Cardiovascular disease in the Australians experiencing homelessness, and the role of Street Side Medics
“The enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being without distinction of race, religion, political belief, economic or social condition”.
– World Health Organisation
Over 100 million people are experiencing homelessness globally, with an estimated 1.6 billion living under inadequate shelter. As of the 2016 Census, there were 116, 427 Australians characterised as homeless(1). Whilst this figure represents less than 1% of Australia’s total population, people experiencing homelessness are over-represented in health statistics, particularly in relation to cardiovascular disease.
Status of CVD in homeless Australians
Cardiovascular disease (CVD) affects 17% of all Australians(2), and is the leading cause of mortality, accounting for a quarter of all deaths in 2019(3). Compared to the general population, CVD amongst those experiencing homelessness has a higher prevalence and mortality, as well as a greater burden of contributing risk factors, and an earlier age of onset (4-6). Whilst Australian data is scarce, international studies have shown a similar or slightly higher prevalence of hypertension, diabetes, and dyslipidaemia in those experiencing homelessness (7-10), and these statistics do not account for the likely under-diagnosis of these conditions. Substance use, particularly tobacco, is significantly more prevalent, with local data demonstrating that up to 81% (11, 12) of those who experience homelessness smoke cigarettes, compared to 15% of the general Australian population(13). Alcohol dependence, as well as cocaine and methamphetamine usage, all of which are detrimental to long-term cardiac health, are more prevalent in the Australian homeless population (14). Similarly, mental health disorders are three times more likely in the homeless population(15), and these have also been linked to poorer cardiovascular outcomes(16), reduced engagement with health services(17) and lower medication adherence(18).
There are various obstacles to delivering healthcare to Australians experiencing homelessness, which can be categorised into personal, practical and relationship barriers (19). Personal barriers refer to competing priorities such as shelter and food instead of medicine or appointments, which lead to many homeless Australians only seeking medical attention in perceived emergencies. Practical barriers refer to the concrete obstacles of finances, transport, and medication security. Finally, relationship barriers encompass the stigmatisation and lack of trust in the healthcare system, arising from prior negative experiences or perceived clinician bias(20).
The role of Street Side Medics
Accessible, opportunistic, and tailored care is essential. Tackling the increased burden of CVD in Australia’s homeless population requires focus on primary and secondary prevention, but also the development of pragmatic interventions which consider and address the underlying social determinants.
One promising strategy is through “drop-in” outreach clinics which make healthcare considerably more accessible. This was the vision of Dr. Daniel Nour, who founded Street Side Medics in August 2020, and for which he won Young Australian of the Year in 2022, recognising the early success of the service. Street Side Medics is a drop-in clinic service, operated from a mobile medical van, which delivers targeted healthcare at homeless food services, shelters, temporary accommodations, and disaster-affected zones in New South Wales. It is a bulk-billed, volunteer run GP led service, which does not require Medicare or identification, and utilises modern medicine technology including point of care testing, portable ultrasound, echocardiography, and spirometry, within a custom-built mobile clinic to provide opportunistic access to healthcare. In doing so, the model strives to alleviate the personal, practical and relationship barriers, which those experiencing homelessness face. This initiative has recently received Australian Federal Government funding in 2022(21)to help expand and adequately deliver its primary care service to homeless Australians. Professor Ravi Bhindi, head of department of the Royal North Shore Cardiology Department has also been involved since conception and has recently initiated a research arm of Street Side Medics, aiming to better understand the burden of cardiovascular disease in Australians experiencing homelessness.
To learn more: www.streetsidemedics.com.au/what-we-do
Moving forward, we need continued government proactivity with increased supply of social and affordable housing. Healthcare services must be adaptive and holistic and involve collaboration with the local community. It is imperative that we continue to spread awareness, not only in the medical fraternity, but within all levels of society. We hope to improve the general understanding of the challenges faced by our homeless population, to facilitate constructive conversations towards a more compassionate and caring society.
Dr. Karan Rao
On behalf of Dr. Daniel Brieger, Dr. Daniel Nour, Ms. Alex Baer & Professor Ravinay Bhindi
StreetSide Medics Homeless Health Research Group
- Australian Bureau of Statistics. Census of Population and housing: Estimating homelessness, 2016. In: Government A, editor. Canberra2018.
- Australian Bureau of Statistics. Causes of Death, Australia: ABS Website; 2020 [Available from: https://www.abs.gov.au/statistics/health/causes-death/causes-death-australia/2020#content.
- Health AIo, Welfare. Heart, stroke and vascular disease—Australian facts. Canberra: AIHW; 2021.
- Flatau P, Lester L, Seivwright A, Teal R, Dobrovic J, Vallesi S, et al. Ending homelessness in Australi: An evidence and policy deep dive. UWA Business School, The University of Western Australia; 2021.
- Al-Shakarchi NJ, Evans H, Luchenski SA, Story A, Banerjee A. Cardiovascular disease in homeless versus housed individuals: a systematic review of observational and interventional studies. Heart. 2020;106(19):1483-8.
- Nanjo A, Evans H, Direk K, Hayward AC, Story A, Banerjee A. Prevalence, incidence, and outcomes across cardiovascular diseases in homeless individuals using national linked electronic health records. Eur Heart J. 2020;41(41):4011-20.
- Bernstein RS, Meurer LN, Plumb EJ, Jackson JL. Diabetes and hypertension prevalence in homeless adults in the United States: a systematic review and meta-analysis. Am J Public Health. 2015;105(2):e46-60.
- Lee TC, Hanlon JG, Ben-David J, Booth GL, Cantor WJ, Connelly PW, et al. Risk factors for cardiovascular disease in homeless adults. Circulation. 2005;111(20):2629-35.
- Scott J, Gavin J, Egan AM, Avalos G, Dennedy MC, Bell M, et al. The prevalence of diabetes, pre-diabetes and the metabolic syndrome in an Irish regional homeless population. Qjm. 2013;106(6):547-53.
- Kim DH, Daskalakis C, Plumb JD, Adams S, Brawer R, Orr N, et al. Modifiable cardiovascular risk factors among individuals in low socioeconomic communities and homeless shelters. Fam Community Health. 2008;31(4):269-80.
- Nielssen O, Chudleigh A, Chen M, Large M, Markovic T, Cooper L. Results of a metabolic health clinic at a hostel for homeless men. Australas Psychiatry. 2017;25(3):270-3.
- Kermode M, Crofts N, Miller P, Speed B, Streeton J. Health indicators and risks among people experiencing homelessness in Melbourne, 1995-1996. Aust N Z J Public Health. 1998;22(4):464-70.
- Greenhalgh EM BM, Scollo MM. 1.3 Prevalence of smoking – adults Melbourne: Cancer Council Victoria; 2021 [updated December 2021. Available from: http://www.tobaccoinaustralia.org.au/chapter-1-prevalence/1-3-prevalence-of-smoking-adults.
- Scutella R, Tseng Y-P, Wooden M. Journeys Home: Tracking the most vulnerable. 2017. 2017;8(3):17.
- Health AIo, Welfare. Mental health services in Australia. Canberra: AIHW; 2022.
- Correll CU, Solmi M, Veronese N, Bortolato B, Rosson S, Santonastaso P, et al. Prevalence, incidence and mortality from cardiovascular disease in patients with pooled and specific severe mental illness: a large-scale meta-analysis of 3,211,768 patients and 113,383,368 controls. World Psychiatry. 2017;16(2):163-80.
- Resurrección DM, Moreno-Peral P, Gómez-Herranz M, Rubio-Valera M, Pastor L, Caldas de Almeida JM, et al. Factors associated with non-participation in and dropout from cardiac rehabilitation programmes: a systematic review of prospective cohort studies. European Journal of Cardiovascular Nursing. 2019;18(1):38-47.
- Kronish IM, Rieckmann N, Halm EA, Shimbo D, Vorchheimer D, Haas DC, et al. Persistent depression affects adherence to secondary prevention behaviors after acute coronary syndromes. J Gen Intern Med. 2006;21(11):1178-83.
- Davies A, Wood LJ. Homeless health care: meeting the challenges of providing primary care. Med J Aust. 2018;209(5):230-4.
- Gilmer C, Buccieri K. Homeless Patients Associate Clinician Bias With Suboptimal Care for Mental Illness, Addictions, and Chronic Pain. J Prim Care Community Health. 2020;11:2150132720910289.
- Commonwealth of Australia. Budget 2022-2023. Canberra; 2022 March 29, 2022.