Abstract
This study uses the Minnesota School Survey to determine the odds of preventive health care utilization among youths who have run away, experienced homelessness, or been stably housed.
Although it is well established that youths with unstable housing face increased health risks compared with peers with stable housing, there is considerable heterogeneity in youths’ experiences of housing instability, with implications for health, clinical practice, and policy.1,2 For instance, adolescents who are homeless with their families may have unique health needs compared with those who are unaccompanied,3 and youths who run away may be at particularly high risk for poor health outcomes.4 Given that annual preventive visits are recommended for all adolescents, they may represent an opportunity to explore housing status and address health needs of youths facing housing instability.1,5 To inform clinical practice and interventions, we sought to compare preventive health care utilization among subgroups of youths who have run away, experienced homelessness, or been stably housed.
Methods
We conducted a secondary analysis of data from the Minnesota Student Survey, a statewide survey that anonymously assesses health and well-being among students in public schools, and this has been described in detail elsewhere.4 Eighty-five percent of school districts participated from January 2016 to May 2016, the period used for this analysis. In accordance with federal laws, the Minnesota Student Survey uses passive written parental consent. The University of Minnesota’s institutional review board determined that this secondary analysis of deidentified data was not human subjects research.
Our analytic sample included 8th-grade, 9th-grade, and 11th-grade students who answered all questions regarding housing status, health care use, and demographics. We created 5 mutually exclusive housing groups by combining 2 measures of adolescents’ report of homelessness and runaway experiences in the prior year: (1) stable housing (for youths who had neither run away nor experienced homelessness); (2) runaway (for youths who had run away but had not experienced homelessness); (3) family homelessness (for youths who had experienced family homelessness); (4) unaccompanied homelessness (for youths who had experienced homelessness alone, without family); and (5) both family and unaccompanied homelessness. The survey also assessed students’ preventive health care utilization and demographic characteristics.
We assessed the association between housing experience and receipt of preventive health services using multivariable logistic regression, controlling for demographics (grade in school, sex, race/ethnicity, socioeconomic status, and area of residence). We conducted data analyses from September 2019 to January 2020 using Stata version 15.1 (StataCorp) with 2-tailed tests and an α of .05.
Results
Of the 114 655 youths included in the sample, 40 815 (35.6%) were in 8th grade, 40 691 (35.5%) in 9th grade, and 33 149 (28.9%) in 11th grade. Most participants (81 554 [71.1%]) were white (Table). The Figure shows the prevalence of preventive health services by housing experience. In multivariable models, the odds of receiving preventive visits was not statistically different for youths who had run away (adjusted odds ratio [aOR], 0.94 [95% CI, 0.89-1.00]) and youths who had experienced both family and unaccompanied homelessness (aOR, 0.77 [95% CI, 0.58-1.01]) compared with youths who had been stably housed. Preventive visits were less likely among youths who experienced either family homelessness (aOR, 0.86 [95% CI, 0.81-0.91]) or unaccompanied homelessness (aOR, 0.70 [95% CI, 0.62-0.80]).
Table. Respondent Characteristics, 2016 Minnesota Student Survey.
| Characteristic | No. (%) |
|---|---|
| Preventive care utilization in the last yeara | |
| Yes | 76 754 (66.9) |
| No | 37 901 (33.1) |
| Housing experienceb | |
| Stable housing | 103 489 (90.3) |
| Runaway | 5039 (4.4) |
| Family homelessness | 4972 (4.3) |
| Unaccompanied homelessness | 940 (0.82) |
| Family and unaccompanied homelessness | 215 (0.19) |
| Grade | |
| 8th | 40 815 (35.6) |
| 9th | 40 691 (35.5) |
| 11th | 33 149 (28.9) |
| Race/ethnicityc | |
| American Indian | 1343 (1.2) |
| Asian | 6571 (5.7) |
| Black | 6097 (5.3) |
| Pacific Islander | 166 (0.1) |
| White | 81 554 (71.1) |
| Multiple races | 8451 (7.4) |
| Hispanic | 10 473 (9.1) |
| Birth-assigned sex | |
| Female | 58 021 (50.6) |
| Male | 56.634 (49.4) |
| Receives free or reduced-price lunchd | |
| Yes | 30 810 (26.9) |
| No | 83 845 (73.1) |
| Area of residence | |
| Twin Cities 7-county areae | 60 260 (52.6) |
| Greater Minnesota | 54 395 (47.4) |
Based on response to a single question (“When was the last time you saw a doctor or nurse for a check-up or physical exam when you were not sick or injured?”), dichotomized by year based on recommendations by the American Academy of Pediatrics for annual well visits.5
Based on student responses to 2 questions about experiences of homelessness (“During the past 12 months, have you stayed in a shelter, somewhere not intended as a place to live, or someone else’s home, because you had no other place to stay?”) and running away (“During the last 12 months, how often have you run away from home?”).
Participants of all racial/ethnic identities other than Hispanic self-identified as non-Hispanic.
Free and reduced-price lunch reflects family income and is an indicator for socioeconomic status.
The Twin Cities are Minneapolis and St Paul. The 7-county area includes Anoka, Carver, Dakota, Hennepin, Ramsey, Scott, and Washington counties.
Figure. Prevalence of Recommended Preventive Visit in Past Year by Housing Experience.
The Figure shows the prevalence of preventive visits for 5 mutually exclusive groups: (1) stable housing (youths who had neither run away nor experienced homelessness); (2) runaway (youths who had run away but had not experienced homelessness); (3) family homelessness (youths who had experienced homelessness with family); (4) unaccompanied homelessness (youths who had experienced homelessness alone, without family); and (5) both family and unaccompanied homelessness. Bars indicate standard errors.
Discussion
This population-based study is among the first examining preventive health services among youths who had experienced homelessness and/or run away that takes the heterogeneity of these populations into account. Despite small but statistically significant differences among some groups, our findings demonstrate that youths who have run away or experienced homelessness are, in fact, connected with preventive care at generally similar levels as their peers in stable housing. Although many youths across groups are not receiving guideline-recommended annual well visits, primary care may represent a natural point of intervention to identify and mitigate the risk of unstable housing.5
Study limitations include a cross-sectional design, self-reported data, and a school-based sample that may underrepresent housing instability. Generalizability to other contexts needs to be established. Despite these limitations, findings from this large, statewide sample suggest that pediatric primary care clinicians are well positioned to screen adolescents for risk or experience of unstable housing and/or running away, connect adolescents and their families with resources, address health concerns, and foster protective factors.6 Research is needed regarding clinical best practices for supporting youths and families who face unstable housing and targeted community interventions and policies to improve health and health care access among youths across a range of housing experiences.
References:
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