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Population Health for Nurses

27.1 People Who Are Experiencing Homelessness

Population Health for Nurses27.1 People Who Are Experiencing Homelessness

Learning Outcomes

By the end of this section, you should be able to:

  • 27.1.1 Define homelessness.
  • 27.1.2 Discuss the extent of homelessness in the United States.
  • 27.1.3 Identify demographic trends of individuals experiencing homelessness.
  • 27.1.4 Describe factors that contribute to homelessness.
  • 27.1.5 Explain the health challenges of individuals experiencing homelessness.
  • 27.1.6 Describe the role of the nurse in caring for individuals experiencing homelessness.

Nurses need specialized knowledge, skills, and appropriate attitudes to provide effective care for marginalized populations like individuals experiencing homelessness. The McKinney-Vento Homeless Assistance Act of 1987 defines homelessness as a situation in which an individual or family lacks a regular, fixed, and adequate nighttime residence. This includes individuals or families living in shelters or in public or private locations not designed for regular sleeping, such as cars, parks, abandoned buildings, stations, and campgrounds. Homelessness also refers to individuals or families who will be losing their housing within a short timeframe and for whom no new residence has been identified. Incarcerated individuals are not considered homeless. The terms houseless, unsheltered, and unhoused are also used to describe individuals who lack housing (LA Community Alliance [LACA], n.d.).

The challenges of gathering accurate data make it difficult to ascertain the full scope of homelessness in the United States. Point-in-time counts provide a snapshot of the number of homeless individuals, both sheltered and unsheltered, on a given night in a given place (Figure 27.2) (HUD, 2022). The U.S. Department of Housing and Urban Development (HUD) Annual Homelessness Assessment Report to Congress estimates that 582,500 individuals were experiencing homelessness on a single night in 2022 (HUD, 2022). This figure equates to 18 of every 10,000 individuals in the United States. Of the population experiencing homelessness, 4 in 10 were unsheltered. The latest data demonstrates a small increase, less than 1 percent, in homelessness nationally between 2020 and 2022.

A group of three people walk together in the dark. One shines a flashlight on a car covered in graffiti that doesn't have any tires.
Figure 27.2 Volunteers search for people sleeping in makeshift outdoor beds to complete a point-in-time count of individuals experiencing unsheltered homelessness. (credit: “Point in time homeless count 2015-Jan” by Milwaukee VA Medical Center/Flickr, Public Domain)

Demographic Data on Homelessness

Homelessness affects every state in the United States, but more than half of all individuals experiencing homelessness are in four states: California (30 percent), New York (13 percent), Florida (5 percent), and Washington (4 percent). In 2022, more than 70 percent of the homeless population in California and Hawaii were unsheltered, while 90 percent or more of the individuals experiencing homelessness in Vermont, Maine, Wisconsin, and New York had shelter (HUD, 2022). Half of all individuals experiencing homelessness were located in major cities. The demographic characteristics of homeless individuals vary greatly by geographic location.

In the United States, Black, Indigenous, and people of color (BIPOC) communities are disproportionately represented among those experiencing homelessness (HUD, 2022). White, non-Hispanic/non-Latino adult men constituted the most individuals experiencing homelessness in 2022, but relative to the total U.S. population, individuals experiencing homelessness were disproportionately from Hispanic or Latina and BIPOC communities. Among individuals experiencing homelessness, 30 percent were women, while among families experiencing homelessness, 60 percent were women. Homelessness in women increased by 6 percent compared with a 1 percent increase in men between 2020 and 2022. Individuals identifying as Native Hawaiians and Pacific Islanders experienced a 23 percent increase in individual homelessness and a 31 percent increase in unsheltered homelessness. Homelessness among children and families is growing. According to the National Alliance to End Homelessness (NAEH), adults and children in families make up 30 percent of the population experiencing homelessness (2023a). Families experiencing homelessness are often headed by a single woman with limited education who has young children and struggles with poverty (NAEH, 2023a).

Factors that Contribute to Homelessness

Factors contributing to homelessness include poverty, lack of affordable housing, lack of affordable health care, domestic violence, substance use disorders, and mental illness.

Poverty

Individuals experiencing homelessness are often considered to live in poverty (National Coalition for the Homeless [NCH], 2022a). Poverty is when an individual lacks the economic resources to pay for basic needs (Agency for Healthcare Research and Quality, 2022). In the United States, poverty is measured by comparing an individual’s or family’s income to a set poverty threshold, the minimum income required to cover basic needs. Those who fall under this threshold are considered poor (Institute for Research on Poverty, n.d.), have limited financial resources, and find it challenging to afford housing, food, health care, and childcare, often leading to difficult choices (NCH, 2022a). A common sentiment among individuals living in poverty or near poverty is that “if you are poor, you are one illness, accident, or paycheck away from living on the streets” (NCH, 2022a, para 3). Individuals living in poverty are at high risk of becoming homeless, and demographic groups that are more likely to experience poverty are also more likely to experience homelessness (NCH, 2022a). See Social Determinants Affecting Health Outcomes for more information on poverty.

In 2021, the official U.S. poverty rate was 11.6 percent, with almost 40 million individuals living in poverty, a little over 15 percent of whom were children (under age 18) (Creamer et al., 2022). The 2020 official poverty threshold for a family of four, consisting of two adults and two children, was a total annual income of $26,246 or less (U.S. Census Bureau, 2022). The demographic data of individuals living in poverty are consistent with the demographic data of individuals experiencing homelessness, further demonstrating the link between the two. Of the total U.S. population living in poverty:

  • 20 percent self-identify as Black;
  • 17 percent self-identify as Hispanic (any race);
  • 10 percent self-identify as White;
  • 9 percent self-identify as Asian; and
  • 24 percent self-identify as American Indian or Alaska Native (AIAN). (This is disproportionate; in 2020, AIAN individuals accounted for only 1.1 percent of the U.S. population [U.S. Department of Health and Human Services, 2023a].)

Housing

The shortage of low-income housing in the United States contributes to homelessness. The National Low Income Housing Coalition (NLIHC) reports a shortage of 7 million affordable homes for the nation’s almost 11 million extremely low-income families (2023). The NLHIC (2023) also estimates that more than two-thirds of all extremely low-income families spend more than half their income on rent, placing them at risk for homelessness. This problem affects every state.

The NLIHC measures income against what it calls a housing wage, an estimate of the hourly wage that full-time workers must earn to afford a rental home at fair market value without spending more than 30 percent of their income on housing. In 2022, the national per-hour housing wage for a modest two-bedroom rental home ($25) was more than three times the federal minimum wage ($7.25 per hour) (NLIHC, 2022; U.S. Bureau of Labor Statistics, 2021). Most low-income families facing severe housing problems are working (NCH, 2022b). The lack of affordable housing and limited housing assistance programs contribute to the housing crisis and homelessness (NCH, 2022b). Of all the households eligible for federal housing assistance, only one in four receives assistance due to insufficient funding (NCH, 2022b; Fischer et al., 2021). With the lack of affordable housing, many individuals and families experience high rents, overcrowding, or substandard housing, further placing them at risk of homelessness (NCH, 2022b). Homelessness endures as the income of low-income households has declined, rents have continued to rise, and the demand for assisted housing exceeds supply (NCH, 2022b). Assisted housing is housing for which people receive financial support under governmental programs such as public housing.

Lack of Affordable Health Care

A lack of affordable health care contributes to homelessness, as individuals who cannot afford health insurance are at risk of financial difficulties and subsequent homelessness if a serious injury or illness arises (NCH, 2022a). It also negatively impacts the overall health of low-income individuals who may not seek needed health care due to cost concerns. Though the percentage of Americans lacking health insurance has fallen to record lows due to expanded Medicaid eligibility, the Patient Protection and Affordable Care Act (ACA), and policy changes that occurred during the COVID-19 pandemic, a significant portion of U.S. residents remain uninsured or underinsured (Collins et al., 2022), and as of 2021, racial and ethnic disparities in coverage persisted (Cha & Cohen, 2022).

According to a Commonwealth Fund survey, in 2022, 43 percent of working adults were inadequately insured, and 46 percent of respondents reported skipping or delaying care due to cost concerns (Collins et al., 2022). The Commonwealth Fund defines underinsurance as having out-of-pocket costs that are 10 percent or more of income in a one-year period (5 percent for individuals living under 200 percent of the federal poverty level) or a deductible that represents 5 percent or more of household income (Collins et al., 2022). According to the CDC National Health Statistics Report, over 28 million individuals, including almost 3 million children, were uninsured in 2021 (Cha & Cohen, 2022). Evidence that health insurance coverage is linked to improved health outcomes was one of the drivers for the passage of the ACA in 2010, which was intended to increase access to health care to decrease disparities and improve health for everyone (Cha & Cohen, 2022).

Domestic Violence

Individuals living in poverty who experience domestic violence may be forced to choose between staying in an abusive relationship or experiencing homelessness. Domestic violence refers to violent or aggressive behavior in the home, usually involving abuse of a spouse or partner. In the United States, an estimated 20 individuals per minute are physically abused by an intimate partner, equating to more than 10 million women and men in a one-year period (National Coalition Against Domestic Violence [NCADV], 2020). In 2020, one in four women and one in nine men reported experiencing severe intimate partner physical violence, and one in five reported experiencing sexual violence by an intimate partner in their lifetimes (NCADV, 2020). Domestic violence and homelessness are directly connected, with national estimates that 80 percent of homeless mothers with children have experienced domestic violence (Institute for Children, Poverty & Homelessness [ICPH], 2018). Experiences of domestic violence are common in individuals who become homeless (NAEH, 2023b), and in 2022, roughly 11 percent of beds were set aside for domestic violence survivors and their families (NAEH, 2023b). See Caring for Families for more information on domestic violence.

Substance Use Disorder

Substance misuse and homelessness are linked, but there is no consensus on whether substance misuse is a precursor to or a result of homelessness (Moxley et al., 2020; NCH, 2022a). Individuals who are experiencing homelessness are much more likely to experience substance misuse than housed individuals, but many individuals begin using drugs or alcohol to cope with the challenges of being homeless (Mosel, 2023; NCH, 2022a). Individuals have unique experiences that may lead to differences in health behaviors. The Substance Abuse and Mental Health Services Administration report that 38 percent of individuals experiencing homelessness misuse alcohol, and 26 percent misuse other substances (Magwood et al., 2020; Mosel, 2023). Individuals experiencing homelessness often lack social support and access to health care, have experienced trauma, and often struggle with untreated mental health illnesses that contribute to the substance misuse in this population (Magwood et al., 2020; Mosel, 2023). See Caring for Populations and Communities in Crisis for more information on substance use disorder.

Mental Illness

Mental illness does not cause homelessness, but an estimated 25 percent of the adult homeless population experiences persistent mental illness (Vohra et al., 2022). Individual mental health is formed and influenced by the SDOH (Alegria et al., 2018; Knifton & Inglis, 2020; Macintyre et al., 2018). Poverty can be both a cause of mental health problems and a consequence of it (Knifton & Inglis, 2020; Macintyre et al., 2018), and because poverty is directly tied to homelessness, mental illness is considered a risk factor for homelessness. The poverty–mental illness link can create a cycle wherein the stress, stigma, and trauma of poverty may result in poor mental health that may then result in loss of employment or underemployment, which may then result in individuals with mental illness living precariously, in and out of poverty (Macintyre et al., 2018).

How Homelessness Intersects with the Social Determinants of Health

Homelessness intersects with the SDOH at every level. Recall from Social Determinants Affecting Health Outcomes that the SDOH are grouped into five domains: economic stability, education access and quality, health care access and quality, neighborhood and built environment, and social and community context. These determinants of health are driven by social status and have a major impact on an individual’s health and well-being. Individuals and families experiencing homelessness lack economic stability and cannot access the resources and care necessary for healthy living. This has a domino effect on the other determinants of health, as a lack of economic stability and housing can result in an unstable educational environment, an unsafe or unstable community, and the inability to access clean air, water, transportation, and healthy food options. As noted, BIPOC communities are disproportionately affected by homelessness, which is rooted in generational poverty and structural racism. Generational poverty is persistent poverty and disadvantage, where children who grow up poor are more likely to be poor as adults (Wagmiller & Adelman, 2009). In many cases, the foundation of generational poverty can be traced to the structural discrimination and racism that contribute to inequitable social and economic opportunities (Office of Disease Prevention and Health Promotion [ODPHP], 2020c). Structural discrimination refers to institutional policies, systems, laws, and practices that limit individuals’ and populations’ opportunities, resources, and power based on race, ethnicity, gender, ability, socioeconomic status, sexual orientation, gender identity, and religion. These deeply rooted practices and beliefs propagate pervasive unjust treatment and oppression of vulnerable individuals (Braveman et al., 2022). See Structural Racism and Systemic Inequities for more information.

Homeless Without Legs

The website Invisible People presents several video interviews with individuals experiencing homelessness.

Watch the video about Monica’s story, and then respond to the following questions.

  1. The National Health Care for the Homeless Council (NHCHC) has stated that housing is a part of health care (2019, p.1). Do you agree with this statement? Why or why not?
  2. What are some actions a nurse can take to address the issues discussed in this video?

Health Barriers Experienced by Individuals Experiencing Homelessness

The National Health Care for the Homeless Council (NHCHC) states that “housing is health care” as health and homelessness are interlinked (2019, p. 1). Statistically, individuals experiencing homelessness have higher rates of illness and have an estimated life expectancy of 30 years below the U.S. average (Watts, 2021). Diabetes, hypertension, and myocardial infarction are estimated to be twice as prevalent in groups experiencing homelessness as they are in the general population, and groups experiencing homelessness have even higher rates of substance use disorders, depression, and hepatitis C (Watts, 2021). Other conditions prevalent among this population include behavioral health concerns; communicable diseases such as HIV, tuberculosis (TB), or hepatitis; and conditions affecting dentition and the feet (Mcenroe-Petitte, 2020). Figure 27.3 depicts the downward spiral that can occur when a person lacks health care and becomes homeless (NHCHC, 2019, p.1).

An illustration of a spiral shows how poor health can spiral into homelessness. At the top of the spiral, an individual breaks their foot. This leads them to miss work, which causes them to lose their job and then lose their healthcare. From there, they are unable to work, lose housing, and become homeless.
Figure 27.3 An individual may quickly spiral into homelessness. Injuries or illnesses may result in unemployment, creating a cycle wherein the individual cannot afford health care and the initial health condition prevents them from regaining employment. Loss of income causes housing instability. Without effective safety nets, poor health may lead to unemployment, leading to poverty and, ultimately, to homelessness (NHCHC, 2019, p.1). (attribution: Copyright Rice University, OpenStax, under CC BY 4.0 license)

Being homeless creates new health issues and intensifies existing ones. Living on the street or in a crowded shelter places an individual under stress and exposes them to communicable disease, violence, malnutrition, and weather. Individuals with chronic health problems such as hypertension, diabetes, and asthma may have no place to store medications properly, thereby worsening their underlying disease process. Maintaining a heart-healthy or diabetes diet is challenging as food pantries and shelters cannot cater to special diets. These situations can exacerbate behavioral and mental health issues such as substance use disorders, alcoholism, depression, and anxiety (NHCHC, 2019). Even minor issues such as a mild cut may develop into more serious problems, as maintaining proper rest and hygiene and keeping bandages clean may be impossible when living in a shelter or on the street. Stable housing provides safety and a place to recuperate from illness or injury. Even the highest-quality clinical services are ineffective if the client’s health is “compromised by the street or shelter conditions as no amount of health care can substitute for stable housing” (NHCHC, 2019, p. 2).

Boston Health Care for the Homeless

In 1985, the Robert Wood Johnson Foundation and the Pew Memorial Trust began the Health Care for the Homeless (HCH) program, funding 19 health clinics around the United States to coordinate medical treatment for individuals experiencing homelessness. HCH funded new respite care programs and provided continuity of care from the streets and shelters to the hospital. There are now 300 federally qualified health centers (FQHCs) and 100 medical respite programs (Watts, 2021). This video features an HCH in Boston.

Watch the video, and then respond to the following questions.

  1. What different client needs do the HCH health care professionals address?
  2. How is HCH addressing the barriers to accessing health care that individuals experiencing homelessness often face?
  3. In your view, is this a sustainable model of health care for individuals experiencing homelessness? Is it replicable in other cities around the country? Why or why not?

Children and Families Experiencing Homelessness

Each year, 1.2 million children ages 5 and under experience homelessness in the United States (U.S. Department of Health & Human Services [USDHHS], 2023b). The McKinney-Vento Act requires school districts to assist students who are experiencing homelessness in receiving needed services and enrolling them immediately even if they lack the typical paperwork. These students are required to be given transportation and uniforms if necessary to get them into school immediately (Beiner, 2022). Homelessness negatively impacts children’s education, health, development, and sense of safety (NAEH, 2023a). Children experiencing homelessness have increased levels of emotional and behavioral problems and increased risk of health problems; are more likely to repeat a grade, be expelled, or drop out of school; and have lower overall academic performance (NAEH, 2023a). They may have a variety of health challenges related to the difficulty in accessing regular health and dental care or nutritious foods, education interruptions, trauma, and overall disruption in family dynamics (USDHHS, 2023b). In comparison to children who are housed, this population is twice as likely to be ill, goes hungry twice as often, has twice the rate of learning disabilities, and is three times as likely to have emotional and behavioral problems (USDHHS, 2023b). Additionally, children experiencing homelessness face social isolation from their peers, increased anxiety levels, disrupted sleep, loss of a sense of place, and an increased risk of adolescent drug misuse (Phillips, 2019). School nurses and other community and public health nurses can assist these families and children in accessing case management services and connecting them with primary health care. They can advocate getting these children the resources they need such as food, clothing, and school supply assistance.

The Nurse’s Role in Caring for People Experiencing Homelessness

Nurses interface with individuals experiencing homelessness in many different settings, from the acute bedside to the emergency department (ED) to the outpatient clinic or in community health settings such as schools, shelters, food pantries, churches, community centers, social service agencies, and even in the street. Nurses need to be sensitive to the different needs of these clients.

This population often faces barriers to primary care and, therefore, may seek treatment in the ED, resulting in fragmented care and further stigma and discrimination in health care settings (Mcenroe-Petitte, 2020; Vohra et al., 2022). Many of the conditions common to individuals experiencing homelessness, including chronic diseases, do not lend themselves to treatment in the ED as they often require specific longer-term treatment plans (Mcenroe-Petitte, 2020).

This population needs holistic care with a focus on access to care. The first step in providing care is to ask the client about their living situation; access to food, support, and medication; and what type of work they engage in. Nurses need collaborative working relationships with community-based primary care and psychiatric care providers so that, after identifying client needs, they can tap into that network to assist the client in accessing health services. Additionally, nurses must individualize care for these clients when reviewing discharge paperwork. Advising a client to rest and elevate their leg is not a feasible plan of care for an individual experiencing homelessness. Involving the care team of social workers and case management can assist these clients in obtaining appropriate community-based services to facilitate healing. Nurses have a role in primary, secondary, and tertiary prevention for caring for individuals experiencing homelessness (Table 27.1).

Primary Prevention
  • Prevent individuals and families from becoming homeless by addressing contributing factors.
  • Advocate for affordable housing
  • Advocate for a living wage
  • Advocate for affordable, accessible health care
  • Refer those with mental health disorders to appropriate counseling and therapy
  • Provide parenting workshops to help families deal with conflict and develop resilience in order to decrease the number of adolescent runaways
  • Advocate for affordable and high-quality childcare
  • Provide violence prevention and anger management classes
  • Advocate for substance use disorder services management and treatment in every community
Secondary Prevention
  • Decrease existing homelessness.
  • Screen for early detection and treatment of adverse health conditions in the homeless population.
  • Refer to social support agencies to assist in applying for aid
  • Assist in locating an available shelter
  • Advocate for more short-term residences for families experiencing homelessness
  • Advocate at the state level for more funding for single-room occupancy (SRO) options
  • Advocate for more medical respite facilities
  • Advocate for local social services in every community
  • Screen for communicable diseases such as HIV, TB, hepatitis, sexually transmitted infections, hypertension, and diabetes
  • Advocate for more community-based health centers that focus on serving disadvantaged populations
  • Advocate for mobile health vans to take clinical medicine to the streets
Tertiary Prevention
  • Prevent recurrence of poverty and homelessness.
  • Advocate for changes at the state and federal level to provide needed services to address chronic homelessness such as providing housing stability and support for those in need. An example is Housing First, a program that prioritizes permanent housing for individuals experiencing homelessness (NAEH, 2022a). It provides permanent housing without prerequisites or conditions beyond those that are typically expected of a renter.
  • All steps included within primary prevention
Table 27.1 Nurses’ Role in Primary, Secondary, and Tertiary Prevention for Clients Experiencing Homelessness
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