shelters. Nilsson and colleagues' study5Nilsson SF Nordentoft M Fazel S Laursen TM Homelessness and police-recorded crime victimisation: a nationwide, register-based cohort study.Lancet Public Health. 2020; 5: e333-e341Summary Full Text Full Text PDF PubMed Scopus (8) Google Scholar begs the question of how we might keep young homeless people safe. This population also lacks regular and consistent medical care, access to essential medications, and even basic hygiene and sanitation. Sexual exploitation increases risks for sexually transmitted infections and unplanned pregnancies. Many young homeless people accept physical and sexual victimisation as normal when it occurs, and later experience shame and emotional disengagement.6Heerde JA Pallotta-Chiarolli M "I'd rather injure somebody else than get injured": an introduction to the study of exposure to physical violence among young people experiencing homelessness.J Youth Stud. 2020; 23: 406-429Crossref Scopus (9) Google Scholar, 7Kipke MD Simon TR Montgomery SB Unger JB Iversen EF Homeless youth and their exposure to and involvement in violence while living on the streets.J Adolesc Health. 1997; 20: 360-367Summary Full Text PDF PubMed Scopus (172) Google Scholar, 8Watson J Understanding survival sex: young women, homelessness and intimate relationships.J Youth Stud. 2011; 14: 639-655Crossref Scopus (50) Google Scholar These experiences compound histories of child and adolescent abuse and further complicate existing mental health problems. Keeping homeless young people safe therefore requires coordinated responses across sectors: provision of safe shelter and accommodation options to mitigate the social and physical risks; re-engagement with education and vocational training; and financial and social support to ensure that a young homeless person can create and sustain their own nurturing social networks. Young homeless people face a service system of unequal provider–client relationships in which their dignity and identity are often devalued.6Heerde JA Pallotta-Chiarolli M "I'd rather injure somebody else than get injured": an introduction to the study of exposure to physical violence among young people experiencing homelessness.J Youth Stud. 2020; 23: 406-429Crossref Scopus (9) Google Scholar, 9Hoffman L Coffey B Dignity and indignation: how people experiencing homelessness view services and providers.Soc Sci J. 2008; 45: 207-222Crossref Scopus (66) Google Scholar Their resulting distrust of service providers commonly brings an unwillingness to engage, becoming a barrier to engagement with mental health and social support services. New approaches are needed. Increasing use of mobile technologies by young homeless people presents options for sensitively and safely providing health resources and support.10Humphry J Homeless and connected: mobile phones and the internet in the lives of homeless Australians. Australian Communications Consumer Action Network, Sydney2014Google Scholar Incorporating integrated models of health care into shelter and other temporary accommodation settings has the potential to ensure the treatment of neglected health problems. Training police, educators, and health practitioners to understand and respond to cumulative trauma will foster safety, trust, and commitment in service system engagement. The work of Nilsson and colleagues5Nilsson SF Nordentoft M Fazel S Laursen TM Homelessness and police-recorded crime victimisation: a nationwide, register-based cohort study.Lancet Public Health. 2020; 5: e333-e341Summary Full Text Full Text PDF PubMed Scopus (8) Google Scholar point us towards future research directions with young homeless people: multisectoral data linkage, either as a stand-alone approach or embedded in more traditional cohort and intervention studies, is likely to provide vital information for service systems. More importantly, their findings point to the need for investment in primary prevention. A focus on groups at high risk would make sense. Those leaving youth justice or out-of-home care are two such groups for which the provision of sustained financial, social, training, and emotional support is essential in the transition to productive and secure adulthood. Equally, for adolescents at risk of early school dropout, especially in a context of family breakdown, schools have important roles in extending educational engagement and ensuring that any transition from school is into vocational training and safe accommodation.3Heerde JA Bailey JA Toumbourou JW Rowland B Catalano RF Longitudinal associations between early-mid adolescent risk and protective factors and young adult homelessness in Australia and the United States.Prev Sci. 2020; 21: 557-567Crossref Scopus (9) Google Scholar It is time for an intersectoral alliance of researchers, policy makers, practitioners, and youth with lived experience of homelessness to come together to end its devastating effects. We declare no competing interests. Homelessness and police-recorded crime victimisation: a nationwide, register-based cohort studyHomeless populations are at substantially increased risk of crime victimisation, highlighting the need for strategic and targeted approaches to prevent homelessness and to help people out of homelessness. Improvements in multiagency working (such as between homeless shelters, health-care services, substance misuse services, and police forces) might be important to reduce the risk of victimisation in marginalised populations, such as those with complex psychiatric or social problems, with experience of homelessness. Full-Text PDF Open Access