Homelessness: Background

The United Nations (2005) estimated in their most recent survey on homelessness that more than 100 million people are homeless, and 1.6 billion people are living in inadequate shelters around the world. In the United States alone, 567,715 individuals are estimated to experience homelessness on any given night, and the prevalence is on the rise (U.S. Department of Housing and Urban Development, 2019).

When discussing homelessness, it is essential to acknowledge that it is defined in a variety of ways (National Health Care for the Homeless Council [NHCHC], 2019a). An individual who lacks a regular, adequate, or fixed nighttime residence can be considered homeless. An individual who has a temporary nighttime residence, such as a shelter, can also be considered homeless. Organizations that provide services to this population typically choose the definitions and criteria that best fit their mission (NHCHC, 2019a).

Individuals who are homeless often experience health disparities and challenges with independent functional living (NHCHC, 2019b). The contributing factors that lead to homelessness are complex and intertwined. OTs possess the skills necessary to address the needs of the homeless population with a holistic approach (Heilfrich, 2019). OTs can provide service to the homeless population in various settings through diverse roles (Heilfrich, 2019). However, OT has limited participation with this population, and advocacy is needed to increase it. 

There have been decades of misguided and faulty policies to address homelessness, and it remains a serious problem (Council of Economic Advisers, 2019). Homelessness often involves individuals who are facing significant hardship and desperate situations. The vast majority of individuals experiencing homelessness have minimal access to supportive services (National Coalition for the Homeless, 2018). When they are faced with options from supportive services, decisions are frequently chosen within the context of extreme duress, untreated mental illness, or substance abuse disorders (Council of Economic Advisers, 2019). 

Prevalence on the Rise

Since the United States Department of Housing and Urban Development (U.S. HUD) began collecting data related to homelessness in 2007, national counts of homelessness have generally trended downward (National Alliance to End Homelessness, 2019). From 2007 to 2016, homelessness had decreased by 15%. Despite this downward trend, the rate of homeless has been increasing in the most recent years (U.S. HUD, 2017, 2018, 2019). Between the years 2016 and 2017, the number of individuals who experienced homelessness increased by about 1 percent (U.S. HUD, 2017). Between the years 2017 and 2018, the rate increased by an additional 0.3 percent (U.S. HUD, 2018). The largest increase in individuals who experienced homelessness was between the years 2018 and 2019 at 3% (U.S. HUD, 2019). For all three time frames, there was a decrease in individuals experiencing sheltered homelessness and an increase in those experiencing unsheltered homelessness (U.S. HUD, 2017, 2018, 2019; National Alliance to End Homelessness, 2019). This data suggests the trend may be changing to a rise in the prevalence of homelessness and an increase in individuals who are homeless without shelter (U.S. HUD, 2017, 2018, 2019).

In general, the states with the highest number of homeless individuals tend to be the most populous (National Alliance to End Homelessness, 2019). However, there are a couple of states, Colorado and Oregon, that top the homeless count list despite having relatively smaller populations. The ten states with the greatest number of individuals who are homeless account for 55% of the total homeless population nationwide. Residents in these ten states spend higher percentages of their income on housing costs compared to other areas of the U.S. (National Alliance to End Homelessness, 2019). 

(Above images from U.S. Hud, 2019) 

Contributing Factors

The cause of homelessness has been conceptualized as a complex integration of structural and individual factors that result in different pathways into a homeless lifestyle (Ecker et al., 2019; MacKenzie & Chamberlain, 2003; Minnery & Greenhalgh, 2007; Timmer et al., 2019). Homelessness has been associated with a lack of affordable, secure housing, access to affordable healthcare, employment, access to community support, and shortened hospital stays (Anderson & Christiansen, 2003; Grandisson et al., 2009). Experiencing a loss of income security, disability, breakdown of family relationships, discharge from correctional services, or drug and alcohol abuse are also linked to homelessness (Anderson & Christiansen, 2003). 

Health Disparities

According to the NHCHC (2019b), living on the streets or in shelters for the homeless has been shown to exacerbate existing health issues and can also lead to new health concerns. For example, individuals who are homeless are at an increased risk for both physical and mental health-related issues that often lead to disability. Furthermore, these individuals have also been found to have decreased participation in their everyday occupations and are at higher risk of a decreased lifespan when compared to the general population (NHCHC, 2019b).

Homelessness also has the capacity to impact children's physical, emotional, social, and behavioral development (Baggerly & Jenkins, 2009; Haskett et al., 2016; Tobin & Murphy, 2013). According to Medcaf, preschool children who experience homelessness are four times more likely to experience developmental delays when compared to their housed low-income peers (Tobin & Murphy, 2013). Many children who are homeless also experience mental health and psychosocial issues such as depression and aggression (Haskett et al., 2016; Tobin & Murphy, 2013).

In comparison to the general population, individuals who are homeless experience a greater burden of mental health, physical health, and substance abuse issues (Fazel et al., 2008; Levitt et al., 2009 as cited in Weber et al., 2013). Some known examples of conditions they are more susceptible to include diabetes mellitus, stroke, cardiovascular diseases, trauma, infections, communicable diseases, depression, affective disorders, psychotic disorders, and dementia when compared to the general population (NHCHC, 2019b). It is important to consider that physical health can negatively impact an individual's mental health and vice versa (Mental Health Foundation, 2016). Tragically, an individual who is homeless is also considered to have a life expectancy of about 17.5 - 61.9 years less than the general population with respect to variations in location and the age of onset of homelessness (Nusselder et al., 2013; Romaszko et al., 2017; Thomas, 2012). 

Without connections to the right types of care in the United States, these individuals often cycle in and out of hospital emergency departments, acute hospital care, detox programs, places of incarceration, and psychiatric institutions which comes at a high public expense (U.S. Interagency Council on Homelessness, 2017). Some studies have found that for each individual who remains chronically homeless, taxpayers pay between $30,000 to $50,000 per year (U.S. Interagency Council on Homelessness, 2017). It also comes at a high personal cost as these individuals fail to receive appropriate ongoing services to manage their chronic illnesses and/or substance abuse disorders (Caton et al., 2007). Whereas accessible primary and preventative services are critical for this population. Barriers to accessing routine and preventative care include a lack of available services, knowledge of where to obtain available services, transportation, trust in providers, care coordination, and insurance (Canavan et al., 2012). The financial cost of receiving care, long wait times to obtain an appointment, and existing substance abuse issues are also known barriers (Canavan et al., 2012).

The ability to perform activities of daily living (ADLs) and instrumental activities of daily living (IADLs) is dependent upon an individual's motor, cognitive, and perceptual abilities (Mlinac & Feng, 2016). Therefore it is easy to understand how a population that experiences the above health disparities would likely have more difficulty participating in everyday meaningful tasks. This population also faces many economic and social barriers that impact their ability to fully engage in occupations within their community (Lloyd & Bassett, 2012). As a result, they are often excluded from many basic aspects of life, such as housing, employment, education, social networks, and health care (Lloyd & Bassett, 2012).

Some programs aim to assist this population by creating opportunities for participation with the above aspects of life through generalized programs. However, individuals who are homeless often lack the necessary skills required to be successful even when opportunities are created (Helfrich & Fogg, 2007). This information can be exceptionally true for individuals who have a mental illness. The combination of homelessness and mental illness often creates a cycle of functional impairment that results in an inability to achieve and retain the basic skills necessary to live independently (Helfrich & Fogg, 2007). Homeless shelters also have limited, if any, resources for individuals who are homeless with mental illness (Helfrich & Fogg, 2007). Although psychosocial rehabilitation programs often provide community reintegration groups based on psychoeducation, few programs teach life skills in a way that permits for practice, integration, retention, and generalization (Helfrich & Fogg, 2007). 

Insufficient Affordable Housing 

Insufficient affordable housing throughout the country leaves many people with no alternative to homelessness. The National Low-Income Housing Coalition's (NLIHC; 2019a) report, titled Out of Reach: The High Cost of Housing 2019, shows prevailing minimum wages and average renter wages are not adequate enough to afford basic rental apartments throughout the country. The accepted federal standard of affordability is that an individual should spend no more than 30% of their income on rent and utilities. With this standard considered, the national hourly wage a full-time worker must earn to afford a modest one-bedroom rental home is $18.65 and $22.96 per hour for a modest two-bedroom. Meanwhile, the federal minimum wage is $7.25 an hour, and the average hourly wage of renters in the U.S. is $17.57 (NLIHC, 2019a).

An individual working full-time at minimum wage would be required to work approximately 127 hours a week to afford a two-bedroom apartment or 103 hours a week to afford a one-bedroom apartment at fair-market rent (NLIHC, 2019a). Overall, the report found there are only 28 counties out of more than 3,000 counties within the nation where a full-time minimum-wage worker can afford a one-bedroom apartment at fair-market rent. Furthermore, no full-time minimum-wage worker in any state, metropolitan area, or county can afford a decent two-bedroom rental home at fair market rent (NLIHC, 2019a).

A full-time worker earning the average renter's wage would be required to work approximately 43 hours a week to afford a modest one-bedroom apartment and 52 hours a week to afford a modest two-bedroom apartment (NLIHC, 2019a). As a result, a full-time worker earning the average renter's wage can afford a modest one-bedroom apartment in only 41% of the nation's counties and a modest two-bedroom in 10% of the nation's counties (NLIHC, 2019a). Individuals living at or below the poverty level and those living outside of the standard of affordability by paying more than 30% of their income towards housing are at risk of housing instability and homelessness (NLIHC, 2019b).

Stigma

Being homeless within the U.S. carries a profound stigmatized identity (Belcher & DeForge, 2012). With possible links to the nation being rooted in capitalistic idealism, society often places blame on the individual for being homeless as opposed to focusing on larger, antecedent economic and social factors such as limited affordable housing, unemployment, and breakdowns in kinship networks (Belcher & DeForge, 2012). The homeless population is often viewed as no longer being functional or useful contributors to society since they are often perceived as not working and supporting the system, perpetuating the idea of worthlessness (Belcher & DeForge, 2012). This stigma feeds into discrimination and prejudice that permits and enables society to limit calls for broader reform and to control individuals who are homeless (Belcher & DeForge, 2012). Furthermore, being labeled as homeless is associated with other vulnerabilities that make people susceptible to being stigmatized, including addiction, mental illness, unemployment, criminal history, and race (McNiel et al., 2005; Skosireva et al., 2014; Tsai et al., 2014 as cited in Weisz & Quinn, 2017). Stigma due to homelessness is associated with poorer physical health, greater psychological distress, and increased avoidance of services after controlling for other factors of race, gender, age, chronic mental illness status, and time spent homeless (Weisz & Quinn, 2017).

Individuals who are homeless have no choice but to perform life-sustaining activities such as eating, sleeping, living in vehicles, and asking for help within public areas; however, these activities are considered criminal in most cities throughout the country (National Law Center on Homelessness & Poverty, 2019). The implementation of criminalization laws prohibiting these activities continues to increase dramatically over time. However, criminalization is ineffective for reducing homelessness and instead creates further barriers to accessing housing, employment, and public benefits for these individuals. Moreover, these laws waste limited community resources by temporarily cycling these individuals through the expensive criminal justice system at great taxpayer expense. Criminalization policies ultimately punish people for being homeless without offering real solutions or constructive alternatives to their problems (National Law Center on Homelessness & Poverty, 2019). Essentially, these laws perpetuate an "out of sight, out of mind" approach.

Limitations of Shelters 

Shelters aim to provide individuals who are homeless with basic needs, but their ability to keep individuals safe, policies, limited funding, and inadequate staffing sometimes contribute to reasons why individuals choose not to utilize their service (Shelton, 2015). For example, individuals who identify as transgender or gender-expansive often face systemic barriers, including sex-segregated programs and institutions that deny the individual's personal identification and articulation of gender. These individuals often face a higher risk of harassment (Shelton, 2015). Furthermore, most shelters restrict pets, even service animals, and this sometimes serves as a deterrent (Hartman, 2013). Lack of childcare services has also negatively impacted individuals who are homeless because they are often required to keep their children with them at all times, making it difficult to obtain an education or to gain and maintain employment (Aviles & Helfrich, 2004).

Furthermore, research shows that shelters have been found to lack sufficient ventilation systems, hygienic bedding, and adequate space for the number of people resulting in overcrowding (Donley & Wright, 2012; Moffa et al., 2018). Skin diseases and tuberculosis infections were also found to be common (Moffa et al., 2018). Sobriety requirements, limited storage spaces, and lack of accommodations for individuals with physical disabilities are also contributing factors (Walker, 2018). Institutional routines with curfews, mealtimes, and check-in times make it difficult for individuals to engage in meaningful occupations and maintain a sense of self (Chard et al., 2009). The possible aforementioned circumstances do not directly cause homelessness. However, they may contribute to chronic homelessness in that individuals are resisting assistance from some of the very services that are in place to help them overcome homelessness.

Limitations of Housing Initiatives 

There are several housing initiatives in practice that aim to help reduce homelessness. One of the most popular initiatives among policy-makers, politicians, and social service providers is the Housing First model (Woodhall-Melnik & Dunn, 2016). Research has shown that individuals who participate in Housing First have reported notable changes in their physical and mental health, identity, self-esteem, relationships, sense of community, and overall quality of life (Patterson et al., 2015). However, it has also shown that these individuals face challenges adjusting to their new homes, especially for those who had been residing on the streets for several years prior. Additional challenges they face include remembering to pay bills, maintaining the home, remembering to carry keys, and adjusting to a new environment in which they were alone. Individuals also report difficulty in setting appropriate boundaries with others. Finding meaningful ways to spend their time is also a significant challenge for many and contributes to feelings of marginalization. Many individuals struggling with substance abuse continue to do so even after housing placement. The challenges above are sometimes contributing factors for individuals losing or leaving their house placements, making the Housing First initiative a temporary solution for some individuals (Patterson et al., 2015). 

Staff Challenges

Program staff serving clients who are homeless are faced with various staffing issues, including proper training and supervision, hiring appropriately skilled individuals, providing appropriate salaries, and adequately supporting staff to help avoid turnover and burnout (Olivet et al., 2010). A lack of professional training has been identified as one of the most acute among direct care staff, and those that do have professional training tend to lack training specific to homelessness. This factor places a significant burden on organizations serving the homeless because they become responsible for all formal and informal training. The ability to conduct or provide these trainings are highly dependent on whether there are resources available to do so, and, in this context, resources are typically very limited (Olivet et al., 2010). Training is considered a key component for helping staff be successful while working with clients that often have complex medical problems, mental health issues, and substance abuse (Burke, 2005 as cited in Olivet et al., 2010). Research by Fiske et al. (1999) has found that staff members encounter many daily challenges, including monitoring the safety of clients and themselves, maintaining appropriate boundaries, and coping with the stress induced by the environment.