homelessness in america research paper

• Open access
• Published: 22 August 2017

Social conditions of becoming homelessness: qualitative analysis of life stories of homeless peoples

• Mzwandile A. Mabhala   ORCID: orcid.org/0000-0003-1350-7065 1 , 3 ,
• Asmait Yohannes 2 &
• Mariska Griffith 1  

International Journal for Equity in Health volume  16 , Article number:  150 ( 2017 ) Cite this article

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It is increasingly acknowledged that homelessness is a more complex social and public health phenomenon than the absence of a place to live. This view signifies a paradigm shift, from the definition of homelessness in terms of the absence of permanent accommodation, with its focus on pathways out of homelessness through the acquisition and maintenance of permanent housing, to understanding the social context of homelessness and social interventions to prevent it.

However, despite evidence of the association between homelessness and social factors, there is very little research that examines the wider social context within which homelessness occurs from the perspective of homeless people themselves. This study aims to examine the stories of homeless people to gain understanding of the social conditions under which homelessness occurs, in order to propose a theoretical explanation for it.

Twenty-six semi-structured interviews were conducted with homeless people in three centres for homeless people in Cheshire North West of England.

The analysis revealed that becoming homeless is a process characterised by a progressive waning of resilience capacity to cope with life challenges created by series of adverse incidents in one’s life. The data show that final stage in the process of becoming homeless is complete collapse of relationships with those close to them. Most prominent pattern of behaviours participants often describe as main causes of breakdown of their relationships are:

engaging in maladaptive behavioural lifestyle including taking drugs and/or excessive alcohol drinking

Being in trouble with people in authorities.

Homeless people describe the immediate behavioural causes of homelessness, however, the analysis revealed the social and economic conditions within which homelessness occurred. The participants’ descriptions of the social conditions in which were raised and their references to maladaptive behaviours which led to them becoming homeless, led us to conclude that they believe that their social condition affected their life chances: that these conditions were responsible for their low quality of social connections, poor educational attainment, insecure employment and other reduced life opportunities available to them.

It is increasingly acknowledged that homelessness is a more complex social and public health phenomenon than the absence of a place to live. This view signifies a paradigm shift, from the definition of homelessness in terms of the absence of permanent accommodation [ 1 , 2 , 3 , 4 , 5 ], with its focus on pathways out of homelessness through the acquisition and maintenance of permanent housing [ 6 ], to understanding the social context of homelessness and social interventions to prevent it [ 6 ].

Several studies explain the link between social factors and homelessness [ 6 , 7 , 8 , 9 , 10 ]. The most common social explanations centre on seven distinct domains of deprivation: income; employment; health and disability; education, skills and training; crime; barriers to housing and social support services; and living environment [ 11 ]. Of all forms, income deprivation has been reported as having the highest risk factors associated with homelessness [ 7 , 12 , 13 , 14 ]: studies indicate that people from the most deprived backgrounds are disproportionately represented amongst the homeless [ 7 , 13 ]. This population group experiences clusters of multiple adverse health, economic and social conditions such as alcohol and drug misuse, lack of affordable housing and crime [ 10 , 12 , 15 ]. Studies consistently show an association between risk of homelessness and clusters of poverty, low levels of education, unemployment or poor employment, and lack of social and community support [ 7 , 10 , 13 , 16 ].

Studies in different countries throughout the world have found that while the visible form of homelessness becomes evident when people reach adulthood, a large proportion of homeless people have had extreme social disadvantage and traumatic experiences in childhood including poverty, shortage of social housing stocks, disrupted schooling, lack of social and psychological support, physical, sexual, and emotional abuse, neglect, dysfunctional family environments, and unstable family structures, all of which increase the likelihood of homelessness [ 10 , 13 , 14 ].

Furthermore, a large body of evidence suggests that people exposed to diverse social disadvantages at an early age are less likely to adapt successfully compared to people without such exposure [ 9 , 10 , 13 , 17 ], being more susceptible to adopting maladaptive coping behaviours such as theft, trading sex for money, and selling or using drugs and alcohol [ 7 , 9 , 18 , 19 ]. Studies show that these adverse childhood experiences tend to cluster together, and that the number of adverse experiences may be more predictive of negative adult outcomes than particular categories of events [ 17 , 20 ]. The evidence suggests that some clusters are more predictive of homelessness than others [ 7 , 12 ]: a cluster of childhood problems including mental health and behavioural disorders, poor school performance, a history of foster care, and disrupted family structure was most associated with adult criminal activities, adult substance use, unemployment and subsequent homelessness [ 12 , 17 , 21 ]. However, despite evidence of the association between homelessness and social factors, there is very little research that examines the wider social context within which homelessness occurs from the perspective of homeless people themselves.

This paper adopted Anderson and Christian’s [ 18 ] definition, which sees homelessness as a ‘function of gaining access to adequate, affordable housing, and any necessary social support needed to ensure the success of the tenancy’. Based on our synthesis of the evidence, this paper proposes that homelessness is a progressive process that begins at childhood and manifests itself at adulthood, one characterised by loss of the personal resources essential for successful adaptation. We adopted the definition of personal resources used by DeForge et al. ([ 7 ], p. 223), which is ‘those entities that either are centrally valued in their own right (e.g. self-esteem, close attachment, health and inner peace) or act as a means to obtain centrally valued ends (e.g. money, social support and credit)’. We propose that the new paradigm focusing on social explanations of homelessness has the potential to inform social interventions to reduce it.

In this study, we examine the stories of homeless people to gain understanding of the conditions under which homelessness occurs, in order to propose a theoretical explanation for it.

The design of this study was philosophically influenced by constructivist grounded theory (CGT). The aspect of CGT that made it appropriate for this study is its fundamental ontological belief in multiple realities constructed through the experience and understanding of different participants’ perspectives, and generated from their different demographic, social, cultural and political backgrounds [ 22 ]. The researchers’ resulting theoretical explanation constitutes their interpretation of the meanings that participants ascribe to their own situations and actions in their contexts [ 22 ].

The stages of data collection and analysis drew heavily on other variants of grounded theory, including those of Glaser [ 23 ] and Corbin and Strauss [ 24 ].

Setting and sampling strategy

The settings for this study were three centres for homeless people in two cities (Chester and Crewe) in Cheshire, UK. Two sampling strategies were used in this study: purposive and theoretical. The study started with purposive sampling and in-depth one-to-one semi-structured interviews with eight homeless people to generate themes for further exploration.

One of the main considerations for the recruitment strategy was to ensure that the process complies with the ethical principles of voluntary participation and equal opportunity to participate. To achieve this, an email was sent to all the known homeless centres in the Cheshire and Merseyside region, inviting them to participate. Three centres agreed to participate, all of them in Cheshire – two in Chester and one in Crewe.

Chester is the most affluent city in Cheshire and Merseyside, and therefore might not be expected to be considered for a homelessness project. The reasons for including it were: first, it was a natural choice, since the organisations that funded the project and the one that led the research project were based in Chester; second, despite its affluence, there is visible evidence of homelessness in the streets of Chester; and third, it has several local authority and charity-funded facilities for homeless people.

The principal investigator spent 1 day a week for 2 months in three participating centres, during that time oral presentation of study was given to all users of the centre and invited all the participants to participate and written participants information sheet was provided to those who wished to participate. During that time the principal investigator learned that the majority of homeless people that we were working with in Chester were not local. They told us that they came to Chester because there was no provision for homeless people in their former towns.

To help potential participants make a self-assessment of their suitability to participate without unfairly depriving others of the opportunity, participants information sheet outline criteria that potential participants had to meet: consistent with Economic and Social Research Council’s Research Ethics Guidebook [ 25 ], at the time of consenting to and commencing the interview, the participant must appear to be under no influence of alcohol or drugs, have a capacity to consent as stipulated in England and Wales Mental Capacity Act 2005 [ 26 ], be able to speak English, and be free from physical pain or discomfort.

As categories emerged from the data analysis, theoretical sampling was used to refine undeveloped categories in accordance with Strauss and Corbin’s [ 27 ] recommendations. In total 26 semi-structured interviews were carried out. Theoretical sampling involved review of memos or raw data, looking for data that might have been overlooked [ 27 , 28 ], and returning to key participants asking them to give more information on categories that seemed central to the emerging theory [ 27 , 28 ].

The sample comprised of 22 male and 4 female, the youndgest participant was 18 the eldest was 74 years, the mean age was 38.6 years. Table 1 illustrates participant’s education history, childhood living arrangements, brief participants family and social history, emotional and physical health, the onset of and trigger for homelessness.

Ethical approval

Ethical approval was obtained from the Research Ethics Committee of the University of Chester. The centre managers granted access once ethical approval had been obtained, and after their review of the study design and other research material, and of the participant information sheet which included a letter of invitation highlighting that participation was voluntary.

Data analysis

In this study data collection and analysis occurred simultaneously. Analysis drew on Glaser’s [ 23 ] grounded theory processes of open coding, use of the constant comparative method, and the iterative process of data collection and data analysis to develop theoretical explanation of homelessness.

The process began by reading the text line-by-line identifying and open coding the significant incidents in the data that required further investigation. The findings from the initial stage of analysis are published in Mabhala [ 29 ]. The the second stage the data were organised into three themes that were considered significant in becoming homeless (see Fig. 1 ):

Engaging in maladaptive behaviour

Being in trouble with the authorities.

Being in abusive environments.

Social explanation of becoming homeless. Legend: Fig. 1 illustrates the process of becoming homeless

The key questions that we asked as we continued to interrogate the data were: What category does this incident indicate? What is actually happening in the data? What is the main concern being faced by the participants? Interrogation of the data revealed that participants were describing the process of becoming homeless.

The comparative analysis involved three processes described by Glaser ([ 23 ], p. 58–60): each incident in the data was compared with incidents from both the same participant and other participants, looking for similarities and differences. Significant incidents were coded or given labels that represented what they stood for, and similarly coded or labeled when they were judged to be about the same topic, theme or concept.

After a period of interrogation of the data, it was decided that the two categories - destabilising behaviour, and waning ofcapacity for resilience were sufficiently conceptual to be used as theoretical categories around which subcategories could be grouped (Fig. 1 ).

Once the major categories had been developed, the next step consisted of a combination of theoretical comparison and theoretical sampling. The emerging categories were theoretically compared with the existing literature. Once this was achieved, the next step was filling in and refining the poorly defined categories. The process continued until theoretical sufficiency was achieved.

Figure 1 illustrates the process of becoming homeless. The analysis revealed that becoming homeless is a process characterised by a progressive waning of resilience created by a series of adverse incidents in one’s life. Amongst the frequently cited incidents were being in an abusive environment and losing a significant person in one’s life. However, being in an abusive environment emerged from this and previously published studies as a major theme; therefore, we decided to analyse it in more detail.

The data further show that the final stage in the process of becoming homeless is a complete collapse of relationships with those with whom they live. The most prominent behaviours described by the participants as being a main cause of breakdown are:

Engaging in maladaptive behaviour: substance misuse, alcoholism, self-harm and disruptive behaviours

Being in trouble with the authorities: theft, burglary, arson, criminal offenses and convictions

The interrogation of data in relation to the conditions within which these behaviours occurred revealed that participants believed that their social contexts influenced their life chance, their engagement with social institution such as education and social services and in turn their ability to acquire and maintain home. Our experiences have also shown that homeless people readily express the view that behavioural lifestyle factors such as substance misuse and engaging in criminal activities are the causes of becoming homeless. However, when we spent time talking about their lives within the context of their status as homeless people, we began to uncover incidents in their lives that appeared to have weakened their capacity to constructively engage in relationships, engage with social institutions to make use of social goods [ 29 , 30 , 31 ] and maturely deal with societal demands.

Being in abusive environments

Several participants explicitly stated that their childhood experiences and damage that occurred to them as children had major influences on their ability to negotiate their way through the education system, gain and sustain employment, make appropriate choices of social networks, and form and maintain healthy relationships as adults.

It appears that childhood experiences remain resonant in the minds of homeless participants, who perceive that these have had bearing on their homelessness. Their influence is best articulated in the extracts below. When participants were asked to tell their stories of what led to them becoming homeless, some of their opening lines were:

What basically happened, is that I had a childhood of so much persistent, consistent abuse from my mother and what was my stepfather. Literally consistent, we went around with my mother one Sunday where a friend had asked us to stay for dinner and mother took the invitation up because it saved her from getting off her ass basically and do anything. I came away from that dinner genuinely believing that the children in that house weren’t loved and cared for, because they were not being hit, there was no shouting, no door slamming. [Marco]

It appears that Marco internalised the incidents of abuse, characterised by shouting, door slamming and beating as normal behaviour. He goes on to intimate how the internalised abusive behaviour affected his interaction with his employers.

‘…but consistently being put down, consistently being told I was thick, I started taking jobs and having employers effing and blinding at me. One employer actually used a “c” word ending in “t” at me quite frequently and I thought it was acceptable, which obviously now I know it’s not. So I am taking on one job after another that, how can I put it? That no one else would do basically. I was so desperate to work and earn my own money. [Marco]

Similarly, David makes a connection between his childhood experience and his homelessness. When he was asked to tell his life story leading to becoming homeless, his opening line was:

I think it [homelessness] started off when I was a child. I was neglected by my mum. I was physically and mentally abused by my mum. I got put into foster care, when I left foster care I was put in the hostel, from there I turn into alcoholic. Then I was homeless all the time because I got kicked out of the hostels, because you are not allowed to drink in the hostel. [David]

David and Marco’s experiences are similar to those of many participants. The youngest participant in this study, Clarke, had fresh memories of his abusive environment under his stepdad:

I wouldn't want to go back home if I had a choice to, because before I got kicked out me stepdad was like hitting me. I wouldn't want to go back to put up with that again. [I didn't tell anyone] because I was scared of telling someone and that someone telling me stepdad that I've told other people. ‘[Be] cause he might have just started doing again because I told people. It might have gotten him into trouble. [Clarke]

In some cases, participants expressed the beliefs that their abusive experience not only deprived them life opportunities but also opportunities to have families of their own. As Tom and Marie explain:

We were getting done for child neglect because one of our child has a disorder that means she bruise very easily. They all our four kids into care, social workers said because we had a bad childhood ourselves because I was abused by my father as well, they felt that we will fail our children because we were failed by our parents. We weren’t given any chance [Tom and Marie]

Norma, described the removal of her child to care and her maladaptive behaviour of excessive alcohol use in the same context as her experience of sexual abuse by her father.

I had two little boys with me and got took off from me and put into care. I got sexually abused by my father when I was six. So we were put into care. He abused me when I was five and raped me when I was six. Then we went into care all of us I have four brothers and four sisters. My dad did eighteen months for sexually abusing me and my sister. I thought it was normal as well I thought that is what dads do [Norma]

The analysis of participants in this study appears to suggest that social condition one is raised influence the choice of social connections and life partner. Some participants who have had experience of abuse as children had partner who had similar experience as children Tom and Marie, Lee, David and his partners all had partners who experienced child abuse as children.

Tom and Marie is a couple we interviewed together. They met in hostel for homeless people they have got four children. All four children have been removed from them and placed into care. They sleep rough along the canal. They explained:

We have been together for seven years we had a house and children social services removed children from us, we fell within bedroom tax. …we received an eviction order …on the 26th and the eviction date was the 27th while we were in family court fighting for our children. …because of my mental health …they were refusing to help us.

Our children have been adopted now. The adoption was done without our permission we didn’t agree to it because we wanted our children home because we felt we were unfairly treated and I [Marie] was left out in all this and they pin it all on you [Tom] didn’t they yeah, my [Tom] history that I was in care didn’t help.

Tom went on to talk about the condition under which he was raised:

I was abandoned by my mother when I was 12 I was then put into care; I was placed with my dad when I was 13 who physically abused me then sent back to care. [Tom].

David’s story provides another example of how social condition one is raised influence the choice of social connections and life partner. David has two children from two different women, both women grew up in care. Lisa one of David’s child mother is a second generation of children in care, her mother was raised in care too.

I drink to deal with problems. As I say I’ve got two kids with my girlfriend Kyleigh, but I got another lad with Lisa, he was taken off me by social services and put on for adoption ten years ago and that really what started it; to deal with that. Basically, because I was young, and I had been in care and the way I had been treated by my mum. Basically laid on me in the same score as my mum and because his mum [Lisa] was in care as well. So they treated us like that, which was just wrong. [David]

In this study, most participants identified alcohol or drugs and crime as the cause of relationships breakdown. However, the language they used indicates that these were secondary reasons rather than primary reasons for their homelessness. The typical question that MA and MG asked the interview participants was “tell us how did you become homeless”? Typically, participants cited different maladaptive behaviours to explain how they became homeless.

Alvin’s story is typical of:

Basically I started off as a bricklayer, … when the recession hit, there was an abundance of bricklayers so the prices went down in the bricklaying so basically with me having two young children and the only breadwinner in the family... so I had to kinda look for factory work and so I managed to get a job… somewhere else…. It was shift work like four 12 hour days, four 12 hour nights and six [days] off and stuff like that, you know, real hard shifts. My shift was starting Friday night and I’ll do Friday night, Saturday night to Monday night and then I was off Tuesday, Wednesday and Thursday, but I’d treat that like me weekend you know because I’ve worked all weekend. Then… so I’d have a drink then and stuff like that, you know. 7 o’ clock on a Monday morning not really the time to be drinking, but I used to treat it like me weekend. So we argued, me and my ex-missus [wife], a little bit and in the end we split up so moved back to me mum's, but kept on with me job, I was at me mum’s for possibly about five years and but gradually the drinking got worse and worse, really bad. I was diagnosed with depression and anxiety. … I used to drink to get rid of the anxiety and also to numb the pain of the breakup of me marriage really, you know it wasn’t good, you know. One thing led to another and I just couldn’t stop me alcohol. I mean I’ve done drugs you know, I was into the rave scene and I’ve never done hard drugs like heroin or... I smoke cannabis and I use cocaine, and I used to go for a pint with me mates and that. It all came to a head about November/December time, you know it was like I either stop drinking or I had to move out of me mum's. I lost me job in the January through being over the limit in work from the night before uum so one thing led to another and I just had to leave. [Alvin]

Similarly, Gary identified alcohol as the main cause of his relationship breakdown. However, when one listens to the full story alcohol appears to be a manifestation of other issues, including financial insecurities and insecure attachment etc.

It [the process of becoming homeless] mainly started with the breakdown of the relationship with me partner. I was with her for 15 years and we always had somewhere to live but we didn't have kids till about 13 years into the relationship. The last two years when the kids come along, I had an injury to me ankle which stopped me from working. I was at home all day everyday. …I was drinking because I was bored. I started drinking a lot ‘cause I couldn't move bout the house. It was a really bad injury I had to me ankle. Um, and one day me and me partner were having this argument and I turned round and saw my little boy just stood there stiff as a board just staring, looking at us. And from that day on I just said to me partner that I'll move out, ‘cause I didn't want me little boy to be seeing this all the time. [Gary]

In both cases Gary and Alvin indicate that changes in their employment status created conditions that promoted alcohol dependency, though both explained that they drank alcohol before the changes in their employment status occurred and the breakdown of relationships. Both intimated that that their job commitment limited the amount of time available to drink alcohol. As Gary explained, it is the frequency and amount of alcohol drinking that changed as a result of change in their employment status:

I used to have a bit of a drink, but it wasn’t a problem because I used to get up in the morning and go out to work and enjoy a couple of beers every evening after a day’s work. Um, but then when I wasn't working I was drinking, and it just snowballed out, you know snowball effect, having four cans every evening and then it went from there. I was drinking more ‘cause I was depressed. I was very active before and then I became like non-active, not being able to do anything and in a lot of pain as well. [Gary]

Furthermore, although the participants claim that drinking alcohol was not a problem until their employment circumstances changed, one gets a sense that alcohol was partly responsible for creating conditions that resulted in the loss of their jobs. In Gary’s case, for example, alcohol increased his vulnerability to the assault and injuries that cost him his job:

I got assaulted, kicked down a flight of stairs. I landed on me back on the bottom of the stairs, but me heel hit the stairs as it was still going up if you know what I mean. Smashed me heel, fractured me heel… So, by the time I got to the hospital and they x-rayed it they wasn't even able to operate ‘cause it was in that many pieces, they weren't even able to pin it if you know what I mean. [Gary]

Alvin, of the other hand, explained that:

I lost my job in the January through being over the limit in work from the night before, uum so one thing led to another and I just had to leave. [Alvin]

In all cases participants appear to construct marriage breakdown as an exacerbating factor for their alcohol dependence. Danny, for example, constructed marriage breakdown as a condition that created his alcohol dependence and alcohol dependence as a cause of breakdown of his relationship with his parents. He explains:

I left school when I was 16. Straight away I got married, had children. I have three children and marriage was fine. Umm, I was married for 17 years. As the marriage broke up I turned to alcohol and it really, really got out of control. I moved in with my parents... It was unfair for them to put up with me; you know um in which I became... I ended up on the streets, this was about when I was 30, 31, something like that and ever since it's just been a real struggle to get some permanent accommodation. [Danny]

Danny goes on to explain:

Yes [I drank alcohol before marriage broke down but] not very heavily, just like a sociable drink after work. I'd call into like the local pub and have a few pints and it was controlled. My drinking habit was controlled then. I did go back to my parents after my marriage break up, yes. I was drinking quite heavily then. I suppose it was a form of release, you know, in terms of the alcohol which I wish I'd never had now. When I did start drinking heavy at me parents’ house, I was getting in trouble with the police being drunk and disorderly. That was unfair on them. [Danny]

The data in this study indicate that homelessness occurs when the relationships collapse, irrespective of the nature of the relationship. There were several cases where lifestyle behaviour led to a relationship collapse between child and parents or legal guardians.

In the next excerpt, Emily outlines the incidents: smoking weed, doing crack and heroin, and drinking alcohol. She also uses the words ‘because’, ‘when’ and ‘obviously’, which provide clues about the precipitating condition for her behaviours “spending long time with people who take drugs”.

I've got ADHD like, so obviously my mum kicked me out when I was 17 and then like I went to **Beswick** and stuff like that. My mum in the end just let me do what I wanted to do, ‘cause she couldn't cope anymore. …I mean I tried to run away from home before that, but she'd always like come after me in like her nightie and pyjamas and all that. But in the end she just washed her hands of me . [Emily]

Emily presented a complex factors that made it difficult for her mother to live with her. These included her mother struggle with raising four kids as a single parent, Emily’s mental health (ADHD], alcohol and drug use. She goes on to explain that:

Ummm, well the reason I got kicked out of my hostel was ‘cause of me drinking, so I'd get notice to quit every month, then I’d have a meeting with the main boss and then they'd overturn it and this went on every month for about six months. Also, it was me behaviour as well, but obviously drink makes you do stuff you don't normally do and all that shit. I lived here for six months, got kicked out because I jumped out the window and broke me foot. I was on the streets for six months and then they gave me a second chance and I've been here a year now. So that's it basically. [Emily]

There were several stories of being evicted from accommodation due to excessive use of alcohol. One of those is David:

I got put into foster care. When I left foster care I was put in the hostel, from there I turn into alcoholic. Then I was homeless all the time because I got kicked out of the hostels, because you are not allowed to drink in the hostel. It’s been going on now for about… I was thirty-one on Wednesday, so it’s been going on for about thirteen years, homeless on and off. Otherwise if not having shoplifted for food and then go to jail, and when I don’t drink I have lot of seizures and I end up in the hospital. Every time I end up on the street. I trained as a chef, I have not qualified yet, because of alcohol addiction, it didn’t go very well. I did couple of jobs in restaurants and diners, I got caught taking a drink. [David]

Contrary to the other incidents where alcohol was a factor that led to homelessness, Barry’s description of his story appears to suggest that the reason he had to leave his parents’ home was his parents’ perception that his sexuality brought shame to the family:

When I came out they I’m gay, my mum and dad said you can’t live here anymore. I lived in a wonderful place called Nordic... but fortunately, mum and dad ran a pub called […] [and] one of the next door neighbours lived in a mansion. His name was [….] [and] when I came out, he came out as in he said “I'm a gay guy”, but he took me into Liverpool and housed me because I had nowhere to live. My mum and dad said you can't live here anymore. And unfortunately, we get to the present day. I got attacked. I got mugged... only walked away with a £5 note, it’s all they could get off me. They nearly kicked me to death so I was in hospital for three weeks. By the time I came out, I got evicted from my flat. I was made homeless. [Barry]

We used the phrase “engaging in maladaptive behaviour” to conceptualise the behaviours that led to the loss of accommodation because our analysis appear to suggest that these behaviours were strategies to cope with the conditions they found themselves in. For example, all participants in this category explained that they drank alcohol to cope with multiple health (mental health) and social challenges.

In the UK adulthood homelessness is more visible than childhood homelessness. However, most participants in this research reveal that the process of becoming homeless begins at their childhood, but becomes visible after the legal age of consent (16). Participants described long history of trouble with people in authority including parents, legal guardians and teachers. However, at the age of 16 they gain legal powers to leave children homes, foster homes, parental homes and schools, and move outside some of the childhood legal protections. Their act of defiance becomes subject to interdiction by the criminal justice system. This is reflected in number of convictions for criminal offenses some of the participants in this study had.

Participants Ruddle, David, Lee, Emily, Pat, Marco, Henry and many other participants in this study (see Table 1 ) clearly traced the beginning of their troubles with authority back at school. They all expressed the belief that had their schooling experience been more supportive, their lives would have been different. Lee explains that being in trouble with the authorities began while he was at school:

‘The school I came from a rough school, it was a main school, it consisted of A, B, C, D and The school I came from [was] a rough school, it was a main school, it consisted of A, B, C, D and E. I was in the lowest set, I was in E because of my English and maths. I was not interested, I was more interested in going outside with big lads smoking weed, bunking school. I used to bunk school inside school. I used to bunk where all cameras can catch me. They caught me and reported me back to my parents. My mum had a phone call from school asking where your son is. My mum grounded me. While my mum grounded me I had a drain pipe outside my house, I climbed down the drain pipe outside my bedroom window. I used to climb back inside. [Lee]

Lee’s stories constructed his poor education experiences as a prime mover towards the process of becoming homeless. It could be noted in Table 1 that most participants who described poor education experiences came from institutions such as foster care, children home and special school for maladjusted children. These participants made a clear connection between their experiences of poor education characterised by defiance of authorities and poor life outcomes as manifested through homelessness.

Patrick made a distinct link between his school experience and his homelessness, for example, when asked to tell his story leading up to becoming homeless, Patrick’s response was:

I did not go to school because I kept on bunking. When I was fifteen I left school because I was caught robbing. The police took me home and my mum told me you’re not going back to school again, you are now off for good. Because if you go back to school you keep on thieving, she said I keep away from them lads. I said fair enough. When I was seventeen I got run over by a car. [Patrick]

Henry traces the beginning of his troubles with authorities back at school:

[My schooling experience]… was good, I got good, well average grades, until I got myself into [a] few fights mainly for self-defence. In primary schools, I had a pretty... I had a good report card. In the start of high school, it was good and then when the fights started that gave me sort of like a... bad reputation. I remember my principal one time made me cry. Actually made me cry, but eh... I don't know how, but I remember sitting there in the office and I was crying. My sister also stuck up for me when she found out what had happened, she was on my side; but I can’t remember exactly what happened at that time. [Henry]

Emily’s story provides some clues about the series of incidents - including, delay in diagnosing her health condition, being labelled as a naughty child at school, being regularly suspended from school and consequently poor educational attainment.

Obviously, I wasn't diagnosed with ADHD till I was like 13, so like in school they used to say that's just a naughty child. … So it was like always getting suspended, excluded and all that sort of stuff. And in the end [I] went to college and the same happened there. [Emily]

The excerpt above provides intimations of what she considers to be the underlying cause of her behaviour towards the authorities. Emily suggests that had the authorities taken appropriate intervention to address her condition, her life outcomes would have been different.

Although the next participant did not construct school as being a prime mover of their trouble with authorities, their serious encounters with the criminal justice system occurred shortly after leaving school:

Well I did a bit of time at a very early age, I was only 16… I did some remand there, but then when I went to court ‘cause I'd done enough remand, I got let out and went to YMCA in Runcorn. Well, that was when I was a kid. When I was a bit older, ‘cause it was the years 2000 that I was in jail, I was just trying to get by really. I wasn’t with Karen at the time. I was living in Crewe and at the time I was taking a lot of amphetamines and was selling amphetamines as well, and I got caught and got a custodial sentence for it. But I've never been back to jail since. I came out in the year 2000 so it's like 16 years I've kept meself away from jail and I don't have any intentions of going back. [Gary]

The move from school and children social care system to criminal justice was a common pathways for many participants in this study. Some including Lee, Crewe, David, Patrick spent multiple prison sentences (see Table 1 ). Although Crewe did not make connection between his schooling experiences and his trouble with law, it could be noted that his serious encounter with criminal justice system started shortly after leaving foster care and schooling systems. As he explains:

I was put into prison at age of 17 for arson that was a cry for help to get away from the family, I came out after nine months. I have been in prison four times in my life, its not very nice, when I came out I made a promise to myself that I’m never going to go back to prison again. [Crewe]

Lee recalls his education experience. He explained:

I left school when I was fifteen… then I went off the rails. I got kidnapped for three and half months. When I came back I was just more interested in crime. When I left school I was supposed to go to college, but I went with travellers. I was just more interested in getting arrested every weekend, until my mum say right I have enough of you. I was only seventeen. I went through the hostels when I was seventeen. [Lee]

None describe the educational experience with a similar profundity to Marco:

On few occasions I came out on the corridors I would be getting battered on to my hands and knees and teachers walk pass me. There was quite often blood on the floor from my nose, would be punched on my face and be thrown on the floor. …. It was hard school, pernicious. I would go as far as saying I never felt welcome in that school, I felt like a fish out of the water, being persistently bullied did my head in. Eventually I started striking back, when I started striking back suddenly I was a bad one. My mother decided to put me in … school for maladjusted boys, everyone who been there including myself have spent time in prison. [Marco]

The trouble with authorities that was observes in participants stories in this category appear to be part of the wider adverse social challenges that the participants in this study were facing. Crewe’s description of arson as a cry for help appears to be an appropriate summation of all participants in this category.

The participants’ description of the social conditions in which were raised and their references to maladaptive behaviours which led to them becoming homeless, led us to conclude that they believe that their social condition affected their life chances: that these conditions were responsible for their low quality of social connections, poor educational attainment, insecure employment and other reduced life opportunities available to them.

The key feature that distinguish this study from comparable previous studies is that it openly acknowledges that data collection and analysis were influenced by the principles of social justice [ 28 , 30 , 31 ]. The resulting theoretical explanation therefore constitutes our interpretation of the meanings that participants ascribe to their own situations and actions in their contexts. In this study, defining homelessness within the wider socioeconomic context seemed to fit the data, and offered one interpretation of the process of becoming homeless.

While the participants’ experiences leading to becoming homeless may sound trite. What is pertinent in this study is understanding the conditions within which their behaviours occurred. The data were examined through the lens of social justice and socio-economic inequalities: we analysed the social context within which these behaviours occurred. We listened to accounts of their schooling experiences, how they were raised and their social network. The intention was not to propose a cause-and-effect association, but to suggest that interventions to mitigate homelessness should consider the social conditions within which it occurred.

Participants in this study identified substance misuse and alcohol dependency as a main cause of their homelessness. These findings are consistent with several epidemiological studies that reported a prevalence of substance misuse amongst the homeless people [ 32 , 33 , 34 , 35 , 36 ]. However, most these studies are epidemiological; and by nature epidemiological studies are the ‘gold standard’ in determining causes and effects, but do not always examine the context within which the cause and effect occur. One qualitative study that explored homelessness was a Canadian study by Watson, Crawley and Cane [ 37 ]. Participants in the Watson, et al. described ‘lack of quality social interactions and pain of addition. However, Watson et al. focus on the experiences of being homeless, rather than the life experiences leading to becoming homeless. To our knowledge the current study is one of very few that specifically examine the conditions within which homelessness occurs, looking beyond the behavioural factors. Based on the synthesis of data from previous studies, it makes sense that many interventions to mitigate homelessness focus more on tackling behavioural causes of homelessness rather than fundamental determinants of it [ 38 ]. From the public health intervention’ point of view, however, understanding the conditions within which homelessness occurs is essential, as it will encourage policymakers and providers of the services for homelessness people to devote equal attention to tackling the fundamental determinants of homelessness as is granted in dealing behavioural causes.

Participants in this study reported that they have been defiant toward people in positions of authority. For most of them this trouble began when they were at school, and came to the attention of the criminal justice system as soon as they left school at the age of 16. These findings are similar to these in the survey conducted by Williams, Poyser, and Hopkins [ 39 ] which was commissioned by the UK Ministry of Justice. This survey found that 15 % of prisoners in the sample reported being homeless before custody [ 39 ]; while three and a half percent of the general population reported having ever been homeless [ 39 ]. As the current study reveals there are three possible explanations for the increased population of homeless young people in the criminal justice system: first, at the age of 16 they gain legal powers to leave their foster homes, parents homes, and schools and move beyond some of the childhood legal protections; second, prior to the age of 16 their defiant behaviours were controlled and contained by schools and parents/legal guardians; and third, after the age of 16 their acts of defiant behaviour become subject to interdiction by the criminal justice system.

The conditions in which they were born and raised were described by some participants in this study as ‘chaotic’, abusive’, ‘neglect’, ‘pernicious’ ‘familial instability’, ‘foster care’, ‘care home’, etc. Taking these conditions, and the fact that all but one participants in this left school at or before the age of 16 signifies the importance of living conditions in educational achievement. It has been reported in previous studies that children growing up in such conditions struggle to adjust in school and present with behavioural problems, and thus, poor academic performance [ 40 ]. It has also been reported that despite these families often being known to social services, criminal justice systems and education providers, the interventions in place do little to prevent homelessness [ 40 ].

Analysis of the conditions within which participants’ homelessness occurred reveals the adverse social conditions within which they were born and raised. The conditions they described included being in an abusive environment, poor education, poor employment or unemployment, poor social connections and low social cohesion. These conditions are consistent with high index of poverty [ 37 , 41 , 42 ]. And several other studies found similar associations between poverty and homelessness [ 42 ]. For example, the study by Watson, Crowley et al. [ 37 ] found that there were extreme levels of poverty and social exclusion amongst homeless people. Contrary to previous studies that appear to construct homelessness as a major form of social exclusion, the analysis of participants’ stories in this current study revealed that the conditions they were raised under limited their capacity to engage in meaningful social interactions, thus creating social exclusion.

Homeless people describe the immediate behavioural causes of homelessness; however, this analysis revealed the social and economic conditions within which homelessness occurred. The participants’ descriptions of the social conditions in which were raised and their references to maladaptive behaviours which led to them becoming homeless, led us to conclude that they believe that their social condition affected their life chances: that these conditions were responsible for their low quality of social connections, poor educational attainment, insecure employment and other reduced life opportunities available to them.

Limitations

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Acknowledgements

The authors wish to thank all participants in this study; without their contribution it would not have been possible to undertake the research. The authors acknowledge the contribution of Professor Paul Kingston and Professor Basma Ellahi at the proposal stage of this project. A very special thanks to Robert Whitehall, John and all the staff at the centres for homeless people for their help in creating a conducive environment for this study to take place; and to Roger Whiteley for editorial support. A very special gratitude goes to the reviewers of this paper, who will have expended considerable effort on our behalf. 

This research was funded by quality-related research (QR) funding allocation for the University of Chester.

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The datasets generated during and/or analysed during the current study are not publicly available due to ethical restriction and privacy of participant data but are available from the corresponding author on reasonable request.

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MM wrote the entire manuscript, designed the study, collected data, analysed and interpreted data, and presented the findings. AY contributed to transcribing data and manuscript editing. MG contributed to data collection, and transcribed the majority of data. All authors read and approved the final manuscript.

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Mabhala, M.A., Yohannes, A. & Griffith, M. Social conditions of becoming homelessness: qualitative analysis of life stories of homeless peoples. Int J Equity Health 16 , 150 (2017). https://doi.org/10.1186/s12939-017-0646-3

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2 Addressing Homelessness in the United States

Homelessness in the United States is a highly complex and dynamic condition that has evolved over time. The demographic characteristics of persons experiencing homelessness have changed due to, among other things, fluctuations in the strength and nature of the economy, broad population shifts, and changes in societal attitudes toward poor, excluded, and disenfranchised persons. While our understanding about the causes of homeless and what interventions are most effective has improved, there is still much more we need to learn about this complex issue.

This chapter briefly describes what we know about who experiences homelessness, how homelessness can impact health and other outcomes, and current housing interventions and the populations these are intended to serve, including permanent supportive housing. For a brief history of homelessness in the United States, please see Appendix B .

• CURRENT STATE OF HOMELESSNESS IN THE UNITED STATES: DATA AND TRENDS

While the numbers have generally been decreasing since 2010, in 2017, more than 550,000 people in the United States were staying in shelters or in places not intended for human habitation on a single night ( HUD, 2017a , b ). Many more people experience homelessness over longer periods, such as 1 year or more. In 2016, 1.42 million people at some point stayed in a homeless shelter or a transitional housing program ( HUD, 2017a ). How homelessness is defined, as described below, impacts how these data are collected, and what we know about who is experiencing homelessness, and informs what services are needed.

Defining Homelessness

The definition of “homelessness” has changed over time, and even today, relevant federal agencies define the term differently. Differences in the characterization of homelessness allow agencies to tailor definitions to represent the needs of their unique subpopulations (e.g., homeless unmarried adults, homeless children, or homeless families) and the goals of the agency's programs and policies. However, having varying definitions can make it more challenging for people to identify and access the appropriate services ( Watson, 1984 ; SAMHSA, 2017 ). For example, children experiencing homelessness are eligible for services through their local educational agency with funding from the Department of Education, which uses a definition of homelessness that is broader than that used by the Department of Housing and Urban Development (HUD). In addition, different definitions create challenges in counting individuals experiencing homelessness, tracking the use of homelessness services, and documenting unmet needs ( HUD, 2008 ; Burt et al., 2010 ).

While it is tempting to make recommendations that a single definition be developed for use across federal agencies and other relevant organizations, this notion was recently abandoned by the U.S. Interagency Council on Homelessness (USICH). In 2010, USICH convened a meeting of experts and stakeholders to discuss the feasibility of adopting standard definitions and a standardized vocabulary as mandated by the Homeless Emergency Assistance and Rapid Transition to Housing Act of 2009. Substantial concerns were voiced that creating a single definition would be too resource intensive for state and local governments to handle and could lead to a loss of resources for local agencies serving unique subpopulations that might not meet the criteria of a standardized definition. Thus, instead of creating a standardized definition, the recommendation was to create a common vocabulary and common data standards that would allow agencies to distinguish the needs of various subpopulations.

A common vocabulary would ensure that a standard terminology would be used in how local agencies define different manifestations of homelessness but still allow for these different manifestations to be defined as homelessness based on a preestablished set of eligibility criteria. This would also increase the ability of local agencies to capture the diversity within their homeless population. A common data standard would also help to ensure that a standard set of information is collected by reporting entities and would facilitate interorganizational data pooling and linkages to characterize the state of the homelessness by pooling data across agencies.

Some progress has been made on common data standards, with one example being efforts to integrate data sources between the Homelessness Management Information System (HMIS) 1 and the Runaway and Homeless Youth Management Information System ( USICH, 2015b ). In addition, the European Typology of Homelessness and Housing Exclusion (ETHOS) has been developed as “a means of improving understanding and measurement of homelessness in Europe” ( FEANTSA, 2018 ). However, there remain many more examples of a lack of data linkages that need to be resolved at the federal, state, and local levels. While it is difficult to precisely quantify the size of the homeless population, HUD has developed several methods for collecting these data, including HMIS and a single point-in-time (PIT) counting system. The best estimate of counting the number of individuals experiencing homelessness is described in Appendix C .

Subpopulations of Individuals Experiencing Homelessness

An assessment of recent data indicates that overall, more men than women experience homelessness. African Americans are significantly overrepresented among persons experiencing homelessness, accounting for 41 percent of the homeless population while constituting only 13 percent of the U.S. population ( HUD, 2017b ). Nearly 22 percent of the individuals in the PIT count 2 were Hispanic/Latino. The numbers of individuals experiencing homelessness among other racial/ethnic minorities is much lower (1.2 percent Asian, 3 percent Native American, 1.5 percent Pacific Islander, and 6.5 percent mixed race). A 2018 study by the Center for Social Innovation's Supporting Partnerships for Anti-Racist Communities of five communities found significant racial disparities in rates of homelessness. In fact, the study found that “Black residents accounted for nearly 65 percent of people experiencing homelessness in the five communities, even though they accounted for only 18 percent of the communities' overall population. Nationwide, black people account for 12 percent of the population, but 43 percent of the homeless population” ( National Low Income Housing Coalition, 2018 ).

Of particular interest to the committee is the number of persons who are defined as chronically homeless: that is, individuals or families (which include at least one adult and one child) with disabilities who have either been continuously homeless for 1 year or more or who have experienced at least four episodes of homelessness in the past 3 years ( HUD, 2016c ). People experiencing chronic homelessness are one of the primary populations that permanent supportive housing (PSH) programs are designed to serve.

In 2017, data from the PIT count indicated that almost three-quarters of the individuals experiencing homelessness on a single night were not chronically homeless ( HUD, 2017b ) and thus are not the primary focus of this report. In 2017, those who were experiencing chronic homelessness as measured on a single night included 86,962 individuals, nearly 7 in 10 of whom were unsheltered. Half of all people experiencing homelessness on a single night who are living in unsheltered locations live in one of five states having more temperate climates—California, Nevada, Oregon, Hawaii, and Mississippi ( HUD, 2017b ).

Veterans represent another subpopulation of particular interest. In 2017, 40,056 veterans were experiencing homelessness, accounting for 9 percent of the population of adults experiencing homelessness. ( HUD, 2017b ). This number represents an increase from 2016, and is due to an increase in veterans experiencing homelessness and staying in unsheltered locations. Box 2-1 describes additional information about veteran homelessness and housing.

Veterans Experiencing Homelessness.

Unaccompanied homeless children and youth on a single night totaled 40,799 in 2017 ( HUD, 2017b ). They are youth under age 25, with the majority between ages 18 and 24. The number of youth experiencing homelessness is particularly difficult to determine with PIT counts. HUD has targeted this group for more focused efforts to produce better PIT numbers. (For more information about a program serving youth experiencing homelessness in San Jose, see Appendix D .) Auerswald et al. (2016) noted that African American youth can be particularly difficult to find, as they are less likely to access services for youth experiencing homelessness.

One group of youth who are at particularly high risk for homelessness are lesbian, gay, bisexual, transgender, and questioning (LGBTQ) youth. Durso and Gates (2012) , in surveying service providers for youth experiencing homelessness, estimated that 40 percent of the youth experiencing homelessness that they worked with were LGBTQ. More information about families and youth can be found in Chapter 6 .

Homeless families with children numbered 184,661 people in the single-night January 2017 PIT count, accounting for a third of the total population of people experiencing homelessness ( HUD, 2017b ). Most families with children experiencing homelessness were sheltered (more than 90 percent).

A recent subpopulation that has grown to be of concern is homeless older adults. The number of persons older than age 65—the aging Baby Boomers—increases daily ( Ortman etal., 2014 ), and some portion of these older persons will experience homelessness. Hahn et al. (2006) examined 14-year trends in the population of individuals experiencing homelessness in San Francisco ( n = 3,534) and concluded that the homeless population is aging by about two-thirds of a year every calendar year, consistent with trends in several other cities. Ng et al. (2013) described the added effects of being both elderly and homeless, noting that “with homelessness, the unsafe and unsanitary living conditions aggravate elderly people's acute and chronic health conditions” (p. 1). Based on the examination of adults age 50 and older in Oakland, California, in 2013–2014 ( n = 350), Lee et al. (2016) found that pre-homeless social support appears to protect this group against street homelessness after losing rental housing. A unique aging trend among the homeless population is further discussed in Chapter 5 .

Although all individuals experiencing homelessness face health risks, women have a unique array of medical needs, including a range of reproductive health issues. For example, women experiencing homelessness have higher rates of unintended pregnancies when compared to housed women ( Crawford et al., 2011 ; American College of Obstetricians and Gynecologists, 2013 ). The experience of pregnancy during a period of homelessness is not difficult only for women. Infants born to mothers experiencing homelessness, when compared to infants born to housed women, are more likely to be low or very low birthweight ( Merrill et al., 2011 ; Richards et al., 2011 ).

• HEALTH OF INDIVIDUALS EXPERIENCING HOMELESSNESS

The experience of homelessness can lead to a variety of negative health outcomes. The Institute of Medicine report on homelessness and health ( IOM, 1988 ) described three types of interactions between homelessness and health. There are health problems that precede homelessness and are likely causal factors for homelessness; health outcomes that occur in response to experiencing homelessness; and health problems including chronic illnesses whose treatment is complicated by the experience of being homeless. Each of these is considered in turn. While numerous studies have documented health problems associated with the experience of either spending time in a homeless shelter, or being homeless and living on the street, the committee acknowledges that there may be additional methodological challenges in assessing the health outcomes in this population which are not described here.

Individuals experiencing homelessness also face overwhelming barriers and obstacles to receiving high-quality, continuous, and coordinated health care. Hospitals, clinics, and reimbursement systems are not designed to cope with the special needs of individuals who spend much of their time on the streets and are exposed to extremes of weather, violence, and a lack of safe, secure, stable housing. Individuals living in shelters and on the streets have a high burden of medical and psychiatric illnesses, often complicated by chronic substance use disorders. They utilize hospital emergency departments for much of their health care and, in general, require more frequent acute care hospitalizations. These frequent hospitalizations are characterized by longer stays while hospitalized ( Kushel et al., 2002 ; Ku et al., 2010 ; Cheung et al., 2015 ; Lin et al., 2015 ). In addition, there are high rates of trauma/victimization, numerous studies documenting evidence of the accumulation of adverse childhood experiences and toxic stress that contribute to serious chronic medical conditions and poor health, including changes in metabolism, immune systems, and executive functioning and cognitive impairment ( Cutuli et al., 2015 ; Lee et al., 2017 ). These issues, including a new paradigm to better understand the impact of permanent supportive housing on health for those with chronic conditions is further discussed in Chapter 3 .

Health Problems Preceding Homelessness

As described below, research indicates that substance use and mental health are both a cause and a consequence of homelessness (e.g., homelessness is related to worsening severity of mental illness and higher-risk behaviors in the case of substance use) ( Johnson and Chamberlain, 2008 ). However, mental illness is a common antecedent to homelessness. The Office of National Drug Control Policy estimates that 30 percent of the population of individuals experiencing chronic homelessness are living with a serious mental illness (SMI) ( ONDCP, 2014 ; SAMHSA, 2017 ). There is a high prevalence of specific mental illnesses in the population of single individuals experiencing homelessness relative to the general population, including depression (20-25 percent prevalence across studies, as compared to 0.35 percent of the general population) and schizophrenia (5-15 percent prevalence across studies, as compared to 0.35 percent of the general population) ( Martens, 2001 ; Perälä et al., 2007 ; Toro, 2007 ). There are systematic reviews that explicitly excluded studies of families because they were so rare that they deemed them a “special population” ( Fazel et al., 2008 , 2014 ).

Substance use disorders, especially alcoholism, are also a major problem for individuals experiencing homelessness, as well as an increasingly common cause of death ( NIDA, 2013 ). Baggett et al. (2010) analyzed data from the 2003 Health Care for the Homeless study ( n = 966) and found that both drug and alcohol use together was a major predisposing factor for experiencing homelessness. The combination of SMI and substance abuse is common in the population of individuals experiencing homelessness ( Salit et al., 1998 ).

Health Outcomes Due to Homelessness

Spending time in a homeless shelter can also lead to negative health outcomes for individuals experiencing homelessness. Kelly (1985) found that homelessness increases the risk of developing health problems, including diseases of the extremities and skin disorders and increases the possibility of trauma, especially as a result of physical assault or rape. In addition, the Centers for Disease Control and Prevention reported outbreaks of tuberculosis in two homeless shelters, one in Duval County, Florida ( CDC, 2012a ), and one in Kane County, Illinois ( CDC, 2012b ). In 1990, McAdam et al. (1990) investigated the prevalence of tuberculosis in a men's homeless shelter in New York City. Over a 73-month period, the authors screened more than 1,800 men and found an infection rate (positive PPD test, history of a positive PPD test, or active tuberculosis) of nearly 43 percent.

Chak et al. (2011) noted that individuals experiencing homelessness have higher prevalence rates of hepatitis C (HCV), particularly those who are infected with HIV. There are shared routes of transmission for the two viruses, and the authors noted that HCV prevalence rates ranged from 19 percent to 69 percent in patients experiencing homelessness.

Dirmyer (2015) investigated hospital readmission rates for persons experiencing homelessness in Albuquerque, New Mexico. One-third of these patients experienced a 30-day readmission to the hospital over the course of a 3-year period, with the most prevalent cause of readmission being neuropsychiatric disorders. The hospital readmission rate for patients experiencing homelessness was higher than national readmission rates and higher than the rate for Bernalillo County, where Albuquerque is located.

Overall, spending time in either a homeless shelter or being homeless and living “on the street” has diverse untoward health consequences.

Chronic Health Conditions

One of the first comprehensive assessments on the health status of persons experiencing homelessness was in the mid-1980s by the Social and Demographic Research Institute of the University of Massachusetts, Amherst. Data from 19 National Health Care for the Homeless Initiative demonstration projects were reviewed ( Wright, 1990 ; Zlotnick et al., 2013 ). The prevalence of health conditions in the adult homeless population was compared to that of adults in the general U.S. adult population. Findings indicated that the prevalence of chronic conditions such as asthma, HIV/AIDS, tuberculosis, hypertension, diabetes, and chronic obstructive pulmonary disease was higher in the homeless group than in the general U.S. population ( Zlotnick and Zerger, 2009 ).

Health and the Experience of Homelessness

Several studies have examined the prevalence of cardiovascular disease risk factors and adverse outcomes among persons experiencing homelessness compared to the general population. In 2002, Szerlip and Szerlip compared the medical charts of 100 patients in a homeless clinic in New Orleans, Louisiana, to those of 200 nonhomeless patients who attended another inner-city primary care clinic. They found that individuals experiencing homelessness had a higher prevalence of hypertension and smoking, but there was no difference in diabetes and total cholesterol compared to the general population. Other studies have confirmed the higher prevalence of smoking among homeless populations, but have not found a higher prevalence of hypertension or a difference in diabetes and total cholesterol ( Lee et al., 2005 ). It has been suggested that for many risk factors, it is not their prevalence but the treatment and management of these conditions that is worse among those individuals experiencing homelessness ( Jones et al., 2009 ; Bernstein et al., 2015 ).

Studies have shown that the prevalence of uncontrolled diabetes is higher among populations experiencing homelessness compared to the general population ( Hwang and Bugeja, 2000 ; Lee et al., 2005 ). More recent evidence also suggests that the burden of cardiovascular disease is greater among subsets of the homeless population, especially those with mental illness. Among this subset, the 30-year risk of coronary heart disease, including (a) being diagnosed with coronary heart disease, (b) having a myocardial infarction, and (c) having a fatal or nonfatal stroke, is higher among individuals experiencing homelessness who also have a mental illness when compared to the general population. This higher risk was greater in men who were also substance users ( Gozdzik et al., 2015 ).

Individuals experiencing homelessness have higher rates of cancer risk factors (e.g., higher rates of tobacco use), but are less likely to undergo cancer screenings. A study of homeless adults in Los Angeles ( Chau et al., 2002 ) investigated cancer knowledge and screening. Although most of the study population demonstrated understanding of cancer screening, their actual screening rates were lower than for Californians broadly.

Asgary et al. (2014) examined colorectal cancer screening rates, predictors, and barriers in two New York City shelter-based clinics. The authors found that the majority of patients were African American or Hispanic, 76 percent were male, and 60.7 percent were homeless. In addition, “domiciled patients were more likely than homeless patients to be screened (41.3 percent versus 19.7 percent; P < .001). Homeless and domiciled patients received equal provider counseling, but more homeless patients declined screening ( P < .001)” ( Asgary et al., 2014 ).

It is not surprising that the experience of homelessness complicates the treatment of health conditions such as diabetes (the need for daily insulin shots) or needed mental health care (due to a lack of community- or shelter-based care delivery).

Mortality Among Individuals Experiencing Homelessness

Individuals experiencing chronic homelessness live shorter lives and, as a group, suffer significant excess mortality. Early studies in this area documented higher premature death rates (three to four times higher) in geographic zones that had a higher prevalence of persons experiencing homelessness, shelters, soup kitchens, and substandard housing compared to the general population ( O'Connell, 2005 ). A recent observational study examined causes of mortality among formerly homeless men in Housing First programs, homeless individuals not in Housing First programs, and the general population ( Henwood et al., 2015a ). The study found that the causes of death differed between the Housing First group and the homeless individuals who were not in the program. 3 Seventy-two percent of the men in Housing First programs died of natural causes, compared to 49 percent of the homeless group. Only 14 percent of Housing First men died due to an accident, compared to 40 percent in the homeless group. Infectious diseases caused 2 percent of deaths in the Housing First group, compared to 13 percent in the homeless group. Death due to hypothermia occurred in 6 percent of deaths in the homeless population, but was not a cause of death for men in the Housing First program.

The findings of more recent studies are consistent with earlier studies. According to data from a study by Baggett et al. (2013) , the most common causes of death for individuals who had experienced homelessness in the Boston area were drug overdoses, cancer, and heart disease. 4 Individuals in the Baggett et al. (2013) study were observed until either the date of death or until December 31, 2008. Among those who died due to drug overdose, over 80 percent of deaths were due to opioid overdoses, a trend mirrored in society at large ( Doe-Simkins et al., 2014 ).

Studies outside of the United States have helped to establish homelessness as an independent risk factor for mortality. As an example, a study in Glasgow ( Morrison, 2009 ) compared mortality data retrospectively over a 5-year period from 6,757 persons experiencing homelessness in the calendar year 2000 with 13,514 age- and sex-matched controls from the general population. The proportion of those dying in the homeless population was 7.2 percent compared to 1.7 percent in the general population. This four-times-higher rate of dying was independent of age, sex, and prior hospitalization. Cause-specific mortality due to drug-related deaths was seven times higher for those experiencing homelessness.

In addition to health-related outcomes described above, studies have examined other outcomes related to the homeless experience, including unemployment, involvement in the criminal justice system, and poor educational outcomes.

• FEATURES AND LEVELS OF HOUSING FOR INDIVIDUALS EXPERIENCING HOMELESSNESS

A number of programs have been developed to meet the needs of individuals experiencing homelessness. These programs are funded from diverse sources and by a range of mechanisms. Below is a brief summary of housing options that may be available to individuals experiencing episodic to chronic homelessness, with the primary focus on PSH models. A brief discussion of the financial mechanisms that might be used to support PSH is also provided.

Temporary Housing Models

Individuals and families experiencing temporary or situational homelessness due to job loss, economic hardship, domestic violence, or other short-term emergencies have very different housing needs from individuals experiencing chronic homelessness. There are several interim housing models for persons who experience situational and temporary homelessness.

Emergency Shelters

Emergency shelter programs are for individuals or families who are in need of short-term shelter ( Locke et al., 2007 ). These programs are designed to provide an immediate alternative to sleeping out of doors or in a location not meant for habitation and can include safe places for survivors of domestic violence and their children. This is the most temporary type of housing available and is meant to be a short-term safety net. Emergency shelters offer shelter overnight but often do not provide daytime access to the facility. Emergency shelters can secure funds through HUD to provide their clients with a range of essential support services, including mental health services, child care, case management, and outpatient health services, among others ( HUD, 2013a ).

Transitional Housing

Transitional housing provides up to 24 months of housing in supervised settings along with social services to help individuals and families prepare for permanent housing. It can be project based, so that residents move out when they exit the program or transition-in-place by assuming the lease at the end of the program. Transitional housing has been a mainstay of the homeless service system for families and individuals who are not deemed to need or who cannot find places in PSH.

Medical Respite Programs

Medical respite care is for individuals experiencing homelessness who are not yet well enough to be on their own. At the same time, they are not sick enough to continue a hospital stay. Without access to medical respite care, individuals experiencing homelessness are unlikely to successfully manage their post-hospital medical regimen. According to Kertesz et al. (2009) , nearly 50 communities in the United States and Canada have created medical respite programs for individuals leaving the hospital while also experiencing homelessness. More recent qualitative data indicate that medical respite programs are useful because they provide linkages to outpatient care ( Zur et al., 2016 ). Doran et al. (2013) systematically reviewed 13 articles in order to investigate the effectiveness of medical respite programs. The lack of evaluations of medical respite programs led the authors to encourage the creation of academic/university partnerships in order to better evaluate these programs.

Permanent Housing Approaches

HUD defines permanent housing approaches to addressing homelessness “as community-based housing without a designated length of stay in which formerly homeless individuals and families live as independently as possible” ( HUD, 2018 ). There are two types of permanent housing: permanent supportive housing (PSH) for persons with disabilities and rapid re-housing. These program models follow the Housing First approach. In some communities, people experiencing homelessness also get priority access to long-term rental assistance in public housing or the private market, with the latter provided primarily by Housing Choice Vouchers. However, these programs typically have waiting lists, so are rarely available to people at the time they experience homelessness. These subsidies do not generally have any associated services.

Housing First

The early PSH services and programs for individuals experiencing chronic homelessness were “treatment first” ( Tsemberis et al., 2004 ). In this traditional model, individuals experiencing chronic homelessness and substance abuse and/or mental illness were required to be treated for their substance abuse or mental health issues prior to being eligible for permanent housing. This required individuals experiencing homelessness to demonstrate “housing readiness” in order to receive housing. Tsemberis et al. (2004 , p. 651) noted that for those individuals experiencing chronic homelessness and desiring housing, the treatment-first approach presents “a series of hurdles” that the individual may not be able to overcome or may be unwilling to overcome to be eligible for housing.

To clarify, Housing First is treated in this report as an intervention where housing is provided to individuals experiencing homelessness with no requirement for participation in services. Pathways Housing First, described below, is a particular model of HF; all HF programs are not Pathways Housing First. Pathways Housing First is described below, with the more general HF described afterward.

Pathways Housing First

The Pathways Housing First model was created in 1992 in New York City by Pathways to Housing ( Tsemberis et al., 2004 ). At its core, founder Sam Tsemberis believes that housing is a basic human right, and therefore, individuals experiencing homelessness should have immediate access to housing. Unlike previous housing programs for individuals experiencing homelessness, Pathways' Housing First model did not require efforts toward sobriety or treatment for mental illness prior to accessing housing. The fact that tenants were not required to participate in substance abuse or mental health services has remained an essential feature of PSH programs. Although comprehensive supportive services provided by interdisciplinary “assertive community treatment” teams or intensive case management are available, participation is voluntary. Pathways Housing First focuses on the housing needs of the homeless individual and views housing needs as “paramount” ( Pearson et al., 2009 ). Currently, Pathways to Housing has programs in the District of Columbia, Vermont, and the Philadelphia area along with Canada and a number of European countries. 5 The program philosophy is based on several tenets, including and primarily, that housing is a human right and individuals experiencing homelessness are given immediate access to housing, with no preconditions ( Tsemberis, 2010 ).

Housing First Approach

The term “Housing First” is now commonly used in a generic sense, both for PSH programs with low barriers and for other programs much less intensive than PSH, such as rapid re-housing. Martinez and Burt (2006) refer to this as a “low demand” model because housing is made available but abstinence from drugs/alcohol is not a requirement. In 2016, California enacted a new law that encourages state programs to adopt a Housing First model in all programs for housing individuals experiencing homelessness. A statement from the U.S. Interagency Council on Homelessness ( USICH, 2017a ) says,

Housing First is a proven approach in which people experiencing homelessness are offered permanent housing with few to no preconditions, behavioral contingencies, or barriers. . . . Housing First is an approach that can be adapted by housing programs, organizations, and across the housing crisis response system. The approach applies in both short-term situations, like rapid re-housing, and long-term interventions, like supportive housing. For crisis services like emergency shelter and outreach, the Housing First approach means referring and helping people to attain permanent housing.

In other words, the Housing First term has been expanded and broadened. In some cases, this dual use of the term “Housing First” has led to confusion.

According to Pleace and Beverton (2013) , “from a strategic and policy implementation perspective, it has to be clear what is meant by “Housing First” (p. 23). Housing First might be best viewed as a philosophy of how PSH should be carried out rather than a specific type of housing. Similarly, HUD refers to Housing First as an “approach” (2014, p. 3), and states that “this approach may not be applicable for all program designs” ( HUD, 2014 , p. 4).

Tsai and Rosenheck (2012) noted that the services component of Housing First needs to address factors other than successful housing outcomes. Because social isolation is a major risk after housing, particularly for those in scattered-site housing, recent research has focused on adding peer support groups for veterans who have formerly experienced homelessness living in supported housing ( Tsai et al., 2014 ) and on the inclusion of trauma treatment for homeless female veterans ( Tsai et al., 2012 ).

Rapid Re-Housing

Rapid re-housing is a program model that follows the Housing First approach in providing short-term rental assistance and services to families and individuals experiencing homelessness. 6 The program also provides housing for individuals and families with other immediate problems such as domestic violence and substance abuse. Individuals experiencing chronic homelessness who are in need of PSH are not a target population for this program.

Some supportive services are provided as part of rapid re-housing programs, the most critical being assistance with identification of housing options ( USICH, 2015b ). Other services include rent and move-in assistance and case management services. The focus of the services provided in rapid re-housing is to help individuals and families resolve their immediate crises, which are most often financial in nature. HUD describes funding for rapid re-housing as short-term or medium-term, with the focus on the provision of assistance including financial assistance, housing search assistance, and targeted services for a period of 6 months ( HUD, 2014 ). The Department of Veterans Affairs also operates a large rapid re-housing program referred to as the Supportive Services for Veteran Families program (see Box 2-1 ).

Permanent Supportive Housing

Permanent supportive housing is an umbrella term for the provision of ongoing, long-term housing coupled with supportive services for individuals and families experiencing chronic homelessness, the unstably housed, individuals living with a long-term disability, and individuals and families who face multiple barriers to accessing and maintaining housing. For the purposes of this report, the committee used the following definition: Permanent supportive housing (PSH) is defined as non-time-limited affordable housing matched with ongoing supportive services appropriate to the needs of the tenants. Note that this definition varies slightly from the formal definition of HUD, but this is the definition that the committee agreed on.

The critical components of PSH are the provision of long-term housing and voluntary supportive services for the residents, including access to mental health care and medical services. By providing housing as described above, PSH is designed to provide individuals experiencing chronic homelessness with a place to avoid the extremes of the elements and a stable place for addressing their health needs. The service piece of PSH is in part designed to address health needs by providing ongoing clinical support. PSH is designed to provide stable housing for very-low-income people who would not be able to sustain housing without supportive services. HUD argues that this is the population that needs to be served first in PSH, rather than on a first-come, first-served approach. A notice from HUD states that “PSH needs to be targeted to serve persons with the highest needs and greatest barriers towards obtaining and maintaining housing on their own—persons experiencing chronic homelessness” (2014, p. 2).

There is no set of agreed-upon supportive services that are core to the PSH model. The Corporation for Supportive Housing ( Post, 2008 ) identifies services that PSH typically provides: case management, substance use treatment and mental health counseling, access to health care, support groups, life skills training; community social activities, and assistance with job hunting services. Participation in services, although encouraged, is not mandatory. Three primary approaches for operating PSH include:

• Congregate or “[p]urpose-built or single-site housing: Apartment buildings designed to primarily serve tenants who are formerly homeless or who have service needs, with the support services typically available on site.”
• “Scattered-site housing: People who are no longer experiencing homelessness lease apartments in private market or general affordable housing apartment buildings using rental subsidies. They can receive services from staff who can visit them in their homes as well as provide services in other settings.”
• “Unit set-asides: Affordable housing owners agree to lease a designated number or set of apartments to tenants who have exited homelessness or who have service needs, and partner with supportive services providers to offer assistance to tenants” ( USICH, 2017b ).

Given the importance of housing as a social determinant of health, it is critical to find, create, and implement housing for individuals experiencing chronic homelessness. The World Health Organization (WHO) defines social determinant of health as “the circumstances, in which people are born, grow up, live, work and age, and the systems put in place to deal with illness” ( NHCHC, 2016 ). People experiencing homelessness have been significantly impacted by a social determinant of health, leading to chronic health conditions, substance use, mental illness, and increased mortality. This realization led to the development of PSH, as defined above. Specific elements of PSH, as outlined in a Substance Abuse and Mental Health Services Administration ( SAMHSA, 2011 ) evidence-based toolkit on creating and managing PSH programs, include the following:

• Tenants have a lease for their housing and have full rights of tenancy under landlord-tenant law.
• Leases for those individuals with psychiatric conditions are no different from the leases for individuals not having psychiatric conditions.
• Participation in supportive services, such as mental health treatment or substance abuse treatment, is voluntary, albeit encouraged.
• House rules are applied equally for all tenants, regardless of mental health status.
• There is no time limit on the housing, as long as the landlord and the tenant are in agreement about renewing the lease.
• Ideally, tenants are asked for their preferences regarding housing, with options that match the options available to individuals not experiencing homelessness at the same income level. If the housing is single site, however, there may not be other housing options.
• Housing is affordable, with tenants paying no more than 30 percent of their income for rent and utilities.
• The use of supportive services may change over time, depending on the needs of the tenant.
• Tenants choose which supportive services they take advantage of. Different supportive services are provided for different tenants, depending upon their needs.
• Supportive services are designed to promote long-term recovery and sustained access to housing.
• The provision of housing and the provision of supportive services are distinct and are managed by separate agencies.

SAMHSA also promotes “integrated housing,” meaning that PSH tenants should have opportunities to interact with neighbors who are not experiencing substance abuse and/or mental illness. However, in single-site housing, this is difficult to achieve. (See the section on scattered-site versus single-site housing in Chapter 5 .)

• FUNDING SOURCES FOR PSH

Funding for PSH is complex and often requires innovative approaches to guaranteeing financing, including braiding together a number of different funding streams. This section reviews the predominant sources of funding used to pay for housing.

Federal Funding

Continuum of care program.

HUD's Continuums of Care (CoC) program is a potential federal funding mechanism for PSH. CoC refers to a local planning group that coordinates and allocates HUD funding to agencies serving people experiencing homelessness ( HUD, 2012b ). CoC's most recent funding competition encouraged the reallocation of existing funds to PSH and rapid re-housing ( HUD, 2015d ) and provided funding for new PSH projects.

HUD Section 8 Housing Choice Vouchers

Housing Choice Vouchers, more commonly referred to simply as Section 8 vouchers or subsidies, are HUD's primary means of assisting low-income individuals and families to pay for safe and secure housing. These subsidies are long term and considered permanent housing ( Technical Assistance Collaborative, Inc., 2012 ). Section 8 vouchers have also been used to address the needs of priority populations. The HUD-Veterans Affairs Supportive Housing (HUD-VASH) program, for example, is specifically designed to help meet the needs of veterans who are chronically homeless. The program blends HUD Section 8 vouchers and VA case management and clinical services. The program began in 1992 and funds are administered through local PHAs.

Additional Funding Sources

There are a number of additional federal funding sources that can be leveraged for PSH, including Supplemental Security Income (SSI), Low-Income Housing Tax Credits, and HOME Investment Partnerships. Other federal funding sources, including the Ryan White HIV/AIDS Program Services and SAMHSA grants, are described below. Other innovative non-federal funding sources include Social Impact Bond/Pay for Success models. Under the Social Impact Bond model, investors provide upfront funding to implement a social service project; the government or a philanthropic organization then contracts to pay back the investors with a small premium if the project achieves its goals.

Ryan White HIV/AIDS Program Services

Several funding opportunities provide housing for low-income individuals experiencing homelessness who are HIV-positive. The Ryan White HIV/AIDS Program provides short-term housing assistance (2 years maximum) and some support services ( HRSA, 2016 ). Funding is given to local communities and state agencies for projects that benefit low-income individuals living with HIV/AIDS.

The Housing Opportunities for Persons with AIDS (HOPWA), managed by HUD's HIV/AIDS Bureau, has two grant funding streams for PSH for this population. The HOPWA Competitive Grant program and the HOPWA formula grant program provide funding for housing to eligible cities and states ( HUD, 2016d ). HOPWA assistance may also include support for substance abuse, mental health, nutrition, job training and placement, and assistance with daily living ( HUD, 2016d ).

Because of the correlation between HIV status and homelessness ( Aidala et al., 2007 ), the provision of housing is an important strategy for improving HIV management, reducing high-risk behaviors, and lowering the possibility of transmission to others ( Buchanan et al., 2009 ). This program also has been important in addressing the disparate impact of HIV/AIDS on racial and ethnic minority groups. African Americans with HIV/AIDS make up 52 percent of those served by HOPWA funding ( HUD, 2016d ).

SAMHSA provides funds through several grant programs for services for individuals experiencing homelessness, including the Grants for the Benefit of Homeless Individuals–Services in Supportive Housing, a competitive grant program that provides communities with funding for services relating to substance abuse, co-occurring mental health and substance abuse disorders, and other support services. The Cooperative Agreements to Benefit Homeless Individuals is also a competitive grant program that allows communities to provide services within PSH approach. Finally, the Projects for Assistance in Transition from Homelessness (PATH) program is a state block grant program that offers similar supportive services.

Views and perceptions about, definitions of, and the approaches to research and amelioration of homelessness have materially changed over time. Similarly, different types of housing for individuals experiencing homelessness have developed to serve different populations. Individuals or families experiencing short-term homelessness have different needs than those individuals or families experiencing chronic homelessness. There are a number of forms of housing for individuals and families experiencing homelessness, with varying time limitations and differing levels of service provision.

PSH is designed to provide housing for individuals and families experiencing chronic homelessness, the unstably housed, individuals living with a long-term disability, and individuals and families who face multiple barriers to accessing and maintaining housing. PSH programs have two essential components: the provision of non-time-limited housing, and the provision of an array of voluntary supportive services. Pathways Housing First was an early model created to provide PSH focused on client choice, although the term “housing first” is now used more broadly as a general approach rather than a particular program.

Additionally, a number of federal financing mechanisms support the building and operations of PSH programs; many of these are state Medicaid options for which waivers may be required. A more recent model for funding PSH programs is the Social Impact Bond/Pay for Success, in which a program receives upfront funding from investors, typically a philanthropic organization, who then is paid back by a government agency when and if the program achieves its goals.

HUD describes the purpose of HMIS “to produce an unduplicated count of homeless persons, understand patterns of service use, and measure the effectiveness of homeless programs. Data on homeless persons [are] collected and maintained at the local level.” HMIS provides sample policies and procedures, training modules, templates and tools, and manuals to support a variety of homelessness services, including the Continuums of Care (CoC) program, HUD-Veterans Affairs Supportive Housing (HUD-VASH) program, and Veterans Homelessness Prevention Demonstration (VHPD) program. For further information see HUD (U.S. Department of Housing and Urban Development). 2018. HMIS Requirements. Available at: https://www ​.hudexchange ​.info/programs/hmis/hmis-requirements . Accessed on April 21, 2018; HUD. 2018. HMIS Guides and Tools. Avail-able at https://www ​.hudexchange ​.info/programs/hmis ​/hmis-guides/#coc-resources . Accessed May 17, 2018.

The PIT count is a count of sheltered and unsheltered persons experiencing homelessness on a single night in January.

However, the two groups were not matched. Housing First clients are selected for the most disabled adults experiencing chronic homelessness. This is a selection bias in that the group with the worst possible health and psychiatric problems is not equivalent to the general population of individuals experiencing homelessness.

The authors note that data limitations made it impossible to determine who was currently homeless and formerly homeless at time of death.

The New York City program has since closed. For details on the Pathways Housing First program, see https://www ​.pathwayshousingfirst.org .

See Appendix D for an example of a rapid re-housing program in Denver.

• Cite this Page National Academies of Sciences, Engineering, and Medicine; Health and Medicine Division; Board on Population Health and Public Health Practice; Policy and Global Affairs; Science and Technology for Sustainability Program; Committee on an Evaluation of Permanent Supportive Housing Programs for Homeless Individuals. Permanent Supportive Housing: Evaluating the Evidence for Improving Health Outcomes Among People Experiencing Chronic Homelessness. Washington (DC): National Academies Press (US); 2018 Jul 11. 2, Addressing Homelessness in the United States.
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