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Authors:
Andrew Gunn, Ann Harrison, Tracy Schrader
The authors are members of the Brisbane Youth Service health team.

Abstract:
Homeless youth are among the most needy groups in our community.  Their health problems are many, but their access to health services is generally poor.  This article utilises the experience of the authors establishing and developing a clinic targeted at homeless young people.  Methods used to promote awareness of the clinic, encourage clients to want to attend, and reduce impediments to their access are discussed.  A retrospective review of casenotes (Aug 1991-Jun 1996) provides further information regarding client access to the clinic.

Introduction:
Homeless young people are unable or reluctant to attend mainstream health services for many reasons(1,2).  Health care provision is still often limited to public hospital emergency departments and detention centres, despite worthy efforts to provide health services targeted at this group dating back at least as far as the activities of the N.S.W. Family Planning Association in the 1970's.  In 1989 the "Burdekin Report"(1) resulted in the establishment throughout Australia of a number of health services aiming to meet the special needs of this group.  Unfortunately these services were never numerous or adequately resourced, and many are currently threatened by reduced government funding.

One of these services has been operated by Brisbane Youth Service (B.Y.S.).  This is a community based organization located in the inner-city area of Brisbane which has provided a range of welfare services for disadvantaged young people since 1977.  The health service at B.Y.S. includes a free primary health care clinic, in addition to youth workers specialising in health promotion, education and training.

The B.Y.S. primary health care clinic is staffed by a nurse practitioner with a medical practitioner attending two sessions per week. It is aimed at 12 to 25 year olds who are homeless or at risk of becoming so(3).  This group includes young people sleeping on the streets, in squats or temporary accommodation, and those still living with parents or guardians but lacking personal supports normally provided by a family.  Ensuring that the clinic is accessed by the target group has always been of prime concern.  This article outlines certain strategies which the authors believe have assisted the B.Y.S. clinic to achieve this.

Promoting Awareness of the Clinic's Existence:
Brisbane Youth Service has had four locations since the clinic was established in 1991.  Moving has initially resulted in a reduction of client numbers, while the clients are learning of, and becoming accustomed to, the new address.  Location and visibility do seem to influence client numbers, and having the clinic at a spot where young people already congregate is advantageous.  Operating as part of a larger youth service has helped to achieve this.  Referrals from word of mouth by peers of clients have also been important, although this cannot be relied upon due to the isolation of many homeless young people.

Widely distributed signs, posters and leaflets have appeared helpful, with clients commenting that this was how they learnt of the service.  These seem to attract most interest when designed by young people.  Hand distribution of leaflets was found effective whilst running an outreach clinic, but this method is very labour-intensive.  Advising other agencies that may be accessed by homeless young people of the clinic's existence has also resulted in many referrals.

Encouraging Desire to Access the Clinic:
Once aware of the clinic, homeless young people may still be reluctant to attend.  Many have past experiences of significant betrayals of trust by adults who they might reasonably have expected to help them(1).  Linking the health clinic with a pre-existing youth service with a good reputation on the streets does seem to have proved helpful reducing this credibility problem.

Comments from clients suggest that first impressions of the service are critical, whether this be from youth workers, posters, or simply the appearance of the building housing the clinic.  The young people need to feel that the service is not intimidating or judgmental(4,5) yet has sufficient resources to provide something they want.

Brisbane Youth Service operates under a harm minimisation philosophy.  This means that energy is focused on reducing the harm resulting from a behaviour, rather than extinguishing the behaviour itself.  Consequently, the services offered include a needle exchange, free condoms, and candid educational material.  Many new clients initially attend to obtain these, but ultimately seek health care from the clinic.

Confidentiality issues are also important(4,5,6).  Young people may feel information about them is less likely to be divulged from a clinic clearly separate from mainstream services.  Clients have also commented that they feel less threatened and more comfortable in the clinic than most health care facilities because it has a "non-clinical" appearance.

Youth workers at B.Y.S. encourage immunisation and the availability of free immunisations attracts many clients.  Also, many clients are injecting drug users with a fascination rather than a fear of needles.  This even results in requests to self-immunise.  Review of casenote entries (Aug 1991 to Jun 1996) revealed 32.5% of clients received at least one immunisation, the most common being for hepatitis B (364 immunisations in 187 clients).

The sex of the clinic practitioner may also influence client attendance.  It has been suggested that young women commonly prefer female doctors5, and that a paucity of male health workers discourages young males from presenting(7).  Statistics published from one youth health service do show a very low rate of attendance of male clients to the available female doctor(8).

The B.Y.S. clinic has always been staffed by a female nurse practitioner, and, at various times, has employed both male and female doctors.  Many young women seen in the clinic are happy to talk to male doctors, but do not want to be examined by them.  A past history of sexual abuse by males is common(1,9,10).

Review of 3,202 entries in B.Y.S. casenotes revealed that male and female doctors did have caseloads skewed toward their own sex.  Male doctors saw more male clients (M:F = 51.1:48.9), and female doctors saw more female clients (M:F = 36.6:63.4).  At B.Y.S. the female nurse practitioner can take genital tract swabs and smears.  Our experience has been that this makes it tenable not to have a female doctor, although ideally doctors of each sex should be available.

Reducing Impediments to Access:
Accessibility of health services can be a central issue for young people(4,5).  Geography should not be overlooked when locating a clinic, because homeless young people do rely largely on walking for transport.  Having service providers travel to the young people is occasionally unavoidable but can be very time-consuming.

Using other attractions to bring potential clients closer to the clinic has proved helpful.  The number of clients attending the clinic typically increases on days when B.Y.S. runs activities for young people (e.g. art workshops, massage clinic).  The needle exchange also attracts clients.

Access is influenced by appointment systems5.  The B.Y.S. clinic has never attempted an appointment system more complex than a sheet of paper tacked to the clinic doorframe.  Clients can write their names here if they wish, but, importantly, are always seen regardless of whether they do.  The list of names assists in settling occasional disputes between clients over who should be seen next.

Attendance at the Brisbane Youth Service Clinic:
Six hundred and sixty-five homeless or at risk clients had clinic casenotes generated during the period August 1991 to June 1996 (although many clinic attendances are not recorded because they are informal or occur with unidentified clients).  Clinic casenotes have been reviewed (323 males, 334 females, 3 transsexual identifying as female, 5 sex unrecorded).  Most clients (52.6%) were aged 16 to 20 years.  Six percent were aged under six years.  These were the children of young people.

Clients generally only attended the clinic for a brief period.  Casenote review from 1991 to 1996 found only 16.2% of clients had an interval of greater than 12 months between their first and last attendance at the clinic.  Indeed, nearly half of all clients (307/665 = 46.2%) had just one entry in their clinic file, similar to the experience of a Victorian youth health service8.  Presumably this indicates the transient nature of the client group rather than dissatisfaction with the clinic (although, contrary to our impressions, one study in emergency departments concluded that presentations by the homeless decrease if they are treated compassionately(11)).

Review of casenotes also revealed that 76 clients (45 female, 31 male; 11.3% of total clients) had ten or more clinic consultations, and six clients (5 female, one male) had over fifty consultations recorded.  One role of the clinic is said to be facilitating referral of clients to mainstream services, but some clients appear to find that the specialised clinic meets their on-going needs more satisfactorily than other alternatives.

Conclusion:
The Brisbane Youth Service primary health clinic for homeless and at risk young people has now operated for over six years.  The first task for any clinic targeting this group must always be to ensure that clients can and will access the service.  This article discusses some factors which may influence this.  The authors hope this may be helpful for other services seeking to attract homeless and at risk young people to their facilities, and stimulate useful further debate and research.

Acknowledgements:
The authors wish to thank Brisbane Youth Service staff including Sarah Roberts, Lea McLauchlan, Damian LeGoullon, and Brendan Taylor for their helpful comments on earlier drafts.

References:
1.  Burdekin B, Carter J, Dethless W. Our Homeless Children: Report of the National Inquiry into Homeless Children for the Human Rights and Equal Opportunity Commission. Canberra. AGPS. 1989.
2. Gunn A, Schrader T. Submission to the working party on the identification, assessment, diagnosis, prevention and management of depression in young people. 1996. Clinical Practice Guidelines: Depression in Young People. NH&MRC. Canberra AGPS. March 1997 p125-126.
3.  Harrison A. Brisbane Youth Service: An innovative health program. Qld Nurse 1992; 11:24
4.  Brisbane Youth Service Health Project ed. "Look I'm not an animal, doctor": Homeless young people's experience of the health system. Transitions Nov94-Feb95 4-10.
5.  Wyn, J. Young women and sexually transmitted diseases: the issues for public health. Aust J Public Health 1994; 8:32-39
6.  Carr-Gregg MRC, Sawyer SM, Clarke CF, Bowes G. Caring for the terminally ill adolescent. Med J Aust 1997; 166:255-258
7.  McLean, K. Innovative Health Services for Homeless Youth Program: Evaluation report. July 1993. Qld Health.
8.  McNair R, Brown R. Innovative Perspectives in Youth Health Care. Aust Fam Physician 1996; 25:347-351.
9.  MSJ Keys Young.  Homeless Young Single Women: Supported accommodation and related support services. Canberra AGPS. March 1991
10.  Sibthorpe B, Drinkwater J, Gardner K., Bammer G..  Drug use, binge drinking and attempted suicide among homeless and potentially homeless youth.  Aust N Z J Psychiatry 1995; 29:248-256
11.  Redelmeier DA, Molin J, Tibshirani RJ. A randomised trial of compassionate care for the homeless in an emergency department. Lancet 1995 May 6; 345 (8958):1131-4.

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			This page was last updated on 10th February, 2003.
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