Homelessness and Impact on Health Introduction
Homelessness is a multifaceted social issue that involves various macro (health policy), meso (health care systems), and micro (individual) structural mechanisms. It is not merely an isolated event but rather a complex phenomenon that occurs within the context of broader social, economic, and personal histories. Researchers in epidemiology, medicine, and social sciences have extensively documented the risk factors correlated with homelessness, such as mental illness, substance abuse, childhood trauma, and experiences of abuse and neglect (Bauman, 1993). However, focusing solely on these individual-level factors provides only a partial understanding of homelessness, underscoring the need to consider the structural and systemic contributors.
Factors Contributing to Homelessness
Homelessness results from a complex interplay of individual and structural factors. Contemporary analyses recognize the importance of understanding how these factors interact to create various pathways into homelessness. Structural factors such as inadequate housing subsidies, a wide gap between median rents and median incomes, and economic instability play a significant role in exacerbating homelessness. These structural challenges often intersect with individual factors like gender, race, childhood or adult abuse history, substance abuse, and the availability of social support (Ringwald, Greene, Robertson, & Mc-Pheetes, 1998).
For instance, when affordable housing is scarce, and income disparities are vast, individuals who face personal challenges—such as addiction, mental illness, or a history of abuse—are at greater risk of becoming homeless. This intersection of structural and individual factors highlights the need for comprehensive interventions that address both macro-level policy changes and micro-level individual support.
Homelessness vs. Poverty
While homelessness and poverty are closely related, homelessness represents a more extreme form of marginalization. Homeless individuals face greater uncertainty and more severe exclusion than those living in poverty. There are various labels for homeless individuals, such as fringe homeless, long-term homeless, temporary homeless, emergency homeless, visibly homeless, and invisibly homeless.
Within these categories, different groups of homeless individuals exist, including single women without children, single pregnant women, single mothers, single men, divorced men with or without children, families with children, runaway adolescents, LGBT+ youth, elderly individuals, disabled persons, veterans, and immigrants. Additional categories include those who have been evicted, those dealing with addiction, individuals with mental illnesses, those experiencing domestic violence, and those recently released from incarceration without transitional support.
Given the diversity among the homeless population, the National Coalition for the Homeless (2002) defines a homeless person according to the Stewart B. McKinney Act as someone who:
- Lacks a fixed, regular, and adequate nighttime residence.
- Has a primary nighttime residency that is:
- A supervised shelter designed to provide temporary living accommodations.
- An institution providing temporary residence for individuals intended to be institutionalized.
- A public or private place not designed for, or ordinarily used as, a regular sleeping accommodation for human beings.
This definition excludes individuals imprisoned or detained under federal or state law.
Where the Homeless are Likely to be Found
The experience of homelessness varies depending on geographic location. People experiencing homelessness in rural areas are less likely to live on the street or in shelters and are more likely to “couch surf” with relatives or friends in overcrowded or substandard housing. Despite the diversity among the homeless population, they share certain basic needs, including affordable housing, adequate income, mental and physical healthcare, and access to substance abuse treatment. Meeting these needs is essential for preventing and ending homelessness.
Census of Homeless
Accurately estimating the number of homeless individuals remains a challenge. Many national estimates rely on dated information, and no single estimate provides a definitive count. The Urban Institute (2000) estimated that approximately 3.5 million people, including 1.35 million children, experience homelessness at some point in any given year (O’Sullivan, 2003). However, these numbers are only the best approximation and may not capture the full extent of homelessness, particularly for those who do not seek services from shelters or who live in hidden locations.
Level or Categorization of Homelessness
Research on homelessness can be divided into three levels of analysis:
- Individual Level: Focuses on the biopsychosocial issues of individuals, such as mental illness, addiction, and disability. These individuals are often disaffiliated from society and may live in shelters or on the streets.
- Contextual Level: Examines homelessness in the context of the individual’s environment, including factors like lack of social support, economic hardship, and exposure to violence.
- Structural Level: Defines homelessness as an outcome of economic dislocation related to housing shortages and broader systemic issues.
A significant amount of research has focused on specific homeless populations, such as those with mental illnesses or those disaffiliated from society (McCarthy, D., Argerion, Huebner, & Lubran, 1991). Additionally, there is a growing increase in the number of homeless elders, attributed to their vulnerability to poverty and untreated mental illnesses, which often leads to early nursing home placement or premature death.
Women, particularly those who are single parents, have also become a major segment of the homeless population. Access to healthcare is a critical issue for these women. A study by Lim et al. (2001) involving 974 homeless women in Los Angeles County found that having health insurance and a regular source of healthcare were key factors associated with improved healthcare access.
Marital Status and Homelessness
Families, especially female-headed single-parent households, represent the fastest-growing segment of the homeless population. These families often face numerous challenges, including violence, abuse, and neglect. Research indicates that homelessness has severe adverse effects on children’s development, health, behavior, and academic success, highlighting the urgent need for targeted interventions and support.
Problems Invited by Homelessness
Homelessness brings with it a wide range of biopsychosocial, cultural, and spiritual health problems. For homeless adolescents, in particular, there is a higher propensity for engaging in delinquent or maladaptive social and health behaviors. Concepts such as risk, resiliency, and connectedness are critical for survival, supported by the formation of peer communities or “street families” (Ensign & Gittelsohn, 1998; Jezewski, 1995; O’Sullivan, 2003; Rew, Taylor-Seehafter, Thomas, & Yockey, 2001).
These street families provide a sense of belonging and support for homeless adolescents, but they also expose them to risky behaviors, including substance abuse, unprotected sex, and violence. Understanding these dynamics is crucial for developing effective nursing interventions to address the specific needs of homeless adolescents.
Nursing Role as an Advocate for Homeless
Nurses play a vital role as advocates for homeless populations, particularly in providing care for marginalized and vulnerable individuals. Nursing research, education, and practice are grounded in the philosophy of advocating for and facilitating healthcare for those who are marginalized. Given the diverse groups of homeless individuals and the known biopsychosocial outcomes of homelessness, there is a pressing need for intervention research to prevent homelessness and to develop programs that educate healthcare providers about the specific needs of homeless populations.
Nursing advocacy involves action on three levels:
- Macro Level: Engaging in policy development and advocacy to address the systemic issues that contribute to homelessness, such as lack of affordable housing, inadequate mental health services, and insufficient social support programs.
- Meso Level: Collaborating with healthcare systems, community organizations, and social services to develop and implement comprehensive care models that address the health needs of homeless individuals.
- Micro Level: Providing direct care, support, and education to homeless individuals, assessing their health needs, and connecting them with appropriate services and resources.
Conclusion
Homelessness is a complex and multifaceted issue that impacts the health and well-being of millions of individuals worldwide. Addressing homelessness requires a comprehensive approach that considers the macro, meso, and micro-level factors contributing to this problem. Nurses have a critical role to play as advocates for homeless individuals, providing care, support, and advocacy to improve health outcomes and prevent homelessness. Through research, education, and practice, nurses can help develop effective interventions and programs that address the specific needs of homeless populations, ultimately contributing to a reduction in homelessness and its associated health impacts.