1. Understanding Homelessness: Definitions and Demographics
What is "Home"?
Before defining homelessness, it's crucial to understand "home." As Mallett (2004) outlines, home is a multidimensional concept, not just a physical structure. It includes feelings and practices related to:
- Security & Stability: A sense of permanence and safety.
- Privacy & Control: The ability to control your living space.
- Haven: A refuge from the outside world (critically, this is not true for victims of domestic violence, who may be "homeless at home").
- Identity: An expression of self.
Defining "Homelessness"
Definitions are socially constructed and have evolved. The Chamberlain & Mackenzie (1992) model provides a comprehensive cultural framework based on "minimum community standards."
| Category | Definition (ABS Operational Groups) | Description |
|---|---|---|
| Primary Homelessness | People in improvised dwellings, tents, or sleeping out. | "Rooflessness." This is the most visible but smallest category of homelessness. |
| Secondary Homelessness | People in supported accommodation; staying temporarily with other households; living in boarding houses. | No tenure or secure occupancy. Includes "couch surfing" and temporary shelters. This is often hidden. |
| Tertiary Homelessness | People in 'severely' crowded dwellings. | Living in housing that falls below the minimum community standard for space and social relations. |
Homelessness in Australia: Key Statistics (ABS 2021)
- 122,494 people were estimated to be experiencing homelessness on Census night.
- Gender: 55.9% were male, 44.1% were female. However, homelessness among females is increasing at a faster rate.
- Age: The highest rates are among young people aged 19-24, followed by those 25-34.
- Geography: The Northern Territory has the highest *rate* of homelessness (564 per 10,000), largely due to severe overcrowding. Victoria had the highest proportion living in boarding houses.
2. Causes and Risk Factors
Homelessness is never the result of a single cause. It is a complex interplay of structural factors and individual vulnerabilities.
| Structural Factors (Societal) | Individual & Relational Factors (Personal) |
|---|---|
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3. The Health-Homelessness Link
A Bidirectional Relationship
Poor health and homelessness are locked in a complex, exacerbating cycle.
- Poor Health as a CAUSE of Homelessness:
- Mental ill-health is a significant risk factor. It can lead to financial, spatial, and relational insecurity (e.g., inability to manage budgets, maintain a tenancy, or sustain family relationships).
- Substance use (especially alcohol) significantly increases the risk of homelessness.
- Long-term health conditions that restrict activity can lead to unemployment and financial hardship.
- Homelessness as a CAUSE of Poor Health:
- Mortality: People experiencing homelessness die 22-33 years younger than the housed population.
- Morbidity: Higher rates of malnutrition, dental problems, infectious diseases (HIV, Hepatitis C, BBVs), physical trauma, and injuries.
- Barriers to Care: Accessing healthcare is difficult due to cost, lack of transport, no address/phone, and experiences of stigma and discrimination from healthcare providers. Health needs are often de-prioritised until they become an emergency.
4. Intersectionality and Priority Populations
Intersectionality and Co-occurring Disadvantage
Intersectionality highlights that people are not just "homeless." They often belong to multiple vulnerable groups, and these co-occurring disadvantages create compounded health crises.
The study by Tweed et al. (2021) on co-occurring homelessness, imprisonment, substance use, sex work, and/or severe mental illness found that individuals with multiple exclusions experience profoundly worse health outcomes and higher mortality rates than those with only one. This requires a coordinated response from health, justice, and social services.
Priority Populations at High Risk of Homelessness:
- Women and Children (FDSV): Family and domestic violence is the leading cause of homelessness for this group. They often become "hidden homeless" (e.g., couch surfing).
- Children and Young People: Often homeless due to family breakdown, FDSV, and abuse. Youth homelessness is a strong predictor of adult homelessness.
- Indigenous Australians: Massively overrepresented (20% of the homeless population vs. 3.2% of the general population), largely due to systemic factors, intergenerational trauma, and severe overcrowding.
- People Exiting Institutions: High risk for people leaving prison or out-of-home care with no housing or support.
- Older People: A rapidly growing group, especially older women, due to low lifetime earnings, lack of savings, and major life disruptions (e.g., death of a partner).
- Veterans: An estimated 5.3% of transitioned veterans experience homelessness, linked to mental health, physical injury, and social isolation.
5. The Paramedic Context: Challenges and Enablers
Challenges for Paramedics
- High Utilisation: People experiencing homelessness have a significantly higher rate of EMS calls (14x in one US study).
- Lower Acuity: Calls are often for psychiatric complaints, minor trauma, or "no medical complaint," rather than high-acuity medical issues. This can lead to bias.
- Barriers to Care: Patients face numerous barriers, including stigma, fear, and low health literacy.
- Referral Difficulty: The transient nature of homelessness makes follow-up and referrals to traditional primary care almost impossible.
The H.O.U.S.E. Mnemonic: An Evidence-Based Approach
This framework reframes the paramedic's approach to address the root causes of health issues in this population.
- [H] Housing Precarity: Identify housing instability. This is a key clinical vital sign.
- [O] Outcomes of mental illness: Screen for and identify mental health issues and their impact.
- [U] Understanding income: Be aware of financial insecurity and income support.
- [S] Start case management for mental health: Initiate referrals to appropriate mental health and social support services.
- [E] Evaluate substance use: Assess for substance use and link to harm-reduction interventions.
Practical Tips for Paramedics (from Davies & Wood, 2018)
- Awareness of Status: Be aware of the power dynamic and social differences. Simple advice on nutrition can feel judgemental to someone who cannot access food.
- Build Trust: Spend sufficient time to ensure the patient feels heard. This is key to future help-seeking.
- Trauma-Informed Care: Assume the patient has a history of trauma. Physical examinations can be an invasion of privacy; only perform what is absolutely necessary and explain everything.
- Health Literacy: Lower literacy and cognitive impairment are common. Explain information clearly, simply, and use visual aids where possible.
- Refer: Connect patients to specialized services (e.g., Specialist Homelessness Services, AskIzzy) that can provide appropriate follow-up.