Homelessness and housing instability — formative SAQs

SAQ 1 — The vital-sign screening principle and the five domains of harm (10 marks)

A four-year-old girl is brought to your clinic for a recurrent asthma exacerbation. Her mother has missed two recent appointments and the address on file is wrong. When you ask gently whether they have a stable place to live, her mother discloses they have been sleeping on a relative's lounge room floor for six weeks since an eviction. ^{[1] [4]}

a) Explain why housing instability is a paediatric health problem rather than a welfare referral, and state the principle that should guide screening. (3 marks) ^{[4] [3]}

b) Outline the five domains of clustered morbidity you would expect and screen for in this child. (4 marks) ^[3]

c) Discuss the role of the portable health summary and how you would protect continuity for this family. (3 marks) ^[10]

Model answer

Housing as a health problem and the screening principle (3). Housing instability is a paediatric health problem, not a welfare referral, because stable, safe, adequate housing is a determinant of child health — it predicts physical illness, developmental delay, mental-health difficulty and educational underachievement, and the harm is biologically embedded through toxic stress. Sandel and colleagues' renter-family study established that unstable housing is an independent health determinant, adding harm above and beyond poverty. The screening principle is that housing is a vital sign: ask about it at every encounter, not only when a family presents in crisis, because the visible tip of overt homelessness is smaller than the hidden iceberg of insecurity, and families rarely volunteer the information. Lebrun-Harris' data show that routine screening in clinical settings identifies instability that would otherwise be missed. ^{[4] [3] [1]}

The five domains of clustered morbidity (4). Expect overlap, not a single problem. First, physical health — recurrent respiratory infections, asthma exacerbations (mould, damp, overcrowding), skin infections and chronic-disease disruption. Second, growth and nutrition — food insecurity drives faltering growth, iron deficiency and poor dietary quality, worst in the youngest. Third, development and education — developmental delay, speech and language difficulty, school absenteeism and lower attainment accumulate over years. Fourth, mental health and behaviour — anxiety, depression, externalising behaviour and sleep disturbance, which Keen's prospective data show can track into adulthood. Fifth, access and continuity — lost GP, lost specialist referrals, lost prescriptions, insurance gaps and fractured vaccination records, as Carroll's data documented. Screen broadly across all five; do not stop at the presenting complaint of asthma. ^{[3] [7] [10]}

The portable health summary (3). The portable summary is the single intervention that protects continuity across the chaos of housing instability. It should contain the child's diagnoses, medications, allergies, vaccination record, growth charts, specialist referrals, and the current care plan, in a form that travels with the family. Carroll's study showed that housing instability is associated with health-insurance gaps and administrative fracture that destroy continuity — addresses change, coverage lapses, and the friction of reinstating care is often insurmountable for a family in crisis. For this family, build the summary now, provide copies to the mother, confirm the GP and asthma-plan continuity, and ensure the prescription for preventer therapy is portable and bridgeable through the move. ^[10]