Access to health services

Addressing determinants of sexually transmitted and blood borne infections among street-involved youth

Background

This fact sheet examines access to health services as a determinant of sexually transmitted and blood borne infection (STBBI) vulnerability among street-involved youth in Canada. It is one in a series based on an analysis of current literature and findings from Cycle 6 of the Enhanced Street Youth Surveillance system.^{Footnote 1}Others address mental health and mental illness; unstable housing and homelessness; education and employment; and experiences with the criminal justice system.

These fact sheets provide considerations for community organizations, public health professionals and federal, provincial and territorial governments of ways to address determinants of vulnerability to and resilience against STBBIs among street-involved youth. Street-involved youth are defined as youth aged 15 to 24 who have no permanent home and spend significant time on the street.^{Footnote 2}

What is the link between access to health services and STBBI vulnerability among street-involved youth in Canada?

• Street-involved youth may experience many negative health outcomes caused by poor living conditions on the street including: frostbite; malnutrition; poor mental health; mental illness; STBBIs; substance use; and thoughts of or attempts at suicide.^{Footnote 3}
• Street-involved youth may experience barriers that affect their ability to obtain testing, treatment or care, including: long waiting lists; limited or inconvenient hours of operation; transportation; access to resources (e.g., money); personal behaviour that is non-compliant with a program's rules; and location of services.^{Footnote 4}
• The biggest perceived formal health care barriers among street-involved youth include not having identification documents, a health card, or medical insurance.^{Footnote 5}
• Attitudinal barriers to health services include: stigma; perception that health care providers are unresponsive and judgmental; mistrust of health care system; embarrassment; and fear of rejection.Footnote 6 These barriers can affect the willingness of street-involved youth to talk to health care providers and get tested for STBBIs.
• Street-involved youth are more likely to access emergency health services such as hospitals and walk-in clinics than preventive services such as family physicians.^{Footnote 7} Those  who live on the street are also more likely to use mobile clinics (e.g., a van or bus) during non-standard business hours.
• Street-involved youth include an over-representation of various minority groups (e.g., Aboriginal, lesbian, gay, bisexual, transgender or questioning (LGBTQ), ethnocultural minorities). These groups face unique barriers to accessing health care, such as homophobia, racism and lack of culturally appropriate services. Multiple layers of discrimination can compound obstacles to accessing health services and information about STBBIs.^{Footnote 8}
• Poor mental health (e.g., low self-esteem, poor body image) and mental illness (e.g., depression, addictions) may have an impact on street-involved youth's ability to access to health services. For example, depression or low perceived self-efficacy may affect the ability of street-involved youth to identify the need for treatment for mental illness or STBBIs and support when they need it.^{Footnote 3,Footnote 5} They are also less likely to access mental health care due to stigma and discrimination.^{Footnote 9}
• Not accessing STBBI testing services, treatment or other prevention services can increase the chances of transmission of STBBIs among youth and make them more vulnerable to STBBIs.

What can be done to address access to health services as a determinant of STBBI vulnerability among street-involved youth?

• Increase opportunities for staff training to foster non-judgmental attitudes and behaviours in providing STBBI prevention services for street-involved youth. For example, staff can be coached to reflect on their own values and belief systems regarding street-involved youth and create strategies for building trust and rapport. Reflecting on personal values, attitudes, and beliefs can help recognize how these factors might influence how health services are being provided.
• Provide STBBI prevention services in a variety of locations. For example, establish mobile services to bring testing for STBBIs to street-involved youth. Establishing multiple points of access within the community at sites where street-involved youth are located may reduce barriers to services and enhance their ability to access and engage in these services.
• Raise awareness about available STBBI prevention programs and services. For example, collaborate with local program providers and other community organizations to host a health fair where street-involved youth can participate in activities, learn about local STBBI prevention services and community resources, and develop a tailored "health plan" with public health professionals. Raising awareness of available services and resources increases the likelihood of accessing these services in the future.
• Use social media, print advertisements and other online resources to involve street-involved youth in a discussion about STBBIs and other related health topics. For example, use bulletin-boards, flyers, websites or business cards to announce local health events such as STBBI clinic testing or screening dates and upcoming health campaigns. Through different media sources, street-involved youth can learn how to access information and local resources available to them.
• Engage street-involved youth in the development of STBBI prevention programs. For example, recruit them as health ambassadors or peer educators to identify priority health concerns and assist in the planning, development and implementation of programs. Engaging street-involved youth in all aspects of the project can be effective in promoting a sense of belonging and resiliency.
• Establish partnerships and collaborate across organizations to ensure a continuum of STBBI prevention, care and programming. For example, organize a local community forum where service providers and community partners across sectors can meet, exchange ideas, share promising practices and identify areas for action to prevent STBBIs. Establishing a collaborative network can influence existing programs and services to work in a more efficient and integrated way to support street-involved youth in the community.

Promising practices in supporting access to health services among street-involved youth

The following are examples of programs and resources which show promise in addressing determinants of STBBI vulnerability and building resilience among street-involved youth.

• Central Toronto Community Health Centres (Toronto, Ontario)
  The Central Toronto Community Health Centres (CTCHC) communities of Queen West and Shout provide comprehensive health services for homeless and street-involved youth under the age of 25 in Toronto. The West Toronto Hepatitis C Support Program offers peer-led hepatitis C support groups that cover topics such as HIV and STI co-infection, access to treatment and nutrition. The Shout Clinic offers treatment for disease and illness and addresses the broader socio-cultural and economic factors that influence health, such as housing, employment and education. Both programs engage street-involved youth in the planning and delivery of services.
• Chez Pops, Dans La Rue (Montreal, Quebec)
  Dans La Rue is a community-based organization. It works with street-involved youth and youth at risk aged 12 to 25. The Chez Pops Day Centre is staffed by a registered nurse and psychologists to consult with and support youth who would not otherwise seek health care. Nurses provide education and prevention information, as well as referrals to local health centres and hospitals when required. Psychologists provide clinical consulting services to help assess high-risk situations and protective needs. They also assess available services for street-involved youth and facilitate preventive care.
• EXIT Community Outreach, Wood's Homes (Calgary, Alberta)
  EXIT is a storefront, outreach and mobile van service located in downtown Calgary. It assists youth aged 12 to 24 who have run away from home, are at risk of self-harm, or are involved with sexual exploitation. Through counselling and service referral, the program promotes the health of youth while they live on the street and provides assistance when they choose to leave the streets.
• Hepatitis C Prevention Program, Youth Services Bureau of Ottawa (Ottawa, Ontario)
  This program provides information through educational workshops and resources for youth aged 16 to 20 who are unstably housed, live in poverty, or are living on the streets. The program uses a peer to peer model to teach youth about the risks of hepatitis C virus (HCV) and other sexually transmitted infections, the steps to take to prevent infection and various treatment options. It also offers extended access to drop-in where youth can access testing, peer to peer support and an HCV nurse.
• HIV & Youth Peer Engagement Program (HYPE), AIDS Committee Durham (Durham Region, Ontario)
  AIDS Committee of Durham provides HIV/AIDS education and support services in the region of Durham. The HYPE program targets youth aged 13 to 25 and includes workshops, presentations, and training for service providers on the needs of vulnerable youth, including HIV/AIDS issues and stigma, in order to increase public health service accessibility.
• PAIR au VIH, CACTUS Montreal (Montreal, Quebec)
  This program uses a peer helper approach to increase HIV testing and access to the health care system, and encourage street-involved youth to know their HIV status. CACTUS Montreal also aims to improve and strengthen collaboration in order to combat discrimination against street-involved youth.
• Resource Assistance for Youth (Winnipeg, Manitoba) Resource Assistance for Youth (RaY) is a non-profit street-level agency working with street-entrenched and homeless youth up to the age of 29. RaY offers a range of programs to meet the needs of youth, including: street outreach; basic needs; addictions and mental health support; housing and emergency shelter; and recreational programming. The outreach team provides youth with information, resources and options to improve their quality of life and reduce the risks associated with life on the streets.
• SEXégalité, Approuvé!, Unité d'intervention mobile L'Anonyme Inc. (Montreal, Quebec)
  This program uses a mobile outreach bus to provide HIV/AIDS prevention services to at-risk youth aged 14 to 30 years. L'Anonyme partners with local public health and health care services to promote screening for HIV and other STBBIs, to distribute awareness materials, and to create interactive videos on STBBIs.

Contact

• Centre for Communicable Diseases and Infection Control
  Public Health Agency of Canada
  Ottawa, ON K1A 0K9
• E-mail: ccdic-clmti@phac-aspc.gc.ca

Endnotes