WEBINAR: Improving the Health Status and Reducing the Mortality Gap for Vulnerable Young Australians
PRESENTER: Dr Jesse Heerde
DATE: 26 April  2022




Philippa Collin [00:00:03] Good morning, everyone. My name is Philippa Collin and on behalf of Professor Kate Steinbeck, the Director of Wellbeing Health and Youth Centre of Research Excellence, who is currently on leave, I'd like to welcome you to our WH&Y Webinar. I am a Co-stream leader in the WH&Y CRE. I Co-lead Stream One, the Ethics of Engagement of Young People in Adolescent Health in the Digital Age, along with Professor Angus Dawson, and it's my pleasure to be hosting the seminar today. 
Philippa Collin [00:00:40] To get started, I'd first like to acknowledge our partners in the wider CRE, and also to acknowledge that we're all joining this seminar from diverse traditional lands around Australia. I want to acknowledge the traditional owners of all of those different lands from which we're joining. I myself am on Gadigal Country and I pay my respects to Gadigal Elders, past, present and emerging. And I invite all of you to add into the chat an acknowledgement of the country that you are on today. 
Philippa Collin [00:01:27] Today's webinar is part of the Community of Practice that WH&Y coordinates and you can find many resources, including from past webinars up on our website. It's essentially a place where people can come together and share resources and information and research around adolescent health. And today's seminar will also be shared up there at a later date. 
Philippa Collin [00:02:00] Just a little bit of housekeeping before we get going. During the webinar, you will all be muted, and your video will be switched off. If you'd like to say anything, if you would like to ask a question of our presenter, Dr. Jess Heerde, you can use the chat panel on the side of your screen. The formal presentation will go for about 40 minutes, after which we will have time for a Q&A at the end of the presentation. So please add any questions that you have at any time into the chat, and we'll add them on to the Q&A at the end. 
Philippa Collin [00:02:40] Let me now introduce our presenter for today's webinar. Dr. Jess Heerde is a senior research fellow in the Department of Pediatrics at the University of Melbourne. She's also an NHMRC Emerging Leadership Fellow and an MDHS University of Melbourne Momentum Research Fellow. I'm not sure what that means, Jess, but I'm sure we'd all love to know more. It sounds really important and exciting. And Jess has established an important area of research around the drivers of homelessness and health consequences of homelessness among young people. And certainly that's an extremely important issue at the moment as we see housing become so challenging for so many of us here in Australia. Jess welcome, thank you for joining us today, and over to you. 
Dr Jess Heerde [00:03:38] Thank you for having me. And look, it's really lovely to get an invitation to come on to talk about this work with everyone. I think homelessness, particularly among young people, is not something that gets a lot of attention, so I feel incredibly fortunate to have received a grant to really get stuck into some of the health issues. As I said, it's really good to have the opportunity to talk about some of the work that I've been doing. And hopefully you will find it interesting, too.
Dr Jess Heerde [00:04:27] [Slide 1: Research Program] I thought I'd start by giving you a bit of an overview of where I sit. I'm a research fellow at Melbourne University and was lucky enough at the end of last year to be awarded an NHMRC grant. Pip mentioned the Momentum Fellowship before, and just briefly it's worth mentioning it because that's a fellowship that Melbourne Uni has brought into our faculty, which is developed to support people who've had significant career disruptions. For me, I live with a chronic illness and that fellowship is really to assist my work. 
Dr Jess Heerde [00:05:17] The premise of my work is around life-course epidemiology related to homelessness. For me, the key things that we really need to think about are, what's going on for young people before they enter homelessness and how can we target those drivers to stem the flow of young people that enter homelessness. But in that, I think it's really important to acknowledge that regardless of what sort of prevention or intervention approaches we have, we're still likely to have a scenario where there are some young people that enter homelessness. My second stream of work is really around how do we decrease the length of time young people experience homelessness, and decrease the impacts of that through access to health care, and how do we decrease morbidity and mortality that might arise from experiencing homelessness. 
Dr Jess Heerde [00:06:21] My work really focuses on those four groups that are listed at the bottom there [Slide 1]. Young people who are at risk of homelessness; young people who enter into homelessness; those young people who have had experiences of homelessness and are now in housing, because I think one of the things we don’t think about in a long-term fashion is the impact of homelessness on an ongoing basis. So even though young people might have come through that experience or survived that experience, there are still long-term impacts that I think we need to really consider and address. And the last group there, and it can be a bit confronting for some, and I do acknowledge that with the group that we have here today, is young people who have experienced homelessness and have passed away during that time. That's a group that I don't think gets enough attention, but I think it's something that we really need to look at if we want to keep pushing action around addressing homelessness. And I will just say that I'm more than happy to answer any questions on any of this, so please feel free to put them in the chat. 
Dr Jess Heerde [00:07:50] I don't want to spend a lot of time on this because I think the group that is here is probably a group that is well versed on homelessness and the issues that young people face. But I guess the main thing that I draw from this is, we have intervention approaches, we have programs that we're running but stemming the flow of young people into homelessness still remains a challenge, particularly for young people.  Over 40% of young people who accessed homelessness services in the last year were under 25 years of age. And I think that's a massive proportion that doesn't really get enough attention. We know that homelessness is a driver of poor health outcomes. We know young people who experience homelessness have their educational and employment opportunities severely impacted. And we know that there are other social inequities that develop from that. This is something that we need to address in its entirety because it does have impacts later on into life. And  I guess that's one of the things that I'm trying to shine a light on here. 
Dr Jess Heerde [00:09:06] Around mortality, we don't really have figures for young people, but what we do know internationally is that life expectancy for adults who experience homelessness is quite low, that in itself, 45 to 47 years, is significantly less than the average lifespan for someone who doesn't experience homelessness. And as I said, we don't know what it is for young people, but that is something that I am going to try and put a figure on over the next few years with my NHMRC work.
Dr Jess Heerde [00:09:43]  In terms of existing research on pathways into homelessness, we don't know a lot. The thing that we can take away from the research that is there, is that prior studies have really looked at selected samples. So most of what we have are studies where the participant group are young people who are already homeless or have experienced homelessness, and they're often small samples without a comparison to young people in the general population, which makes it really difficult to look at what are the predictors across the life course, what's happening in young people's lives that's driving homelessness. The approach that I am taking is one that is focused on population level prevention, looking at what's happening for young people at the population level before they enter homelessness. And if we can identify some of those drivers and target those, my theory is that we can then stem the flow of young people who enter into homelessness over time. But the point to note is it is going to be a long-term process. It's not something that we're going to get hard and fast answers on. And like any prevention approach, it takes time to see the effects, and I think that's one of the things that we probably need to focus on a little bit more, even though all of us want a really quick response, and we want to reduce the number of young people who enter homelessness quickly. 
Dr Jess Heerde [00:11:32] [Slide 2. Stream 1: Life-course pathways] As I said, my work focuses on two streams of work, and I want to go through both of those in a little bit of detail. But I think the question that we need to look at first is why use a life-course approach? And for me, it comes back to, let's think about what is going on for young people from birth to the point that they experience homelessness and let's try and target some of the things that are influencing the likelihood of homelessness down the track. And the way to do that really is through this interdisciplinary approach, looking at what's going on in a young person's environment, within their family, within their school, within their community, the social context as a whole, not just one aspect of that context. What's happening across development and how does that development influence aging as someone progresses through their life, and what are the health impacts of what young people are going through? 
Dr Jess Heerde [00:12:42] I don't know if anyone here has heard much about the International Youth Development Study. I hope that you have. It's a long-term study, and I'll go through a little bit of detail about it. But I think the main points to note about this study is really what we're trying to do is look at the development of health- risk behaviours and socially disruptive behaviour, things like substance use, mental health, engagement in anti-social behaviour, or victimisation - how are they developing throughout the period of adolescence and into young adulthood. And we want to understand the different drivers of those behaviours. As I was saying before, what's happening in the environment, what's happening at the individual level, what's happening in families, school, community. A really interesting part of this study is that we have a cross-national sample. So we have young people both here in Victoria and in Washington State in the US. And that effectively gives us two opportunities to look at the same questions, so we can look at a question for young people here in Victoria, and we can see that if the results to that question then hold for young people in Washington State. Then we can say that those drivers are not really about policy, but they are core developmental processes. If they are different, then we need to look at why that is. And it could be that the contextual environment is different in both states. And just the last point in this life-course approach, is really looking at how the timing of one's transition to adult roles influence their behaviour later on. 
Dr Jess Heerde [00:14:43] [Slide 3. International Youth Development Study Sample] This is the quick overview of the sample itself. We have several cohorts of young people who were initially surveyed early on in their lives, at 5th, 7th and 9th grade. I don't want to go too much into the details of the sampling process, but I'm happy to send those details to anyone who wants them. The study itself has multiple waves of data. It first began in 2002, and we followed these same young people through to most recently 2020. In terms of age, we've effectively followed young people from around the age 10-12, right through to now, the mid to late 20s, which gives us a  big opportunity to look at what's happened in early life and mid adolescence and then what's happening later on into later adolescence and adulthood. 
Dr Jess Heerde [00:15:51] [Slide 4. Survey Measures] What I've got here is just an overview of some of the things that we have measured with the survey and that I'm looking at in this homelessness work. We're looking at things like childhood accommodation transitions, how many times have young people moved in their childhood, and family homes. In their adolescence where they are engaging in things like anti-social behaviour, alcohol or other drug use, what's their family environment been like? What are some of the characteristics of their peer group, of their school, and the community that they're attached to? I've obviously looked at homelessness as our main outcome, but then I've started to look at some other health behaviour. In this case, relationships between homelessness and anti-social behaviour and also victimisation. 
Dr Jess Heerde [00:16:47] [Slide 5. Stream 1: Life-course pathways (Study 1)] I'll take you briefly through some of the results that we've got. What we've done with this study is really try and order it quite sequentially on purpose. And the first step was to look at if we take these individual, family, peer-group, and school risks or protective factors, and we look at them in isolation, what's their relationship to homelessness later on? In the sample that we have, we can see at the top some of the percentages of the groups that experienced homelessness. At age 21, we had 6.5% of young people who reported experiencing homelessness in the past year, about 4% at age 23, and 2.5% at age 25. And what we saw in this first study is these factors that I've got listed here, measured at age 13, predicted homelessness at age 25. Effectively, what we can see is that young people who were engaging in anti-social behaviour at age 13, that that behaviour predicted homelessness at age 25. We can also see in terms of poor management strategies within the family, situations where parents, for example, may not know exactly where young people are at a point in time, or conflictual communication patterns, were associated with later homelessness. The two big ones down the bottom there, which surprised me, particularly being someone who has had a background as a secondary-school teacher, young people who are suspended or who were not achieving academically were also showing risk for later homelessness. 
Dr Jess Heerde [00:19:02]  Also, I just want to draw your attention to these other two factors. Belief in the moral order, and prosocial peers. I think sometimes with homelessness, we focus a lot on what are the risks. And part of what I want to do with this work is look at not only the risks, but also what sort of things might protect young people from experiencing homelessness. For this one, what we can see is young people who are engaged with peers who are displaying prosocial behaviour age 13 seem to be protected against later homelessness. 
Dr Jess Heerde [00:19:41] [Slide 6: Life-course pathways (Study 2)] Study 2 really tried to look at what are the developmental processes or developmental paths that we might see in young people who experience homelessness. With this study, what we tried to do was say, okay, if we look at, say, poor family management at age 13, how does that experience risk look two years later in other domains. In this case, how does poor family management affect young people's engagement with peers who might be using drugs or engaging in anti-social behaviour? How does that poor family environment then influence school suspension or academic failure at age 15? And then how do these aged-15 factors impact homelessness at age 25? What we can see here is actually quite interesting. What we've got is essentially that poor family management at age 13 influences each of the later risks at age 15. The risk we looked at within the peer group, within the school and within the community, and again, similar to the first study, what we have seen is that poor family management influences both school suspension, academic failure and one's attachment to their neighborhood. And then those three factors influence homelessness at age 25. 
Dr Jess Heerde[00:21:26] I think the thing to take from this is, yes, we have young people who might be experiencing problematic family environments, and that's really important. But the other important thing is the way that being situated in that environment then influences risk in other social settings that also influences homelessness down the track. 
Dr Jess Heerde [00:21:55] [Slide 7. Stream 1: Life-course pathways (Study 3)] If we go to Study 3 and we've essentially done the same thing, but we've changed the family environment variable. So what we can see from here is how does family conflict influence risk in other social settings? And we see the same thing, that conflict then influenced young people's engagement with peers who were engaged in anti-social behaviour or suspension or how attached someone was to their neighbourhood. But family conflict also then influenced homelessness through young people's peer engagement. Young people who were in a highly conflictual family were more likely to engage with friends who use drugs, more likely to engage with peers who were displaying anti-social behaviours, and then more likely to experience homelessness down the track. That's a bit about Stream 1, and I hope that I haven't gone through that too briefly, but I'm sure you’ll have questions about that down the track. 
Dr Jess Heerde [00:23:01] What I want to look at now is some of the work that we've done around homelessness and its impact on health and mortality. Like I said earlier, we don't know a lot about mortality among young people who experience homelessness and that is something that is a big focus for me over the next couple of years. But what we do know around homelessness and mortality in adult populations is that rates of mortality are higher than what we see in the general population. There is a broad range of causes for those. Importantly, many of those are preventable. We see things like deaths related to suicide or overdose and accidents, including acts of violence. And then we see rates are higher for females than for males, particularly around mental health. When we look across these different causes of death, the thing that really jumps out for me and I think comes through the literature quite clearly, is that not only are people who are experiencing homelessness dying earlier than people who don't experience homelessness, many of the causes of death are preventable, which for me really highlights the need to look at homelessness from a public health perspective as well as a social perspective. If we can address many of these health-related impacts, then we're likely to decrease the number of people who experience homelessness and pass away. As I said earlier, we don't have a lot of data on this, but I think the thing that's going to come out of this study is that for people who experience homelessness and then are provided with housing or transition from that homelessness experience, I think we're still going to see higher rates of mortality among that group. It's really going to highlight the fact that, yes, we need to look at housing options, but we need to look at support on a more long-term basis, both socially and from a health perspective.  
Dr Jess Heerde [00:25:44] [Slide 8. Stream 2: Homelessness, health, and mortality] How are we going to do this? The grant that I'm fortunate enough to have from the NHMRC has funded what we call a national data linkage study. So the work for the next few years is going to be linking up what we have in terms of national homelessness data with data that we have in the National Death Index, and then linking those two sets of data to data from the Pharmaceutical Benefits Scheme, and the Medicare Benefits Scheme to look at what sort of health care people who are experiencing homelessness or have experienced homelessness but are now housed, are accessing. And that will be with people up to about 35 years of age. I really want to focus on the young group with this work. 
Dr Jess Heerde [00:26:43] [Slide 9. Homelessness, violence, victimisation (Study 1)] What I want to look at here is what sort of things informed the development of that study. Prior to getting this grant, I'd done quite a bit of work around young people experiencing homelessness and their experience of engaging in violence and also being victimised, which really highlights the health impacts on an ongoing basis of experiencing homelessness in any form. The young people I've spoken to are young people who have been rough sleeping, but they're also young people who've been couch surfing or in transitional or crisis housing. So we've got a range of young people. What I tried to do in this study here is really look at, as I was saying with the International Youth Development Study, how are homelessness, violence, and victimisation related across young adulthood. And what we can see from this is obviously homelessness at one point drove homelessness at the next point and the next point, the same for anti-social behaviour and victimisation. But the key thing that came out of this study was homelessness, for instance at age 21, did not predict anti-social behaviour or violence at age 23. It did predict that at age 21, so within time, but it didn't predict it across time. For this group, we didn't see anything happening longitudinally, which is important because what it points out is the need for intervention at the point that young people are experiencing homelessness. I guess the key thing here is that homelessness for these young adults and for this sample, that we have, really increased young people's vulnerability to engaging in violence and also being victimised, which in turn heightens risk for things like physical injury and mental health related concerns, shame, stigma, trauma and also contact with the justice system. So intervening at that point in time that young people are experiencing homelessness or accessing services is important if we want to reduce their risk of violence and victimisation. 
Dr Jess Heerde [00:29:17] [Slide 10. Homelessness, violence, victimisation (Study 1) Contd]. That was the first step within that study. The next thing that we want to do is look at what are some of the drivers within time that might also predict violence or victimisation. And I think  based on some of my other work, things like substance use or peers that young people who are homeless are engaging with, housing situations, they're all going to influence risk down the track. And I think the other point to make is that we didn't see a difference in violence or victimisation among males and females. And we did only look at male and female gender within this study. 
Dr Jess Heerde [00:30:11] [Slide 11. Homelessness, violence, victimisation (Qual)] So how do we bring a bit of context to this? One of the other arms of my work over the last few years has been to really look at the experiences of young people through qualitative data. I went out and interviewed around 60 young people about their experience of homelessness, their concept of home, the way that they saw themselves as young people, and also what they want for their future. And these are just a few points that have come from that. I don't think that it's anything new, those of us who are working in the sector have seen this from young people before, and so we know what it's like. But I think in terms of putting this out there, really to highlight what young people's experiences are is important. And they've talked about homelessness being really dangerous, being exhausting, being an issue where each day they combat things like physical assault or sexual coercion or violence. I think when we're working with young people, these are things that we need to kind of keep in mind. 
Dr Jess Heerde [00:31:39] We also asked them about their access to health care and how they found that experience. The biggest things that came out of this were very much around shame and stigma, the shame of experiencing homelessness, but also shame associated with needing to ask for help. The young people that I interviewed were very self-sufficient. So the fact that they needed to seek help for something that they were going through, an injury they had experienced, the process of seeking out help was shameful for them, that's how they felt. Many young people talked about in health-care settings feeling secondary, that power relationship between the medical professional that they were seeing and their own situations, the judgment, feeling undeserving of treatment or being treated kindly. Particularly in terms of violence and victimisation, there's very much a fear of police and a fear of disclosing what they had been through in case child protection or the police became involved. These are things we probably need to consider as we continue to work with young people in health-care settings or other settings that young people are visiting. 
Dr Jess Heerde [00:33:10] [Slide 12. Homelessness & health care access (Qual)]  So how can we help? For the young people that I interviewed, trust was the most important thing for them. I'm not a clinician, I haven't worked in health-care settings, but in terms of working with young people it's really difficult to build trust in a short amount of time. Maybe that's something that we can think about in the health-care setting. I'm not going to prescribe what that should be, I don't know what that should be, but I think this is one of those situations where I think we can really take a multi-sectoral approach to looking at how we can build interactions or services that are not only inclusive but are welcoming for young people to attend - they are likely to still feel shame and stigma, but how can we lessen that, I think that is the point. 
Dr Jess Heerde [00:34:12] Also for young people, knowing workers by name was important to them. Many young people talked about having seen a different worker each time, and that was kind of off putting for them. And young people wanted to be included in decisions about their own health. I don't think that's anything new for us as people who are working in this setting, but it was something that young people highlighted, and which I think we just need to really keep thinking about. And I think the other point there, and this is very much linked into shame and stigma, is that acknowledging the social context of homelessness for the young people that I interviewed, it was really clear that, you know, engaging in violence, for instance, wasn't about creating some sort of social unrest, it was about rejection. And I think that's something that young people really feel, I guess, to find it hard to convey to those of us who are not in the same situation as they are. 
Dr Jess Heerde [00:35:30] [Slide 13. Key Summary Points] What are the key points from all of this stuff? I think the first point is that it is possible for us to identify drivers of homelessness at the population level in young people before they experience homelessness. Those may be things like suspension from school, an academic failure, we need to look more into that. We also need to look into elements of the family environment that are not at that abuse level that we typically associate with homelessness. I think one of the things we really need to look at in more detail is what's going on at the family environment level that isn't at that level where services get involved but is still harmful for young people. Also, what's happening in schools, communities, and peer groups? 
Dr Jess Heerde [00:36:28] I've gone through shame and stigma so I'm not going to go through that again. But in terms of next steps, this mortality work is going to have a lot to do with that over the next few years. I think also it's really looking at what are the life-course predictors and drivers, can we identify them, and do they hold up in other samples outside of the sample that I'm looking at right now? And exploring prevention approaches. I think that's a shift that we need to make. Yes, intervention and early intervention is important, but I think we also need to add population-level prevention to that in order to start to see some effects over time on the number of young people who do experience homelessness.
Dr Jess Heerde [00:37:24] [Slide 14. Relevant publications] I've got some relevant publications here. I'm happy if anyone wants any more details on any of the stuff that I've gone through today, I'm more than happy to send any publications directly to you. 
Dr Jess Heerde [00:37:39] Slide 14. Acknowledgements] There are a number of collaborators to this work, so I do want to acknowledge the people who are listed there, as well as the young people who have participated in the work that we've done, and the range of funding that both I've had and that the study itself has had over time. That's it. I'm happy to answer questions or have other discussions. 
Philippa Collin [00:38:06] Jess, thank you so much for that presentation. It's just an extraordinarily important area of research. I think the statistics are shocking and the picture that you've painted around how health inequity presents or the health impacts of homelessness for young people and the rapidity, the way in which that health inequity is so quick to have an effect as a result of homelessness is really confronting. And so it's been great to hear about that today. 

Philippa Collin [00:38:44] We do have a couple of questions, but I'm going to be really cheeky, as the Chair I'm going to kick them off. I think, especially for our WH&Y community, one of the things we're very interested in and that you have covered, is around young people's own ideas about what interventions can look like in terms of arresting or addressing some of the health impacts. But I wonder whether you could briefly share with us what young people said could help prior to them experiencing homelessness. You said a little bit about what they said could help while they're experiencing homelessness. What are the insights you've got around that period before or leading up to homelessness? 
Dr Jess Heerde [00:39:39] I did a piece on this a couple of years ago, particularly related to the educational context, because I wanted to know what was going on for young people in that time prior to their transitioning to homelessness for want of a better term, in the educational setting, given what we have seen here around academic failure and suspension. The biggest things that came out of that were young people feeling they needed to connect with staff, they wanted support, but they didn't know how to get it. And they suggested things like maybe organisations who work with homelessness could come to the school and talk to the student cohort in general. Or the student welfare or counseling support within schools, needing more information about homelessness and young people. I mean, there's a lot about mental health, there's a lot about eating disorders, there's a lot about substance use. But the young people that I spoke to really didn't feel like homelessness was something that was mentioned as a possibility for them as young people. I think it comes back to this whole thing of let's look at young people and target young people as a whole rather than focusing on those that we see who are at risk. I think once young people are at risk, we have a chance of losing them down the track. But if we can build an awareness and even if it is just an awareness of homelessness, somewhere to go early on, maybe that can make a difference. 
Philippa Collin [00:41:27] Yes. 
Dr Jess Heerde [00:41:29] I mean, the young people also talked about things like, you know, experiencing homelessness and trying to manage their schooling at the same time. Going to school but hadn’t  had anywhere safe to sleep the night before, hadn’t eaten, hadn’t showered. These are all things that impacted them. I think underlying all that was a desire to stay engaged in education, seeing the value of that, but not having the capacity to do that in light of everything else. 
Philippa Collin [00:42:02] Plenty more to say about that, I'm sure. But I will go now to the questions. A clarifying question, I guess. Helen's asked: “If you could clarify, what does victimisation mean, the victim or the perpetrator?” 
Dr Jess Heerde [00:42:25] Victimisation refers to a young person who has been the victim of, in this case, an assault. So someone who has been experiencing homelessness and been beaten up by another person. In the study that we've conducted, violence really refers to what young people might be perpetrating, victimisation to what young people might be experiencing. 
Philippa Collin [00:42:54] Okay. Well, hopefully that answers your question, Helen. Sharon says: “Thank you for such an interesting talk. It's striking that even when people get into housing, they might still have poor outcomes, including early death. I guess that means after experiencing a period of homelessness. What sorts of ongoing support do you think could turn this around?” 
Dr Jess Heerde [00:43:20] Look, I think there are multiple things. The key thing for me is homelessness itself is a form of trauma. And despite the fact that young people, people in general, might be housed, that trauma doesn't go away straight away. It may not go away for their life. And so I think discussions around trauma are really important here because we have things like substance use as a coping mechanism or other coping mechanisms aside from substance use that might not be healthy per se. I think there's that aspect around that sort of support. But then I think there are other things that might not be as obvious, things for young people who haven't had the opportunity to finish their education, they may be in jobs or employment that is casual, temporary or where there's not a lot of income coming through, which then impacts things like young people's capacity to have healthy diets, whichin the long term will also influence health and wellbeing. I think social connection is another one. I struggle with this a little bit because, having worked and talked to so many young people, they're very grateful for situations where they do have housing. But loneliness is a big thing because they've had to leave their peer group that did give them a sense of safety, even if the environment itself wasn't safe. The capacity to build new social connections and the opportunity to build new social connections is there. I think this is why we need to really look at homelessness through a health lens as well as a social lens because there are many ongoing impacts to health and wellbeing that I don't think we realise. 
Philippa Collin [00:45:48] That point, around loneliness, is so important. We hear that in relation to other areas of care, such as aged care, where just having a roof over your head doesn't necessarily mean you feel connected and have meaning or feel valued in that environment. So very important. 
Dr Jess Heerde [00:46:09] Tina asks, and I guess this is sort of slightly connected to that prior question. She points out that: “It's interesting that the Young Australian of the Year, Dr. Daniel Noah, is working to improve access to health care for homeless people through his mobile health initiative. Do you have any thoughts on this model of care, whether young people might access a service like that? What might its broader benefits be?” 
Dr Jess Heerde [00:46:44]  in terms of young people accessing that service, I'm not sure. That said, in interviewing the young people that I have, I have to say that one of the things that has come out for them is they're engaging with other kinds of similar peers, but not so much adult networks. And I think what I was saying before around a fear of authority may come into accessing a service like that for young people. In particular, that fear of are police going to be contacted, is child protection going to be involved. Where young people have had a history of that before, I think those are things that we need to take into consideration with any health care that we present to young people. Sorry. The answer is I don't really know if young people are accessing that service, but I think it would be useful. 
Philippa Collin [00:47:53]  Maia has asked a question about gender: “Taking into consideration the point that you made about the way that gender has been conceptualised in the study to date, and whether or not you're thinking or looking at how to add or incorporate or understand more diverse gender identities in the study. And I'm keen to know whether gender identity and diversity has come up in the qualitative research that you've done.”
Dr Jess Heerde [00:48:30] On the first part, in the International Youth Development Study, we do have a retrospective question around sexual diversity and gender diversity. And I think at the time that this study and also other studies I've seen were started, unfortunately it wasn't something that was at the forefront of people's minds, so I'm glad that it is now. We'll be able to put that variable, and that sounds terrible, I know, into the analysis down the track. So that is beneficial. But yes, it has come out in the qualitative work. It wasn't something that that I set out to look at in the qualitative work, but I would say that maybe 30% of young people that I interviewed identified as gender diverse or some other category of sexual diversity, so that is something that we're looking at. I think one of the important things with that and I don't know if this is the forum for it but I'm going to put it out there anyway, I think for me as someone who's a cisgender woman, I don't feel comfortable doing that analysis. I can't identify with young people's experiences in that sense. But I do have a colleague who is coming on board to look at that data and really look at the nuances within that. So that will be forthcoming. I think it'll be quite interesting. We're hoping to potentially do some comparison between gender diverse and non-gender diverse identifying young people. Time will tell with this stuff. 
Philippa Collin [00:50:30] I think everyone here would appreciate what you've just said there and also the way in which you're proposing to take gender and sexuality forward in the study. Certainly, there are WH&Y investigators who are experts in this area that I'm sure you're already aware of and would certainly love to work with you on it. 
Dr Jess Heerde [00:50:57]  Please reach out. If we can put a team around this, then that would be so much better. 
Philippa Collin [00:51:01] And we do have the Wellbeing Health & Youth Commission of young people who advise around youth health research and translation, and certainly gender and sexuality are key, I guess areas that they've been pushing for us to sort of really think through and be better incorporated and better researched within the broader field. Really important. 
Dr Jess Heerde [00:51:31] I think we've got time for just one more question, if that's all right. Serita asks: “Have you looked at the association between homelessness and involvement of young people with the youth justice system and if so, how the justice system is impacting. And I'd like to know what you think your research tells us about what some of those interventions or changes might be necessary to turn it around.”
Dr Jess Heerde [00:52:01] There are two points that I want to make there. The first one, is a little bit off tangent with the question, but I'll go to it first. There's a lot of talk around homelessness policy development going around now and I think that's important. But I think one of the key things we're not thinking about but that we need to think about further is what are those points where there is a nexus between homelessness and another setting. Youth justice is one of those. I think out-of-home care is another one. And the third one that really comes to mind for me is young people who are in mental health settings. I think if we're going to come up with a policy, I think part of that policy needs to be that young people leaving those settings cannot leave those settings into homelessness. I think that's fresh right now. So it's a bit aside, but I think that's an important one because yes, there is a nexus between youth justice and homelessness. And I think that comes partly from the fact that young people who are experiencing homelessness have had contact with the justice setting through violence that they've come across or that they've engaged in while they're experiencing homelessness. And I think the second is just that the release from one setting into the other, we haven't had a lot to look at in that with the International Youth Development Study, but it is a key component of the mortality work that I'm going on to. One of the focus groups for me is going to be what is health care access like and what are the rates of mortality for young people who experience homelessness and have contact with the justice setting? I'll have to come back in a couple of years and update you on that. 
Philippa Collin [00:54:05] That would be great, and I won't put you on the spot with this one right now, but I mean, there is obviously a big debate in Australia about the age of criminalisation, of criminal responsibility as well. I suppose that also feeds into this as well. I think your point about what happens to young people when they leave some of those settings is very crucial too. 
Philippa Collin [00:54:33] I want to ask one more question if that's okay. I connect this with the international comparative element of the study. And I just wondered if you could conclude by sharing with us any of the key differences that might exist between the two state settings and what we can learn about what we could do differently here to reduce homelessness and improve health outcomes for young people who experience it. 
Dr Jess Heerde [00:55:10] I think the first point to make is that the drivers of homelessness that I was talking about earlier are no different between the young people who are residing in Washington State and the young people who are in Victoria. They're the same predictors. There are, so far, no state-based or country-based differences in those. And that's important because what it says to me or what it implies for me is that these drivers are universal. It's not that they're more pronounced for one country over another. It's that they're coming up for young people, regardless of their context. What does that mean for homelessness or health care access? I think what it means is we really need to take a look at and put the evidence around those programs that are already targeting those drivers. For instance, say we have anti-social behaviour come up, there are already evidence-based, tested and effective programs that address anti-social behaviour. For me, it's not about ‘let's produce something new or pick bits and pieces of different things and see if that works’. It's about coming out with these universal key drivers and using what's already there to test if addressing those drivers reduces homelessness. I really think we need to put the evidence base around that. 
Philippa Collin [00:56:56] Well, that is a somewhat hopeful note to end on. I think we already know what can work and so the impetus there is to scale and implement better. And it seems to me that the research that you're doing is really providing a very strong case for that to happen. 
Philippa Collin [00:57:18] Jess, thank you so much for presenting to our WH&Y Webinar today. Like I said, it's been a very powerful and interesting presentation. We will, with your permission, share the recording from today on the website so that people can look back on it. And anybody who hasn't been able to join us can still see it. We wish you all the best with your research and hope that we're working with you into the future. Thank you. And thanks to everybody for joining us today. 
Dr Jess Heerde [00:57:54] Likewise. Thank you, too. And thank you to everyone who's come along. It's been lovely.