homelessness in the uk essay

Homelessness in England has reached record levels – here’s why, and how to fix it

Professor of Housing and Social Inclusion, De Montfort University

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Jo Richardson does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.

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Record numbers of people are living in temporary accommodation in England, according to the UK government’s latest reported figures . Statistics on statutory homelessness show that in March 2023, 104,510 households – including over 131,000 children – were living in hotels, hostels, B&Bs and the like.

These figures are the result of multiple crises. There is an insufficient supply of available and affordable housing in the UK, with more than 1.2 million households on social housing waiting lists in England alone. At the same time, there has been a sustained fall in social housing homes being built (39,562 in 2010 compared with 7,644 in 2022).

Government data also shows that the private rented sector has nearly doubled in size since 2020. It is now the second biggest tenure after owner occupation. This means that what happens in the private rented sector is affecting proportionally more and more of the population – and hits younger people particularly hard.

Tents are pitched outside a pub in London.

In March 2020, in a bid to stop the spread of COVID, the government funded interventions to get people sleeping rough off the streets. This public health intervention, dubbed the Everyone In campaign prompted a drop of 37% in the 2020 homelessness figures and a further 9% in 2021.

This confirms what my research has long shown: with the necessary funding and political support, local authorities and social housing providers can dramatically improve the lives of people experiencing homelessness.

The English housing lottery

According to a recent analysis by the BBC, competition in the private rented sector has left 20 people vying for each tenancy. This represents a tripling of demand since 2019.

In May 2023, prospective tenants interviewed by the Evening Standard testified to the extent to which demand has outstripped supply in London. They spoke about properties in mouldy condition, others going for £150 or £200 above the asking rental price, others still with six-month break clauses. They described how looking for a place to rent – and facing discrimination in the process – was affecting their mental health. As one man put it:

You feel powerless because landlords know that if you don’t take it, they’ll find someone who’ll offer more.

The local housing allowance – the rate used to calculate housing benefit available to people – has been frozen since 2020. As a result, the amount of state support people are able to get does not track market rates , which have risen by 20% in that same period.

In July 2023, secretary of state for levelling up, housing and communities, Michael Gove, announced that his department would prioritise “urban regeneration and new inner-city renaissance” as a means for getting more homes built. This suggests Gove is seeking to further tweak the planning system by focusing on investment urban areas.

Instead of widening potential land use, Gove wants to regenerate cities. This will compound the housing issues facing those living in rural areas – tourism and the second home boom is affecting rural and coastal property markets, making housing even more unaffordable for local people and driving hidden homelessness – homelessness not accounted for in official statistics.

At the same time, Gove has not addressed the need to boost building for social rentals in order to meet the needs of the millions of people on the waiting list.

Housing precarity among young people

Where there is a lack of affordable housing and a lack of rental housing, there will be more homelessness. With the Everyone In campaign’s success in 2021, the government demonstrated that it had the means to actually tackle this problem.

However, in 2022, the numbers spiked again. Relative to the 2021 figures, there was a 26% increase in people sleeping rough.

A House of Commons library briefing in March 2023 highlighted that, if the government wants to meet its stated target of eradicating rough sleeping by 2024, research has long shown what needs to be put in place – a long-term strategy, thorough cross-party working and long-term funding. The briefing also pointed out that the government’s own figures suggest that without such bold action, it will miss its own target.

Youth homelessness is of particular concern. Data collated by charities, including Homeless Link and the New Horizon Youth Centre, in 2022 showed that 129,000 young people had sought help with housing from their local authority.

Much of this is hidden from public gaze. These young people often stay with friends for short periods or live in precarious conditions. Their vulnerability is only heightened by societal assumptions that they are “adult enough” to manage on their own, but not “grown-up enough” to expect to have their own place.

These assumptions are made clear in the fact that benefits are capped at a “shared accommodation” rate unless there are specific circumstances, for example, proven experience of domestic violence.

Those who no longer fall in the 18-24 age bracket, but are part of “ generation rent ”, have already been campaigning on the impact of inequality in housing and the issues faced in the private rented sector.

In 2022, I researched what had worked in how the Everyone In campaign was implemented. I found that where local authorities, social housing providers, healthcare, charities and the private sector were funded and supported, they could work nimbly, effectively sharing information and collaborating to achieve outcomes quickly.

At national level, however, the single most vital ingredient is the political will to actually deliver properly affordable housing. This requires the state to provide sustained funding and to have a long-term strategic approach. Failing this, the lessons learned since the start of the pandemic, on the importance to society of a place to call home, will be lost.

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Homelessness
Housing crisis
Statutory homelessness
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Home — Essay Samples — Social Issues — Homelessness — The Socio-Economic Issue of Homelessness in the United Kingdom

The Socio-economic Issue of Homelessness in The United Kingdom

Categories: Homelessness

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Words: 1133 |

Published: Mar 1, 2019

Words: 1133 | Pages: 2 | 6 min read

Homelessness in the uk, causes of homelessness, strategies to combat homelessness, homelessness act 2002/2004.

Is the person intentionally homeless?
Is the person eligible for assistance?
Does the person have a local connection?
Is the person homeless?
Is the person in a priority need?

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http://orcid.org/0000-0003-2532-3415 Johannes Lenhard 1 ,
Megan Margetts 1 ,
Eana Meng 2
1 University of Cambridge , Cambridge , Cambridgeshire , UK
2 Harvard Medical School , Boston , Massachusetts , USA
Correspondence to Dr Johannes Lenhard, University of Cambridge, Cambridge CB21ST, Cambridgeshire, UK; jfl37{at}cam.ac.uk

People experiencing homelessness in the UK were unconditionally offered housing (and support) from the beginning of the first lockdown in March 2020. For many, that meant ‘(re)entering’ the support system and having a chance to ‘move on’ to longer-term housing. This beneficial effect of some of the policy reactions to the pandemic on people experiencing homelessness was unexpected. On the flip side, however, particularly for people struggling with drug use and mental health issues, adequate support was not available for long periods of time; support was either suspended temporarily or people were excluded from institutional support for not adhering to, for instance, lockdown rules. Similarly, digital support alternatives—modelled on increasingly widespread telemedicine—did often not work specifically for people struggling with complex needs or women experiencing homelessness. This research paper reports detailed evidence of what we observed as continued and catalysed exclusions based on interviews and ethnographic observations with both people experiencing homelessness and service providers from the beginning of the COVID-19 pandemic. Referring to our insights and learnings from three locally and temporally overlapping research projects between May 2020 and April 2021, we also propose changes to redesign future (health)care provision to prevent such impasses—which extend beyond lockdown situations to general conditional housing and support.

Anthropology
Drug and alcohol misuse
Mental health care
Health policy

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Data are available upon reasonable request.

This is an open access article distributed in accordance with the Creative Commons Attribution 4.0 Unported (CC BY 4.0) license, which permits others to copy, redistribute, remix, transform and build upon this work for any purpose, provided the original work is properly cited, a link to the licence is given, and indication of whether changes were made. See: https://creativecommons.org/licenses/by/4.0/ .

https://doi.org/10.1136/medhum-2021-012367

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COVID-19 homelessness and care

While many groups: elderly people ( Chen et al . 2021 ), communities of colour and people with disabilities ( Abrams and Szefler 2020 ; Dovie, Mariela, and Magdalena 2020 ) were hit especially hard by the pandemic (and the effects of lockdowns, in particular) forcing many to lose their jobs and potentially their homes, people experiencing homelessness experienced a silver lining during COVID-19 in the form of UK government funding ( Ian Hamilton: Covid-19—Are We Rationing Who We Care about? - The BMJ ). Financed mostly by the Treasury ( “£105 Million to Keep Rough Sleepers Safe and off the Streets during Coronavirus Pandemic - GOV.UK.” ) under an extension of the ‘Homelessness Initiative’ of 2018, the scheme entitled ‘Everyone in’ ( Crisis 2020 ), was focused on providing emergency accommodation during the lockdown as well as the promise to create 3300 move on homes by the end of March 2021 ( COVID-19: Housing People Sleeping Rough - Public Accounts Committee - House of Commons ).

While effective for some—with 37 000 people given emergency accommodation (‘ Everyone In” Scheme Exposed Gaps in Government, Crisis UK )—the needs of some groups, particularly those requiring specialist healthcare services, continued to be overlooked ( Homeless Migrants Still Sleeping Rough despite PM’s Pledge ). Based on almost 1 year of ethnographic fieldwork and interviews, performed by the three authors in joint and individual projects in a UK university town, in this paper, we focus on two particular kinds of exclusion. Abstracting from observations from a multitude of support institutions for people experiencing homelessness (emergency housing/assessment centre, Covid-specific hotel, healthcare providers), we illuminate both the exclusion of people experiencing homelessness with complex needs and problems surrounding digital support, specifically for women in situations of homelessness. While these exclusions are not new or caused by COVID-19 and the surrounding lockdown measures, the measures made the exclusion of some people particularly visible. On the one hand, additional rules (eg, during lockdown) led to the exclusion to specific groups (eg, people with complex needs) to protect the majority, for example, in a Covid-hotel; on the other hand, shifting service provision (from inperson to online) also affected certain groups (eg, women experiencing homelessness). All of this happened despite additional funding available—which itself still had a positive impact for many people experiencing homelessness. We believe our observations show issues on a systemic level with the care provision for people experiencing homelessness which has—over years—become atomised and disadvantaged people who are already more marginalised. Consequently, in the final section of the paper, we propose several (counter) measures to set up a more inclusive system of care provisions.

Methods and participant involvement

Applying rapid ethnographic assessment ( Sangaramoorthy and Kroeger ) with a focus on listening to different stakeholders in the community ( Listening Carefully to Communities Should Inform Our Response to Covid-19 - The BMJ ), the three coauthors conducted several months of anthropological fieldwork and semistructured interviews adhering to COVID-19 restrictions in a variety of homeless support institutions in a UK university town between May 2020 and April 2021. Between the three authors, we conducted several dozen interviews with people working in social services (over 30 interviews with more than 15 people) and people experiencing homelessness (9 formal interviews; around 20 informal conversations; with people in different kinds of supported accommodation at the time of the interviews). All institutions—anonymised in this paper—were informed about the nature of this research and agreed to participate (through consent from senior executives/managers as well as employees) and so were all individual participants (whose names are also all anonymised). For each interview with a person experiencing homelessness (seven people) we made it a specific priority of soliciting verbal (and where situationally possible, written) consent—based on detailed explanations of the exact nature and purpose of the research. Informants were not compensated for their participation.

Two of the three core research projects (led by EM and MM, guided by JL as Principle Investigator (PI)) underlying this paper were funded by a rapid response grant as well as a later-stage impact grant at the University of Cambridge (and the Economic and Social Research Council), specifically targeting COVID-19-related projects; the third project (led by MM under the guidance of JL as the PI) was unfunded and conducted in cooperation with several local homeless service providers. The first project was focused on tracing the impact of COVID-19 and the first lockdown on people experiencing homelessness; it involved ethnographic and interview-based research in an emergency housing provider and lasted from May 2020 until November 2020. The second project followed the first in time (November 2020 to May 2021) and focus (engaging local stakeholders to observe the impact of COVID-19 on people experiencing homelessness); it led to the establishment of the Cambridge Homelessness Impact and Research Network (CHIRN) in April 2021. The third project, facilitated by the newly established research exchange by CHIRN, started in December 2020 and will be closed by the end of Q1 2022 with a final assessment report and stakeholder workshop; it was focused on an experiment trialling telemedical means to enable easier access to healthcare for people experiencing homelessness while in a local Covid-hotel between January and May 2021. This project, like the first, involved stakeholder interviews and several days of ethnographic observation in the Covid-hotel and adjacent service providing institutions. The three research projects hence overall provide a comprehensive overview of the local context of service provision for people experiencing homelessness between different kinds of housing and healthcare; the people experiencing homelessness circling and passing through (sometimes for years, as confirmed by senior staff of service providers) the different service and housing providers are connecting the institutions in a deeply embodied way.

The research questions and design as detailed above were informed originally by the insights from several of the support practitioners involved in institutions where fieldwork was conducted; several consultations with the practitioners at key stages of the project helped further shape the directions of research as well as its analysis. The data we processed for this article consisted of interview transcripts from all three projects (with both service providers and people experiencing homelessness; written up and edited for clarity based on initial Otter.AI transcription) and notes from fieldwork encounters (from JL and EM). According to anthropological and ethnographic convention ( Mol 2008 ; Sangaramoorthy and Kroeger, n.d.) the data was not formally coded but organised in case-study-like narratives (mostly centred either around individual people or specific situations, based on ‘thick description’) ( Geertz and Darnton 2017 ), individual vignettes and specific fragments ( Veer and Thomas 2016 ). Comparing both findings from our different but connected field sites and individual analysis from the three coauthors led to our initial set of insights and the establishment of exclusion as a core vector ( Candea 2018 ; Schnegg and Lowe 2020 ). All three coauthors participated in the analysis leading initially to the production of short reports based on our preliminary findings per research project. In early 2021, we consulted with and presented these preliminary findings to a (local) institutional group of people with lived experience; their feedback and further questions shaped both the last phase of research and analysis and our recommendations (see final section below). We will disseminate the results of the research leading to this paper through our established research-exchange community (CHIRN), recently founded by two of the authors, which includes service providers and people with lived experience and is open to the interested public. All three projects passed ethical review in the University of Cambridge’s anthropology department. No clinical settings were part of the study so no other specific approval was required. Moreover, all relevant (institutional) parties mentioned above were already consulted individually with the findings of this research and were able to provide feedback.

Multiple exclusions: substance use, complex needs and digital shortcomings

As care provision for people experiencing homelessness, including healthcare, has become increasingly more specialised, it has been divided into individual systems rather than focused on providing a holistic approach. For the general population, care similarly often has become disjointed and uncoordinated with each patient seeing several doctors to provide adequate care for one condition. For people experiencing homelessness, the support they are (often) dependent on has been further under pressure. Generally, driven by de-institutionalisation and a push for community care as early as the 1970s in the UK ( Baldwin 1993 ; Craig and Timms 2009 ) and more recently austerity measures and welfare reforms, service provision has become reduced and fragmented for people experiencing homelessness ( Cameron et al . 2016 ; Gunner et al . 2019 ). In the local set-up where our research studies took place, we observed this development acutely already pre-COVID-19: different parts of support and care provision for people experiencing homelessness were distributed both geographically and institutionally. Specialist, individual service providers were respectively responsible for the provision of housing, benefits, education/training, substance use (including support groups), drug testing, mental health support (if available at all) and physical health. Any individual person experiencing homelessness and struggling with a variety of issues would be tasked to interact with as many different service providers as that person was encountering problems . In few cases, support workers (eg, at the place of housing provision) were tasked with and able to provide coordination and continuity of care. In fact, the commissioning of the different pieces of the support network was done by different parts of the local councils, to begin with (drug use, housing, healthcare—generally all treated separately) going back to individual budgets (per issue area). As a result, people experiencing homelessness in general were—driven by large institutional changes over decades—forced to operate a multistakeholder, specialised and fragmented service provision system; in our specific empirical context, they were only occasionally supported and accompanied through the entirety of this system by a specific support worker. Additionally, we observed a lack of institutionalised coordination and even communication (eg, supported by a single software system) by the support providers making the desired continuity of care and support ( Jego et al . 2016 ; Lamanna et al . 2018 ) complicated if not impossible and leaving many people experiencing homelessness without access to the care they needed.

For people experiencing homelessness and struggling with complex needs, navigating a fragmented healthcare system is even more challenging. The National Institute for Health and Care Excellence (NICE) defines people with ‘complex needs’ as ‘people needing a high level of support with many aspects of their daily life and relying on a range of health and social care services’ either because of ‘illness, disability, broader life circumstances or a combination of these’ ( Guideline Scope Adults with Complex Needs: Social Work Interventions Including Assessment, Care Management and Support ). So not only do people with complex needs have more support needs (eg, housing as well as mental health and substance use support), they also struggle more likely with navigating everyday administrative tasks ( Viertiö et al . 2012 ; Dewa, Thompson, and Jacobs 2011 ). Overall, it is well established that individuals experiencing homelessness are at a greater risk of negative health and social outcomes, with an average life expectancy of 45 years for men and 43 years for women (30–40 years less than the UK national average) ( Deaths of Homeless People in England and Wales - Office for National Statistics ). Unsurprisingly, numerous studies have highlighted disproportionate levels of cardiac problems, long-standing tuberculosis, hepatitis C compared with age-matched housed individuals ( Aldridge et al . 2018 ). This trend is also seen in mental health: a recent study by Groundswell found that 64% of homeless women questioned were experiencing mental health problems compared with 21% within the general population ( About Groundswell 2020 ).

People experiencing homelessness and struggling with specific and often complex needs often require support from multiple specialists to manage their care; many of these individuals would also need additional support from a care coordinator to oversee appointments and advocate for their needs.However, currently, there is very little research into how to best support people with complex care needs ( Fortin et a l. 2005 ; Fortin et al. 2007 ) leaving many people to fall between the cracks ( Coleman 2003 ) of support. It was only in October 2021 that NICE compiled its first-ever draft guideline for the ‘Integrated health and care for people experiencing homelessness’ ( NICE 2021 ); so far, many clinicians are unaware of this new guidance and do not use it routinely in their clinical practice. Although a handful of specialist homeless mental health services do exist, most have been disbanded due to lack of funding ( St Mungo’s 2011 ).

While this exclusion is partly driven by the fragmented set-up of the support provision system, an additional factor is discrimination ( Homeless People Are Among the Most Vulnerable to the Coronavirus. Yale Psychiatry’s Lo Is Making Sure They Still Receive Care Amid the Pandemic. < Yale School of Medicine ), and yet another factor is strict exclusion criteria for certain services, for example, around the so-called condition of being housing- or treatment-ready ( Padgett et al . 2010 ; Padgett, Henwood, and Tsemberis 2015 ). As a result, an additional burden falls hardest on those with complex needs or dual diagnosis (concurrent mental health problems and substance use) ( Schütz et al . 2019 ), where (despite regulation changes) these individuals are continuously sent from service to service as they do not meet the ‘treatment-ready’ requirements for substance use or stable mental health, ( St Mungo’s 2011 ).

With the onset of COVID-19, the already atomised and hard-to-access resources were further stretched and access made complicated ( Shock to the System: COVID-19’s Long-Term Impact on the NHS - The Health Foundation ; Aburto et al . 2021 ; Propper, Isabel Stockton, and Stoye ). In the empirical context of our research studies, we observed how service provision for people experiencing homelessness were either reduced in scope (eg, fewer beds offered to adhere to social distancing, certain services (like drug testing) suspended for the same reasons) or altogether (temporarily) suspended (eg, drug and substance use support groups were suspended for several months during the first lockdown in our local context). Additionally, given the lack of overall specific government instructions for homeless support institutions at the beginning of the lockdowns, guidelines had to be made up on the spot (eg, by the management of service providers) and were often changing and unclear; eventually, these guidelines became stricter as we explain below, particularly impacting people with specific support needs to protect what was perceived to be the (more compliant) majority of people. Individuals experiencing homelessness were on the one hand supported more, particularly with housing, with additional government funding being made available. On the other hand, however, specialised support (eg, for people with complex needs or dual diagnosis) was even harder to access. This was also not alleviated for certain groups (eg, women) with a (experimental) shift to digital platforms as we will show further down below. With a lack of suitable technology and inadequate training many of these individuals were and continue to be unable to access even basic (health) services—often both digitally and inperson—which increases their reliance on underfunded but trusted non-profit organisations to fill in the gaps.

Addiction hurts, at least twice, during COVID

Ben really isn’t keeping up well. He looks fine, but he’s been complaining and he’s constantly out. […] You don’t see a change with everyone, but with him […] it’s so obvious. He is back on the crack, too. And he was supposed to move out soon – but at the moment nobody is moving. They are all staying longer than the 28 days [the supposed length of an average stay at the assessment centre].

Dannie explained to me (JL) who Ben was while we were standing behind the kitchen counter during an evening which I spent volunteering at a short-term hostel (the Centre) in a UK university town in April 2020. Dannie was a long-term volunteer and familiar with many of the people circling through the centre and my partner on that particular evening. Ben was obviously not doing very well; he was zigzagging through the room towards the counter we stood behind, trying not to fall. Dannie and I were responsible for serving the dinner—one of the tasks for the two evening volunteers—and Ben had come to get his. While COVID-19 restrictions, such as social distancing, were taken very seriously in the Centre, there wasn’t enough space for that during dinner. As a result, residents were sitting on the couches; a loud action movie was running on the television. When Ben arrived at the counter, we both smiled at him: ‘Do you also want dinner? Any special requests?’. Looking up briefly, Ben’s teeth were moving and he fumbled around with his hands in his pockets; he wasn’t able to stand still. Mumbling a short ‘No’, he quickly grabbed his plate and disappeared within minutes, having gulped down his dinner.

At the beginning of the full restrictions of the first COVID-19-related lockdown in the UK, homeless service providers were facing their limits and so were the people depending on their support and care. In a Harvard Health post from 2020, a US-front-line doctor (and recovered opiate user) contextualises the double hit we observed also in the UK ( A Tale of Two Epidemics: When COVID-19 and Opioid Addiction Collide - Harvard Health ). Reporting on what he calls the ‘two great epidemics of our generation’, he argues that people suffering from substance use on the one hand ‘are vastly more vulnerable to coronavirus’; on the other hand, they also suffer from shortages of supplies (of methadone and other medications, for instance, at times even clean needles) and of increased issues of isolation, specifically when it comes to the lack of access to their recovery community and peer-support groups that were so often suspended during the pandemic lockdowns.

In the UK context, we observed both of these issues hitting people like Ben hard, too. Ben was young, reasonably healthy and very much used to accessing his friendship group—some of whom were not experiencing homelessness—outside the Centre most hours of most days before the pandemic and its restrictions. His friendship group also doubled as his circle of drug buddies, people Ben would consume drugs with every day, as well as pool money with to buy supplies more cheaply. While his drug use—as he explained in an interview later, of crack and cocaine—continued before the pandemic, Ben was seen as doing reasonably well; he was on track to access longer-term housing, as one of the assessment centre’s managers explained in a later conversation. During the first lockdown, as institutions such as the Centre were experimenting with how to best protect their community, leaving the Centre was not permitted, apart from for specific (mostly medical and ‘exercise-related’) reasons. As a result, Ben was not regularly allowed to go out and hence not able to access the community he usually relied on (‘I rely a lot on my community […] experienced a lot of community through prison’, he explained in an interview with JL in summer 2020). While he breached this rule for a while on an almost daily basis (and was initially not sanctioned), his drug use was rapidly increasing; Ben called it ‘a sort of non-stop relapse’ in the interview with JL, including smoking crack in the assessment centre (‘one of the times the fire alarm went off’). Difficulties with accessing drug supplies (drug dealers weren’t out as frequently and buyers had to travel farther) made his drug use more complicated and forced him to go outside frequently and for long stretches of time, against the rules eventually installed and enforced by the Centre. Given an explanation from one of the support workers familiar with Ben (and the recorded history this support worker mentioned), we can assume that he was additionally struggling with mental health issues, such as anxiety and depression (while he did not mention those in the interview with us). A vicious circle was pushing Ben to the point where JL first encountered him (see initial vignette above).

Even though staff and volunteers at the Centre noticed the increased support needs for Ben and others (as our interviews showed explicitly), there was very little specific support they could offer, particularly during the first lockdown in spring/summer 2020. Ben, for instance, had relied on regular inhouse drug testing to keep himself accountable (‘to rebuild (his) life’, as he explained); that support stopped to adhere to social distancing and as a precaution to keep staff safe. Internally, a major concern was to protect staff (from COVID-19 infections) in the different institutions we observed to keep a minimum of operations functional. Already before the pandemic, the vast majority of specialised mental health and substance use support services had been outsourced systematically to specific service providers; the local substance use support service stopped providing any support during the first lockdown and switched to phone support eventually after a several-months long suspension.

At the Centre, one way of coping with the increased support need and burden was to experiment with changing rules. While COVID-19-related lockdown rules (as mandated in other institutional contexts by the UK government) were introduced, other rules were relaxed. One of the Centre managers, John, explained how balancing residents’ needs and the responsibility to protect staff (and the functioning of the Centre as a whole) was complicated but something they attempted by granting residents certain liberties inhouse. While the Centre—like most service providers—was a ‘dry Covid-hotel’, that is, no alcohol (or other substances) was allowed on-site, a specific area downstairs was opened up for the consumption of certain (weak, up to 5% vol) alcohol during the first lockdown in April 2020. This rule was further relaxed—removing any restrictions on the type of alcohol allowed—several weeks into the lockdown. But people’s rooms were out of bounds, still. John reflected: ‘How are we supposed to keep that [being a dry Covid-hotel] up when people aren’t allowed to leave? They aren’t even allowed to sit in the park. […] Many of our residents have a substance use problems. […] That’s the least I can do. We even buy it for people if they are self-isolating and ask us to. […] One of our biggest problems is keeping people inside, behavioural issues, really’. While for many residents—in the Centre and many other homeless institutions—relaxing restrictions around alcohol consumption were tremendously helpful in a time of stress and crisis, as the case of Ben above shows other substances were even more complicated to manage.

While restrictions around consuming ‘hard drugs’ were impossible to relax legally, Centre staff showed a certain kind of lenience with Ben and others initially. Another staff member, Ollie, explained to JL in an interview: ‘I know from personal experience, if you are in (drug or alcohol) withdrawal, nothing will stop you going out to get your substance; coronavirus won’t even cross your mind’. Ollie was sympathetic with the struggle of people like Ben, but also wary of handing over a blank check to people who use drugs in a situation of crisis: ‘If you turn a blind eye to it: drug-dealing, drug-sharing, violence, reliance on each other – it’s a whole different culture!’. The staff seemed to be united in being unable to alleviate Ben’s particular struggle—fearing the situation could slide completely out of control. Setting a wrong precedent was deemed even more dangerous than supporting people—in whatever way or form was possible—under exceptional circumstances.

Over time, with lockdown restrictions staying in place for months, management at the Centre was increasingly overwhelmed; while Ben’s problems were significant, others were struggling, too. More and more staff were self-isolating, putting additional pressure on the remaining members of the team. Managing the day-to-day operations became a stretch, to begin with, and the team overall managed incredibly well (there was not a single case of COVID-19 reported among residents in the assessment centre in 2020). Dealing with people who had increased support needs was putting a lot of pressure on the functioning of the institution as a whole. The immediate goal for management was to enable all residents to be as supported as possible; they were facing a trade-off as Ben and others would not stop excursions outside and put all people in danger (of ‘importing’ COVID-19 into the Centre). Ben himself reflected that he was surprised to be ‘let loose’ for so long: ‘(I had) so many final warnings. […] they let us go four or five (hours) […] then they finally cracked down’. Faced with a decision to be lenient with some or keeping the majority of the Centre (and its staff) as secure as possible, management ultimately decided to stay on the side of more solid enforcement of rules and structure. Over the course of several weeks in late spring 2020, not only Ben but several other people—most of them struggling with complex needs between mental health and substance use—were evicted (or as I was told: ‘asked to leave’) from the Centre after receiving at least two warnings but continued to breach the ‘stay at home’ order.

At the Centre in the UK university town where we conducted a significant portion of our research, but also in many other homeless service institutions, emergency shelters and temporary ‘COVID-19 hotels’ in the UK, Europe and the USA ( Homeless People Are Among the Most Vulnerable to the Coronavirus. Yale Psychiatry’s Lo Is Making Sure They Still Receive Care Amid the Pandemic. < Yale School of Medicine ; Homeless in Europe the impact of COVID-19 on Homeless people and services contents ) the people who were hit most by COVID-19 and the reactions to it were among the most marginalised and in need. Given that most specialised support—particularly for people who use drugs and/or struggle with mental health issues—has historically become outsourced to specific service providers (including general practitioners (GPs)), restrictions of the free movement of people hit those particularly hard who were dependent on accessing a larger variety of different support providers. Many were not able to access any support for their often ever-increasing support needs during the pandemic. Even when some support shifted online or to the telephone (often until today, see below), people with complex needs continued to struggle to engage. COVID-19 (and the restrictions around it) hit people with complex needs at least twice: while stress levels and mental health needs increased (eg, due to isolation, fear of catching COVID-19, no ability to meet friends, new behavioural rules (particularly during periods of lockdown), self-medication with drugs was made more complicated. Not only was supply harder to come by on the street (and so was money from begging, often needed as supplementary income), people in places like the Centre were also simply not supposed to be outside, a rule that was increasingly enforced. Lockdown not only disrupted normal routines, but it also quasi-criminalised some of the routine behaviours our informants’ well-being depended on, either by government-imposed or institutional rules (eg, ‘hanging out’ with friends outside). As a result of the ‘misbehaviour’ and ‘disobedience’, some residents like Ben were eventually evicted from the support institutions, to protect ‘the majority inside’. As a final result, being back on the street, left people (at least temporarily) even further marginalised from healthcare support (beyond street outreach which laudably was in operation throughout most of the lockdowns).

Digital care? talk of the future…

From the outset, a shift to digital consultations promises to change the landscape of healthcare access to the better, also for people experiencing homelessness.

People no longer need to travel to appointments or leave their places of residence or comfort (eg, a day centre); digital technology allows them to access healthcare services from anywhere with the right mobile device and sufficient signal ( You Mean I Don’t Have to Show Up? The Promise of Telemedicine - The New York Times ).

While the use of video consultations in healthcare has steadily been increasing for a number of years ( Car et al . 2020 ), it was with the start of the COVID-19 pandemic that we have seen another sudden shift to remote consultation, in some settings completely replacing any face-to-face interaction. To protect both patients and doctors, inperson consultations were reduced to a minimum across the UK’s healthcare system already during the first lockdown. Telephone triage became the new normal and doctors and patients alike were forced to learn to adapt to new methods of communication, including specific applications (eg, accuRx ( General Practice )).

Although mobile phone use and texting are very common among people experiencing homelessness (with between 89% and 94% of individuals having regular access to a mobile device ( Moczygemba et al . 2017 )), many of the mobile devices provided are unable to support video consultations and those that do tend to be unaffordable ( Moczygemba et al . 2017 ). As a result, with more (healthcare) services shifting to digital platforms during COVID-19, the chasm of digital inequalities continued to widen: 79% of homeless service providers screened reported increasing issues due to lack of digital access for people experiencing homelessness in the first lockdown ( Boobis and Albanese 2020 ).

In an attempt to overcome some of the barriers associated with a lack of suitable technology and inaccessibility, a GP service in an unnamed UK university town trialled the provision of ‘mobile health consulting’ specifically with one so-called temporary ‘COVID-19 hotel’ for people experiencing homelessness. The set-up was simple: use (video) telemedicine to connect people experiencing homelessness in a local Covid-hotel directly (and quasi on-demand) to a specialised GP service for non-emergency healthcare consultations.

The implementation of this new service divided the opinions of both staff and the people who used it in the COVID-19 hotel. While some staff—doctors and nurses alike—fundamentally did not agree with the idea of video consultations as a substitution for (or even addition to) inperson consultations, other staff wholeheartedly supported the idea. Several staff members commented that with the introduction of video consultations, they saw ‘terrific engagement from many clients who would not normally engage with the service’. One key success story was with Brody, one of the residents of the local COVID-19 hotel:

Brody was a deeply entrenched individual; encouraging this person to go to the surgery was always a difficult task […] suddenly, we were able to provide a consultation which meant that all we had to do was go from one side of the building to the other. It was a real success to get him involved. Support worker

The benefit of new and unseen engagement was particularly noted in people with limited mobility. As two people with lived experience noted, not having to travel to see a doctor also made it easier for people who struggle with anxiety or depression (and might not want to leave their house) to connect to healthcare in an environment they felt comfortable in. One person who used the service commented:

While the video appointment was still daunting it was far less scary than a face to face appointment and definitely helped with my anxiety around seeing health professionals

For the healthcare providers, video consultation can also solve several issues at once: they make DNA (people who ‘do not attend’ the appointment) less likely, ensuring the continuing provision of consultation also during lockdown conditions while reducing (inperson) appointments (potentially dangerous for vulnerable people). For one nurse frequently in contact with people experiencing homelessness during street outreach tours, this was a very strong point: ‘It is another string to my bow that I can offer people when I am out on outreach’.

However, from our time-constrained small-scale observations during the one local trial we accompanied, only a certain group of people, a subgroup of people experiencing homelessness, were able to enjoy the benefits. The ‘success stories’ of video consultations we observed were with young male individuals who were already familiar with video communication. Women, older individuals and those who were less comfortable with technology remained less or not at all engaged. This highlights several problems with the service more generally and some general principles of how to design (and test) similar services in the future.

Privacy needed, particularly for women

During the 3 months of this particular study at the local Covid-hotel, no women requested a video consultation and one female person living in the hotel which MM encountered during fieldwork asked specifically to speak inperson to a GP as she was concerned about privacy. The idea of speaking openly about physical and mental health problems is often challenging ( Gangi et al . 2016 ; Mak and Wu 2006 ). Fear, stigma, relationship to the listener and the perception that mental health problems are less important than physical health are all sighted as reasons that contribute to a delayed presentation of people with mental health problems and trauma to primary and secondary care ( Grice 2016 ; Reavley, Morgan, and Jorm 2018 ; Bedard-Gilligan et al . 2012 ; Bolton 2003 ; (US), Center for Substance Abuse Treatment 2014 ).

Hence, while the consultations were held in a private space or the person’s room (depending on their choice), there was still fear that other residents could overhear the conversation or even hear that a consultation happened. Furthermore, with no referral pathway that was anonymous or allowed the person requesting the consultation to contact the GP directly to make an appointment, people were required to speak to a member of staff both to make the original referral and to get access to the equipment for the consultation. Finally, a lack of client training sessions meant that digital privacy was not addressed and individuals who were unfamiliar with the technology often required facilitation (by members of staff) during the consultations which again may have made it more difficult for some individuals to open up. 1 This might have been another reason for some individuals within the hotel not to access the service. However, from interviewing GPs working within the sector, the lack of engagement of women experiencing homelessness in healthcare was seen to be a systemic problem. This is also reflected within a recent study by Groundswell which highlighted that 65% of homeless women interviewed struggled to find the motivation and confidence to deal with health issues ( Groundswell ). This highlights that a lot more research needs to be done to look into why homeless women are not using primary care services and what we can do to improve this, particularly with a focus on telemedicine which is projected to become increasingly widespread.

Technological barriers

The greatest concerns among participants, healthcare professionals and people in the co-production group we consulted were around technological barriers. How could you ensure the availability of a good enough (phone) connection, good camera resolution, strong enough phone volume and most importantly the technological literacy required to use such a mobile device generally? This point was particularly evident during one consultation with an elderly resident in the hotel. The poor sound quality meant that the resident needed to repeat parts of his story two or three times; this led to frustration and made it incredibly difficult to build up a rapport between the doctor and the person. This frustration was furthered by the small screen size which limited the doctor’s view and made it more difficult to assess how the person was coping. As one nurse stated:

A lot of information in a face to face consultation […] cannot be caught on camera, particularly the way the person walks into the room. For example, drug-seeking people may be dancing out the front of the building but when they come in they may be asking for pregabalin for their pain

All of these issues were encountered during the trial phase despite the relative stability of the Wi-Fi connection in the COVID-19 hotel. Taking the technology of video consulting to a different context (eg, people experiencing homelessness calling in themselves, possibly from a street setting) risks increasing the frequency of the technological problems drastically.

While several studies have suggested that people experiencing homelessness are willing to engage in digital forms of support for managing their mental health and prescriptions ( Jennings et al . 2016 ; Glover et al . 2019 ), the digital divide must be addressed before telemedicine technology can be considered to be a feasible method for improving healthcare accessibility among individuals experiencing homelessness.

While phone access is widespread ( Rhoades et al . 2017 ; McInnes et al . 2014 ), only 50% of the devices could support video calls. Furthermore, maintaining telephone connectivity is often challenging due to financial constraints. ( Jennings et al . 2016 ), hence additional funding would be required to ensure that all individuals had access to reliable technology.

Although ensuring adequate privacy and overcoming technological problems were both barriers that contributed to the limited success and uptake of the service, the sudden set-up of the service and the failures to involve all relevant parties also might have contributed to the difficulties we observed.

First, not all GPs at the practice were engaged with the telemedicine project. This meant that people who requested a video consultation would often be placed with an unfamiliar GP practitioner. For a consultation to be successful there must be a strong trusting relationship between the doctor and patient ( Ruberton et al. 2016 ; Skirbekk et al . 2011 ; Grassi, Caruso, and Costantini 2015 ); this is even more important for individuals experiencing homelessness, many of whom have a history of trauma and negative previous experiences of healthcare services. One person, Tim, mentioned this problem explicitly. Although support workers had commented that it had been a ‘great success’ to get Tim involved in a consultation, he was both unsettled by the new technology and was far less willing to engage and open up to an unfamiliar healthcare professional. It was only after the telemedical consultation that Tim was visited inperson by his regular GP; during that visit, Tim received what the doctor afterwards called ‘satisfactory care’. Tim even commented that he may be willing to engage in a telephone consultation (despite his preferences for face-to-face visits) as long as it was with his regular doctor. This experience reflects the view of many healthcare workers we interviewed, who commented that it is far more successful to build rapport in a face-to-face context with a new person before moving to a digital platform in a second step.

The second problem resulted from a lack of more general preparation and set-up of the service, particularly in terms of missing staff training and not raising enough awareness among hotel residents. Publicity for the digital consulting problem was primarily through word of mouth which in itself introduced unconscious bias and may have meant that not all residents were made aware of the service. It was only at the end of the project that information leaflets were created to inform people in the Covid-hotel about the service. To add to the confusion, healthcare staff from the GP service (outside the core group of doctors and nurses) and within the Covid-hotel were either unaware of the service or unclear about which people should be referred in what way. Both of these faults could partially explain the general lack of uptake from people during the project, with less than eight video consultations performed over 3 months, most of which fell in the last month. Better, more direct and more comprehensive communication from the beginning of the roll-out period would likely alleviate this problem.

In summary, the first-of-its-kind local experiment to introduce telemedicine to promote inclusivity and widen access to healthcare for people experiencing homelessness had mixed results; the rapid implementation of the project (without, eg, adequate accompanying communication and onboarding for all relevant parties) could be seen as ‘teething issues’. But the trial we observed also highlighted more general problems of adequate privacy and technological barriers likely to be aggravated in less ideal set-ups. On some level the service did fulfil its role in allowing a small proportion of individuals to access healthcare who otherwise would not engage, however in doing so, it ostracised others from accessing the services they required; in particular, we observed this happened to women who experienced homelessness. Moving forward the first experiences of providing telemedicine to people experiencing homelessness did have positive outcomes which could be applied to other services (eg, mental health provision ( Schueller et al . 2019 ), or mobile-based buprenorphine treatment ( Iheanacho, Payne, and Tsai 2020 )) but this will only be effective if we take onboard the lessons we learnt from this pilot study. We will go into some more depth with our recommendations in the following, final section.

Learnings: provide more specialised care and accelerate the right digital services towards an integrated system of care

Based on our key findings around the impacts of COVID-19 and the accompanying responses in the system of service provision for people experiencing homelessness, we propose three tangible suggestions to improve the delivery of such services; we imagine that a system of care and support is possible which is specialised but integrated and can harness the potential of telemedicine to widen access for people experiencing homelessness, especially to healthcare.

Particular attention and specialised care for those struggling with substance use and mental health . By far, those managing substance use, mental health conditions or both (complex needs/dual diagnosis) were most strongly and negatively impacted by the pandemic and the mitigation strategies around it. The safety net was not sturdy enough—or too atomised—to catch, in particular, people with more complex needs. As such, money and resources should go to specialised services for complex needs (ie, hiring support workers with training in dual diagnoses). While people we spoke with and observed suffered particularly from the temporary closure of some specialised services locally (or the inability to visit them due to lockdown rules), service providers and doctors agreed that not enough specialised services were offered in any case ( St Mungo’s 2011 ). Our research (mirroring that of others ( Grassi, Caruso, and Costantini 2015 ; Skirbekk et al . 2011 ; Ruberton et al . 2016 )) also shows the importance of establishing and maintaining healthy routines and habits (often connected to a continuity of care), as they can provide both stability and a sense of security for many. When people were no longer able to engage in their usual daily practices, we saw negative effects on both physical and mental health. This observation thus calls for a harm reduction approach to drug use; harm reduction emphasises the inevitability of drug and substance use in society and aims to ‘reduce the adverse health, social and economic consequences of the use of legal and illegal psychoactive drugs without necessarily reducing drug consumption’ ( International Harm Reduction Association 2010 ). We believe there should be more conversation around embracing the approach of safe injection facilities in the UK ( Safe Injection Sites: Coronavirus Underlines Why They Make Sense: Cato Institute ), which would have benefited both institutions and individuals alike over the last 2 years.

Incorporate, encourage and normalise the use of digital services . The difficulties with the uptake of telemedicine we observed, might largely be a product of novelty and the fast and unprofessional set-up. With time and normalisation, people will adjust and some might perhaps even come to prefer it (as we also saw during our observations). Young adults have particularly benefited from mobile phone outreach and support; in some contexts, it can be used to provide community-based buprenorphine therapy for people experiencing homelessness ( Glover et al . 2019 ; Harris et al . 2020 ). It can increase and further personalised care. The great potential of digital services, however, is contingent on several conditions: for example, access to a private and safe space for consultations (particularly important to make women experiencing homelessness feel safe), adequate connection to the internet and the availability of the necessary hardware and technology support and training ( Thiyagarajan et al . 2020 ; Blandford et al . 2020 ). Without sufficient and necessary preparation and intention, it would not be a surprise if the incorporation of digital services only worsened situations, that is, disorganised, non-transparent, convoluted instructions would agitate, rather than alleviate problems.

As such, the service design must be inclusive, equitable and comprehensive. For example, there must be different ways for people experiencing homelessness to set up video or phone consultation appointments (either people can directly call healthcare providers or support workers on their phones, or with provided phones and computers at centres or other local organisations). There must be an assurance of the continuity of care, where people experiencing homelessness would be able to access the same resource/person each time, from phones/video call options to the same healthcare providers. Furthermore, many experienced service providers have never used digital and online platforms. Their expertise is based on a very different and valuable skill set grounded in inperson human connection. Their knowledge must be consulted to make sure digitisation aids, rather than detracts, from their ability to work successfully with others. Comprehensive service design thus must also include communication and training with all staff in a coordinated way before roll-out. This will also require an accessible method of collecting feedback, allowing the various constituents of the set-up to feel comfortable to give suggestions for areas of improvement.

Working towards a collaborative and integrated system of care . Proper integration requires more than just the creation of a network of linkages (eg, through a unified software) between different actors (from people experiencing homelessness to specialised providers and the healthcare system). If the various actors are simply connected, with no attention paid to particular needs and backgrounds of various individuals, improvement would be uncertain. The disorganisation that came from the initial scramble to transition to lockdown rules would prolong and cause further aversion to digital services. This would not only discourage many from engaging, but it would also cause isolation—for all actors involved. To combat this, then, there must be a change towards intentional and integrated care provisions on a systematic level.

Overall, we continue to be surprised that the COVID-19 pandemic has provided substantial short- and mid-term alleviations for many people experiencing homelessness and shown us avenues and possibilities for longer-term change. Novel and unexpected policies have pushed many previously slowly developing approaches—especially around telemedicine—into a much quicker and wider experimental adoption. We sincerely hope that the health and housing fields will take seriously the learnings the pandemic has accelerated and given us, at overall great costs. Only then will we move substantially down the path of finding long-term and inclusive solutions that centre and uplift the people that have historically and structurally been most left excluded. However, these solutions will only come into fruition if they are supported by funding from long-term national policies that extend universal basic services to include individuals experiencing homelessness and those with complex care needs in their complexity .

Ethics statements

Patient consent for publication.

Not applicable.

Ethics approval

This study involves human participants and was approved by the University of Cambridge, Department of Anthropology. Ethics Committee ID was not provided as the ethics committee does not give out IDs. Participants gave informed consent to participate in the study before taking part.

Acknowledgments

The authors thank everyone who shared their lives, knowledge and expertise with them, in particular the people experiencing homelessness.

1. Obviously, the project was a short-term experiment; training would be easy to facilitate in a longer instalment of a similar service.

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Contributors JL was the PI on three research projects conducted together with MM and EM; all three authors conducted fieldwork and interviews as well as contributed substantially to the analysis and writing of this paper. JL is the guarantor and accepts full responsiblity of this work.

Funding Two of the three research projects received funding through a University of Cambridge/UKRI scheme, a rapid COVID-19 grant and an impact grant, respectively. The third research project was unfunded.

Competing interests None declared.

Patient and public involvement Patients and/or the public were involved in the design, or conduct, or reporting, or dissemination plans of this research. Refer to the Methods section for further details.

Provenance and peer review Not commissioned; externally peer reviewed.

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Int J Environ Res Public Health

Homelessness and Public Health: A Focus on Strategies and Solutions

David a. sleet.

1 School of Public Health, San Diego State University, San Diego, CA 92182, USA; moc.liamg@teelsadivad

2 Veritas Management, Inc., Atlanta, GA 30324, USA

Louis Hugo Francescutti

3 School of Public Health, University of Alberta, Edmonton, AB T6G 1C9, Canada

4 Faculty of Medicine & Dentistry, University of Alberta, Edmonton, AB T6G 1C9, Canada

5 Royal Alexandra Hospital, Edmonton, AB T5H 3V9, Canada

On any given night, hundreds of thousands of people are homeless in the United States and Canada. Globally, the problem is many times worse, making homelessness a global public health and environmental problem. The facts [ 1 ] are staggering:

On a single night in January 2020, 580,466 people (about 18 out of every 10,000 people) experienced homelessness across the United States—a 2.2% increase from 2019.
While 61% percent of the homeless were staying in sheltered locations, the remainder—more than 226,000 people—were in unsheltered locations on the street, in abandoned buildings, or in other places not suitable for human habitation.
Homelessness has increased in the last four consecutive years.
The increase in unsheltered homelessness is driven largely by increases in California.
In 2020, 171,575 people in families with children experienced homelessness on a single night.
A total of 3598 homeless people were children under the age of 18 without an adult present.
Veterans comprised 8% of all homeless adults (over 46,000 veterans struggle with homelessness).
People of color are significantly over-represented among those experiencing homelessness.

A layman’s definition of homelessness is usually “a person that has no permanent home”. However, many scholars have divided the broad group of people characterized as homeless into three (or more) categories:

- People without a place to reside;
- People in persistent poverty, forced to move constantly, and who are homeless for even brief periods of time;
- People who have lost their housing due to personal, social, or environmental circumstances.

While this definition refers specifically to homeless individuals, it is equally applicable to homeless families.

Homelessness is closely connected to declines in physical and mental health. Homeless persons experience high rates of health problems such as Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome (HIV/AIDS) and Hepatitis A infections, alcohol and drug addiction, mental illness, tuberculosis, and other serious conditions. The health problems facing homeless persons result from various factors, including a lack of housing, racism and discrimination, barriers to health care, a lack of access to adequate food and protection, limited resources for social services, and an inadequate public health infrastructure. Legal and policy interventions have often been used to attempt to address homelessness, although not always from a public health perspective.

In health care, for example, if someone experiencing homelessness comes to an emergency department for medical aid, once treated, the only alternative is to release the patient back onto the street. This creates an endless cycle of emergency department visits, increasing costs and expending resources in the health care system.

Recent work [ 2 ] has emphasized the important role of public health, the health care system, and health care providers in homelessness prevention. In this Special Issue of the International Journal of Environmental Research and Public Health (IJERPH), we have brought together researchers, practitioners, and community organizers to articulate the public health problem of homelessness and identify clear strategies to reduce homelessness and provide more adequate health care and housing for this population. We also explore solutions for important subpopulations, including adults, families with children, adolescents, women, transitional aged youth, and those suffering from mental illness, PTSD, alcohol dependency, mental illness, adverse childhood experiences, and chronic homelessness.

We address many of these issues in the context of public health and explore the public health implications and potential solutions to homelessness, focusing on contemporary and emerging research and innovative strategies, and highlighting best practices to address homelessness among key populations. The papers in this Special Issue attempt to answer several questions related to homelessness and public health, such as:

What is the extent of homelessness and why do people become homeless?
What are the public health and health services implications of homelessness?
What role does housing play as a precursor to and potential solution for homelessness?
What public health and health care interventions are being employed, and what effectiveness is being achieved?
What long-term strategies can be developed to prevent homelessness?

The 13 research papers and one commentary in this Special Issue are summarized as follows:

Conceptualizing an Interdisciplinary Collective Impact Approach to Examine and Intervene in the Chronic Cycle of Homelessness. This study by Abdel–Samad et al. [ 3 ] focuses on a novel, interdisciplinary academic–practice partnership model for addressing the problem of homelessness. Whereas singular disciplinary approaches may fall short in substantially reducing homelessness, this approach draws from a collective impact model that integrates discipline-specific approaches through mutually reinforcing activities and shared metrics. The paper describes what is necessary for capacity-building at the institution and community levels, the complementary strengths and contributions of each discipline in the model, and future implementation goals to address homelessness in the Southern California region using a cross-disciplinary approach.
Mental Illness and Youth-Onset Homelessness: A Retrospective Study among Adults Experiencing Homelessness . Iwundu et al. [ 4 ] conducted a retrospective study and evaluated the association between the timing of homelessness onset (youth versus adult) and mental illness. The results indicated that mental illness (as a reason for current homelessness) and severe mental illness comorbidities were each associated with increased odds of youth-onset homelessness, providing a basis for agencies that serve at-risk youth in order to address mental health precursors to youth homelessness.
Well-Being without a Roof: Examining Well-Being among Unhoused Individuals Using Mixed Methods and Propensity Score Matching. Ahuja et al. [ 5 ] found that the mean overall well-being score of unhoused participants was significantly lower than that of matched housed participants, with unhoused participants reporting lower mean scores for social connectedness, lifestyle and daily practices, stress and resilience, emotions, physical health, and finances. The unhoused participants had a statistically significantly higher mean score for spirituality and religiosity than their matched housed counterparts. The qualitative interviews highlighted spirituality and religion as a coping mechanism for the unhoused.
Combatting Homelessness in Canada: Applying Lessons Learned from Six Tiny Villages to the Edmonton Bridge Healing Program. Authors Wong et al. [ 6 ] discuss the Bridge Healing Program in Edmonton, Alberta, a novel approach to combatting homelessness by using hospital emergency departments (ED) as a gateway to temporary housing. The program provides residents with immediate temporary housing before transitioning them to permanent homes. The paper discusses effective strategies that underlie the Tiny Villages concept by analyzing six case studies and applying the lessons learned to improving the Bridge Healing Program and reducing repeat ED visits and ED lengths of stay among homeless individuals.
Change in Housing Status among Homeless and Formerly Homeless Individuals in Quebec, Canada: A Profile Study. Kaltsidis et al. [ 7 ] used a cluster analysis to develop a typology of the housing status change for 270 currently or formerly homeless individuals who were residing in shelters and temporary or permanent housing. The findings suggest that the maintenance or improvement in the housing status requires the availability of suitable types and frequencies of service use (enabling factors) that are well-adapted to the complexity of health problems (needs factors) among homeless individuals. Specific interventions, such as outreach programs and case management, are prioritized as necessary services, especially for individuals at a higher risk of returning to homelessness.
Urban Stress Indirectly Influences Psychological Symptoms through Its Association with Distress Tolerance and Perceived Social Support among Adults Experiencing Homelessness. To investigate the simultaneous impact of intrapersonal characteristics (distress tolerance) and interpersonal characteristics (social support) and their association with homelessness, Hernandez et al. [ 8 ] recruited homeless adults from six homeless shelters in Oklahoma City who self-reported urban life stress, distress tolerance, social support, major depressive disorder, and PTSD symptoms. Based on the resulting associations, their findings stress the importance of implementing interventions aimed at increasing social support for homeless persons, something that may also increase skill development for distress tolerance and indirectly lead to a reduction in depression and PTSD.
“I Felt Safe”: The Role of the Rapid Rehousing Program in Supporting the Security of Families Experiencing Homelessness in Salt Lake County, Utah. Garcia and Kim [ 9 ] describe their research into The Road Home (TRH) program, which provides services to homeless individuals and families. TRH is known for their emergency shelters and also administers the Rapid Rehousing Program (RRHP), designed to help homeless families transition back into stable housing. After collecting qualitative data from focus groups with participants and families, landlords, case managers, and service providers, they make recommendations for program improvements that can increase the residential security of families experiencing homelessness.
“It’s Just a Band-Aid on Something No One Really Wants to See or Acknowledge”: A Photovoice Study with Transitional Aged Youth Experiencing Homelessness to Examine the Roots of San Diego’s 2016–2018 Hepatitis A Outbreak. In this study, Felner et al. [ 10 ] examined the experiences and needs of transitional aged youth (TAY) aged 18–24 experiencing homelessness who may have been uniquely affected by an unprecedented outbreak of hepatitis A virus (HAV). The findings documented a stigmatization of TAY, interventions that failed to address root causes of the outbreak, and interactions with housing- and social support-related resources that limited rather than supported economic and social mobility. The findings have implications for understanding how media and public discourse, public health interventions, and the availability and delivery of resources can contribute to and perpetuate stigma and health inequities faced by TAY experiencing homelessness.
Predictors of Overnight and Emergency Treatment among Homeless Adults. Iwundu et al. [ 11 ] aimed to identify the sociodemographic predictors associated with overnight and emergency hospital treatment among a sample of homeless adults. Participants were recruited from a shelter in Dallas, Texas and were predominantly uninsured, low-income men and women from various social and ethnic groups. In logistic regression models, gender emerged as the only predictor of overnight treatment in a hospital and treatment in an emergency department. Women were more likely than men to be treated overnight and use emergency care. The authors concluded that interventions and policies targeted toward homeless women’s primary health care needs would reduce health care costs.
Association of Problematic Alcohol Use and Food Insecurity among Homeless Men and Women. In a study on alcohol use and food insecurity among homeless men and women, Reitzel et al. [ 12 ] investigated the link between problematic alcohol use and food insecurity among homeless adults in Oklahoma. Problematic alcohol use was measured using the Alcohol Quantity and Frequency Questionnaire and the Patient Health Questionnaire. Food insecurity was measured with the USDA Food Security Scale-Short Form. The results indicated that heavy drinking and probable alcohol dependence/abuse were each associated with increased odds of food insecurity. The results question whether alcohol may take precedence over eating or food purchases among this population of homeless individuals.
Exploring Tiny Homes as an Affordable Housing Strategy to Ameliorate Homelessness: A Case Study of the Dwellings in Tallahassee, FL. “Tiny Homes” is an emerging strategy to combat homelessness, and Jackson et al. [ 13 ] raise a number of questions about the intentions, efficacy, and policy feasibility of this strategy. The paper seeks to understand the strategies used by stakeholders to plan, design, and implement a “Tiny Homes” strategy, and to assess their effectiveness. Using a case study, they examined how the community was planned, the experiences of residents, and the constraints to success. Their findings highlighted how funding constraints and NIMBYism (Not in My Backyard-ism) stymied stakeholder efforts to achieve equity and affordability, resulting in the inability to achieve project aims to develop affordable housing that served homeless populations.
Predictors of Emergency Department Use among Individuals with Current or Previous Experience of Homelessness. The study by Gabet et al. [ 14 ] assessed the contributions of predisposing, enabling, and needs factors in predicting emergency department (ED) use among 270 individuals with a current or previous experience of homelessness. Participants were recruited from types of housing in Montreal, Quebec (Canada) and were interviewed about their ED use at baseline and again 12 months later. The findings revealed two needs factors associated with ED use: having a substance use disorder and low perceived physical health. Two enabling factors—the use of ambulatory specialized services and stigma—were also related to ED use. ED use was not associated with the type of housing. The authors suggest that improvements are needed to manage substance use disorders and the physical health of homeless individuals in order to reduce ED use.
Being at the Bottom Rung of the Ladder in an Unequal Society: A Qualitative Analysis of Stories of People without a Home. The Mabhala and Yohannes article [ 15 ] examines the stories of homeless people and their perceptions of their social status using interviews in three centers for homeless people in Cheshire, in the English Northwest. Education, employment, and health were three domains that provided a theoretical explanation for the reasons that led to their homelessness. Participants catalogued their adverse childhood experiences, which they believe limited their capacity to meaningfully engage with social institutions for social goods, such as education, social services, and institutions of employment. They conclude that, although not all people who are poorly educated, in poor health, and unemployed end up being homeless, a combination of these together with multiple adverse childhood experiences may weaken resilience and contribute to homelessness.
Commentary: Investing in Public Health Infrastructure to Address the Complexities of Homelessness. In a final commentary, Allegrante and Sleet [ 16 ] introduce the notion that investments in public health infrastructure are needed to address the complexities of homelessness, including the continued threats posed by SARS-CoV-2 (COVID-19) and its variants. The lack of affordable housing, widespread unemployment, poverty, addiction and mental illness, which all contribute to the risk of homelessness, would be well-served by improving the fundamental public health infrastructure. They argue that homelessness is exacerbated by system-wide infrastructure failures at the municipal, state and federal governments and from the neglect to invest in public infrastructure, including a modern public health system.

In conclusion, shelter is a basic human need. Thus far, we have an inadequate understanding of all the medical and nonmedical, public health, and infrastructural influences that drive homelessness and why so many people are living without adequate shelter. Housing is one of the most critical factors in addressing homelessness and one of the best-researched social determinants of health. Several articles here focus on innovative approaches to providing temporary or permanent housing for those who need it, and it is well known that selected housing interventions can improve health and decrease health care costs. From that perspective, some professionals in the field contend that housing equates to health [ 17 ] and that improved housing options for homeless individuals and families would advance population-level health.

Many of the articles in this Special Issue [ 18 ] focus on specific aspects of life, quality of life, and co-morbidities related to behavioral and social variables influencing homelessness. Explored in detail are factors such as lack of housing, distress, wellness, emergency department use, mental health, drug and alcohol addiction, poverty, low educational attainment, inadequate health care and social services, adverse childhood experiences, ongoing infections, unemployment, and public health infrastructure. In addition to highlighting the impact these factors can have on the likelihood that someone would become homeless, many of the articles also provide recommendations for relevant policies, practices, and interventions that could help reduce homelessness and improve overall well-being.

The intersection of environmental, behavioral, and social factors, in addition to the lack of an adequate infrastructure, must also be considered when studying the determinants of homelessness and designing appropriate interventions. Our ultimate goal in producing this Special Issue of IJERPH is to encourage the development of better evidence to inform public health, social services, and medical care policies and practices that will result in better health for homeless populations.

Acknowledgments

We thank the authors and reviewers for their commitment to preparing and editing these manuscripts and for adding to the knowledge base of this important public health problem.

Conflicts of Interest

The authors declare no conflict of interest.

Publisher’s Note: MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affiliations.

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Homeless people and health: a qualitative enquiry into their practices and perceptions

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Dave Mc Conalogue, Nicky Maunder, Angelika Areington, Katherine Martin, Vikki Clarke, Sarah Scott, Homeless people and health: a qualitative enquiry into their practices and perceptions, Journal of Public Health , Volume 43, Issue 2, June 2021, Pages 287–294, https://doi.org/10.1093/pubmed/fdz104

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Homeless people experience poorer health and shorter life expectancies than the UK average, but their health needs and expectations have received little attention in research. This study aims to understand homeless people’s health perceptions and experiences.

Semi-structured interviews took place with 28 homeless people in Gloucestershire. The transcripts were thematically analysed drawing out key themes.

Homelessness was often rooted in early trauma or an unstable family unit. Participants described poor support on leaving prison, termination of a cohabiting relationship or financial issues as factors precipitating homelessness. There was an expansive and positive understanding of health and its determinants. Mental health issues were common, often linked to traumatic life-events. Substance misuse issues were expressed as a mechanism to manage mental health issues. Participants were frustrated that this co-dependency was not recognized by support services. Participants’ living situation curtailed their ability to make health-enhancing choices, which was compounded by issues accessing mainstream healthcare services.

Mental health in homeless people must be recognized in the context of substance misuse and early trauma. Dealing with housing and addiction are critical to enable prioritisation of healthy behaviours. Healthcare services should recognize the chaotic nature of homeless people and their competing issues.

The number of homeless people in England is increasing. In 2018, there is estimated to be approximately 4700 rough sleepers in England; 3000 more than in 2010. 1 Similarly, the number of families living in temporary accommodation has grown by 68% between 2010 and 2017. 2 However, because of the nature of homelessness and the way in which it is monitored, much of homelessness remains hidden; the true extent of the issue is believed to be far reaching and growing. 3 Homelessness in the developed world is a particular issue because it is considered largely preventable and due to underperforming or under-funded support systems rather than a lack of resources. 4

Homeless people live substantially shorter lives, spend a much greater proportion of their life in poorer health, 5 and have higher health and social care needs than the general population. 2 In the UK, the life expectancy of a homeless person is 47 years, compared to 77 years for the general population. 6 This difference in outcomes is related to higher rates of exposure to risk factors including alcohol, smoking, substance misuse and poor mental health. 5 While some health issues are a reflection of a homeless person’s living conditions, they can also be a factor in becoming and remaining homeless. 7 Understanding the health issues and experiences of homeless people is critical to help deal with these issues in the short and longer terms, and to ultimately support them into a stable housing situation.

The relationship between homelessness and health is under-researched, particularly in terms of qualitative research, with the majority of studies originating in the USA or Canada. Understanding the experiences, practices and perceptions of homeless people in managing their health is essential to inform effective interventions to improve health outcomes. This study aims to explore homeless people’s experiences and perceptions of health and health services to inform policy, commissioning and service provision to deliver better health outcomes for this group. The study was carried out in Gloucestershire (County in South West England). The county has two large urban centres (Gloucester and Cheltenham) with a large rural geography. This was chosen as the study sight due to the access of the researchers to the homeless population. It was also felt homeless issues in Gloucestershire will offer insights for other counties with a similar geography and population.

Participant recruitment

A convenience sampling approach was applied in recruitment of homeless participants present in Gloucestershire between January and March 2018. Homelessness was defined as any person who stays at or engages in rough sleeping, staying at hostels, bed and breakfast and other temporary accommodation, squats, derelict buildings, barns and other buildings not used for accommodation, ‘doubling up’ or ‘sofa surfing’, and ‘survival sex’ as a means of securing accommodation. Participants were recruited through non-health organisations providing services to homeless people in two urban locations within Gloucestershire. Participants provided written or recorded verbal consent.

Data collection

Twenty six semi-structured interviews were completed in private offices by interviewers. Twenty four interviews were with an individual and two with homeless couples. The interviews were digitally recorded where consent was given. Where consent to record was not given (one interview), detailed notes were taken.

The interviews were directed by a topic guide, which was structured around research objectives. The format of the interviews ensured key areas was examined, whilst allowing the flexibility to explore relevant themes arising through dialogue. Subject areas covered during the interviews included reasons for homelessness, understanding of ‘being healthy’, experiences and practices managing health, relationship between living environment and health and experiences and perceptions of healthcare services.

Data analysis

An interpretivist approach guided the study design and data analysis. Digital recordings were transcribed, and thematically analysed. The thematic analysis applied the Braun and Clarke 8 approach to thematic analysis: familiarisation with data, generation of codes, searching for themes, reviewing themes and defining and naming themes. All transcripts and subsequent data analysis was anonymized, and participant names replaced with pseudonyms.

The research proposal for this study was presented to the Gloucestershire County Council Research Governance Committee. The committee is supported by the Gloucestershire NHS Research Support Unit. The Committee reviewed the proposal and concluded that the primary purpose of the research was to inform service and system development in Gloucestershire to support homeless people. The committee also judged that participation would not induce undue psychological stress or anxiety. On this basis, the committee concluded that the research did not require formal ethics approval.

Twenty eight homeless people were interviewed. The majority of participants were living in supported housing (54%) or rough sleeping (39%). The remainder defined themselves as sofa surfers or living in bed and breakfast accommodation. Twenty nine percentages of the participants were female. However, only 18% of those identifying themselves as rough sleepers were female. Seventy one percentages were of White British ethnicity. Interviews ranged between 20 and 50 minutes.

Becoming homeless

Participants described longer term causes of homelessness as stemming from the breakdown of a family unit when they were young, or where the family situation was chaotic. The instability normally involved one or both parents leaving the family home or bereavement of a significant family member or carer. Participants often described physical and emotional abuse within the family when describing their family situation. Participants related these traumas during their childhood to their subsequent misuse of drugs and/or alcohol. They recognized the relationship between the trauma, use of substances to manage the psychological impact and their subsequent loss of accommodation. Moreover, they appreciated their inability to deal with the early childhood trauma and drug/alcohol abuse affected their ability to manage their life and come out of homelessness.

Following release from prison, participants often attributed the most recent cause of homeless to a lack of support (resources or support networks), which left them without the ability to secure accommodation. Others described the breakdown of a relationship resulting in the loss of accommodation, and financial management issues which led to eviction from their accommodation. These issues whilst attributed by homeless people as the contributing factor to their most recent episode of homelessness are exacerbated low social capital and few alterative resources to call on. Additionally, having to manage substance misuse and/or mental health issues often left the individual unable to cope with the administration side of finding and sustaining accommodation.

Becoming homeless quotes.

Perceptions and understanding of health

Many participants descriptions of health including having control over their life and being able to determine their future. Being healthy was also described as not using drugs or alcohol, being able to manage mental health conditions, having social networks, having access to showering facilities and clean clothes and being able to sleep without disturbance. Participants understanding of health and ‘being healthy’ was complex and diverse, and extended well beyond a disease based paradigm. Commonly, their descriptions focused on control over their environment or future.

Although participants felt health was important, there were other issues which they prioritized above this; mainly achieving stable housing. Participants living in supported housing were keen to move into private rental accommodation, where they perceived they would have greater control over their lives and be able to gain more stability. Other priorities for homeless people focused on managing mental health issues and achieving control over addiction to drugs and/or alcohol. Participants felt that gaining control over these issues would then permit them to concentrate on achieving a healthier lifestyle.

Health issues for homeless people

Most participants reported a mental health or a physical health issue, often both. Mental health issues were most commonly reported: depression, anxiety, personality disorders and post-traumatic stress disorder. Participants understood the role substance misuse played in their mental health; however, they also described the role of drugs and alcohol in providing immediate short-term relief. Drugs and alcohol were used to block out memories or to help deal with traumatic experiences from their childhood, normally involving abuse or bereavement. Participants described episodes of self-harm and suicidal thoughts, which they related to their mental health issues and traumatic childhood events; some described attempting suicide on one or more occasions. Dividing issues between social and health categories was not useful or possible for many of the participants. Childhood trauma, mental health, substance misuse and homeless were not separate issues; they formed part of the complexity of their life and needed to be dealt with together.

Physical health issues were relatively common including Hepatitis C, physical disabilities, diabetes, pancreatitis, ulcers, cirrhosis of the liver, asthma, deep vein thrombosis and migraines. These were rarely treated as priorities as more focus was placed on their mental health, housing and substance misuse.

Understanding and managing health quotes.

Managing health

Participants had knowledge of proactive actions they could undertake to maintain their health. They understood what a balanced diet was and its benefit to their health. While rough sleepers had access to enough food, they had limited control over their diets and took what they were offered. This commonly meant they had limited access to fruit and vegetables unless they supplemented it with additional food purchases.

Conversely, those in supported housing have access to catering facilities, giving them more control over their diet. Although, some reported less access to the quantity of food previously available when rough sleeping. This appeared to be dependent on the proximity to services providing free meals. Participants in supported housing rarely reported a high level of fruit and vegetable intake. In both forms of homelessness, there appeared to be an issue over control and access.

When describing physical activity, participants normally talked about accessing a gym. Although none had access to a gym, many had aspirations to join one in the future. Most participants, particularly rough sleepers, described walking considerable distances during the day but very few viewed it as exercise. Again, exercise as an activity to manage health was seen as an aspirational activity, which would be addressed when more immediate base needs were fulfilled.

Many participants were regular tobacco smokers and recognized the impact on their health, but reducing or quitting smoking was a very low priority. Most were not interested in accessing support to stop or reduce tobacco use. If cessation attempts were important to the participant, they would be addressed after their other priorities were resolved.

Social networks and health

Many of the participants perceived dangers from socialising with their peers, usually where the participant was managing a substance misuse issue and did not want to interact with current users. The availability of substances and seeing others using could lead to them partaking. This often resulted in excluding themselves from socialising with other homeless people. Particularly among rough sleepers, there was a perception of having to manage relationships to avoid becoming a ‘victim’. Trust levels appeared to be low with a perception that peers might take advantage for material gain. Participants did not tend to rely on their peers for social and emotional support; few described close relationships with other homeless people. This was a difficult situation for many, as they understood the importance of social networks for their wellbeing, but also realized the implications of integrating with their peers.

Some participants described a reluctance to engage with family members due to their current situation, normally described as not wishing to make the participant’s issues a problem for their family. However, there were several instances where participants were maintaining family relationships, and finding these a source of support. For many, reconnecting with their family was a motivating factor to address their substance misuse issues and to find stable accommodation.

Social networks and the impact of the living situation quotes.

Accessing health services quotes.

The relationship between health and living environment

Whilst rough sleepers acknowledged the discomfort associated with sleeping in wet, cold and windy conditions, they did not tend to relate this to their health. For many, the living environment was a housing issue, not a health one. They viewed their living environment as removing control over health attaining activities. They were precluded from accessing the resources they might have in a more stable situation.

In supported housing, there were positive experiences; with improvements in sleep and feelings of security, particularly for participants moving from rough sleeping or chaotic living situations. Negative impacts related to stressors in the living environment; usually noise and disturbances from other residents. This was felt to affect feelings of security, contributing to levels of anxiety and depression, as well as impacting on the sleep of some. Those within supported housing were focused on moving into private accommodation. This was felt by many as a key step out of homelessness, and away from the social networks and risk taking behaviours they perceived precipitated their homelessness.

Primary and secondary healthcare services

The dedicated NHS Homeless Healthcare Team, which provides primary care services to the homeless, was perceived very positively by participants. The key benefit was accessibility; it was based in a location that they frequented for other services, with relatively little waiting time. Participants reported being reminded about appointments and medication.

Rough sleepers felt it was difficult to access mainstream primary care services as they did not have a permanent address. Several described experiences where they were asked to provide proof of address before they could register at a GP Practice.

Whilst some participants expressed satisfaction with mainstream NHS services, several felt that they were being ‘judged’ or ‘looked down on’ by staff on account of their living circumstances or substance misuse problems. One participant acknowledged this perception may be a reflection of their own psychological state at the time of accessing the service.

Experiences of mental health (and substance misuse) services

Accessing mental health support was a priority for a large proportion of those interviewed. While participants understood mental health and substance misuse as part of the same problem, they felt that health services viewed them as independent issues. Participants felt they were required to be ‘clean’ before they could access mental health support which left them, at least temporarily, with potentially no resources to manage their condition. Some frustration was expressed regarding the waiting times to access mental health services, or where they believed there was no mental health support available or offered. Similarly, some referenced a wait time to access substance misuse support services, or that the treatment protocol did not match the treatment they had been on previously.

Main finding of this study

This study provides a new insight into how homeless people understand, manage and prioritize health. Homeless people understand early trauma, family instability, mental health, substance misuse and homelessness as co-dependent variables, which have to be addressed together. They expressed frustration with supporting services, which compartmentalized these elements. Homeless people had an expansive positive understanding of health and the actions they could take to support their health, although rarely experienced control over these factors. Homeless people understand the importance of social networks, but also experience peer socialising as risky and often isolate as a protective measure. Homeless people report difficulties accessing mainstream primary care services. Some homeless people also perceive being ‘looked down on’ by healthcare staff.

What is already known on this topic

The relationship between homelessness and early trauma is examined in the wider literature, which highlights an association between homelessness and presence of abuse. The evidence regarding Adverse childhood Experiences also supports this association 9 and further highlights the potential benefit of routine inquiry across the life course as a means of breaking the cycle of adversity. 10 Moreover, the cumulative impact of adverse incidents on a person’s personal resilience, coupled with a weak or absent social support network may result in higher propensity to become homeless. 11 , 12 Research has also demonstrated a complex relationship between substance misuse and homelessness. 13 This study describes a much more complex interaction of co-dependent variables, which should not be considered in isolation.

Other studies use the concept of intersectionality as a framework for understanding homelessness. 14 , 15 This highlights the interconnectedness of social categories which define the issue of homelessness. Our study also highlighted specific traits which appear to be related to, or possibly a determinant of, homelessness. Looking at homelessness through the lens of intersectionality helps to expose homelessness as a complex set of determining factors, which is reflected in a diverse population who cannot easily be considered as a homogenous group. Our study did not explicitly consider the exploration of intersectionality in its design or analysis, but future studies would be greatly enhanced by doing so. Healthy behaviours were prioritized below issues such as housing by participants. This is supported in the wider literature which suggests that base level needs, such as housing and security must be addressed before the adoption of healthy behaviours. 16 , 17 , 18 Rae and Rees 18 also note that while health issues are recognized, they are often not prioritized. Our study additionally goes some way to describing why particularly physical health is not prioritized because of competing mental health and substance misuse issues.

There was low trust in homeless social circles and peer groups were not experienced as a source of support. The absence of robust social networks is a key precipitating factor in becoming homeless and a strong determinant of health outcomes. 11 , 12 , 19 , 20 The lack of trust between homeless people suggests that building social capital may have to be facilitated by professionals, 21 until they can form new networks outside of their homeless peer group. Other studies have also linked the promotion of positive social networks as being helpful to deliver ‘recovery capital’, which may ultimately help to address issues of addition, 22 which have a close relationship with homelessness.

Mainstream primary care services were perceived to have substantial barriers to access, such as requiring a permanent address. This is a recurring theme in the wider literature, which may be a real barrier to access in some circumstances and a perceived barrier in others. 18 While dedicated services are more effective in engaging homeless people, they may also be an important element in the ‘citizenship’ of homelessness. 23 The perception of being stigmatized and judged by mainstream health services because of their personal situation is a common experience and barrier to access for homeless people. 17 , 24 , 18

The interdependence mental health and substance misuse issues was a strong theme throughout the study. There was frustration with the perceived independence of substance misuse and mental health services. This is an issue that has been recognized in research and policy. 25 , 26 Dual diagnosis (co-occurring mental health and substance misuse) is prevalent and must be dealt with as part of a common integrated approach that does not attempt to silo these co-dependent variables. 26 , 25

What this study adds

This study points to the requirement to deal with base level needs before healthy behaviours can be successfully adopted. This research also calls for an integrated approach to the understanding of and response to early trauma, family stability, mental health, substance misuse and homelessness. While the interventions to address the health issues for homeless people are important, the policy approach must be to work to eliminate the issue of homelessness and the stark health inequality that this represents. This can only be addressed by tackling the determinants of homelessness, which are often rooted in childhood experiences. This will mean early identification of risk factors related to adverse childhood experiences, and the timely deployment of support to manage this before the implications are realized.

Limitations of this study

Participants were recruited through non-healthcare services for homeless people. Only those who were accessing support services were ‘heard’ in the data. This may mean that the least engaged homeless people are omitted. Additionally, a self-selecting cohort of participants may not reflect the wider population of homeless people. All of the interviews were carried out in two urban centres. The experiences of homeless people living in these areas may differ to those who are homeless in more rural parts where services are limited.

With thanks to the Gloucestershire County Council team who supported interviews and transcriptions; B. Bhula, J. Cheminais, H. Ellis, N. Hargrave and D. Lane. A special thanks to the staff and volunteers at Gloucester City Mission, Elim Housing, P3 and Cheltenham Open Door who facilitated access to participants. We would also like to thank those who gave up their time to participate in the study.

Dave Mc Conalogue , Consultant in Public Health

Nicky Maunder , Commissioning Officer

Angelika Areington , Commissioning Officer

Katherine Martin , Data and Analysis Manager

Vikki Clarke , Commissioning Officer

Sarah Scott , Director of Public Health

This study was not funded.

None declared.

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Bhui K , Shanahan L . Homelessness and mental illness: A literature review and a qualitative study of perceptions of the adequacy of care . Int J Soc Psychiat 2006 ; 52 ( 2 ): 152 – 65 .

Public Health England . Better Care for People with Co-Occurring Mental Health and Alcohol/Drug Use Conditions . London : PHE , 2017 .

Crome I , Chambers P , Frisher M et al. SCIE Research Briefing 30: The Relationship Between Dual Diagnosis: Substance Misuse and Dealing with Mental Health Issues . London : SCIE , 2009 .

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Homelessness Essays

Homelessness in England Essay

A homeless person is generally known to be one without a settled or permanent accommodation (Tania 2001). There is also another less observed but equally grave form of homelessness, often referred to as concealed homelessness, among persons housed temporarily by friends or family; living in overcrowded environments; living in night shelters or hostels; living in health-threatening conditions; living in abusive homes; and even those who live in squats and streets. Such persons are still homeless even if they have roofs over their heads because they do not have rights to stay where they live. In England and Wales, officially recognised homeless persons or those threatened with homelessness are entitled to help from their local councils. Such help is given based on priority need as determined by the council’s evaluation. Persons who will be considered to have a priority need are those with dependent children, are pregnant, have been rendered homeless by emergencies like fire or floods and are vulnerable because of old age, mental and physical disabilities (Wilson 2013). This paper will discuss priority needs, the housing homeless persons Act, effects of benefit cuts, domestic violence, vulnerable people and the positive and negative results of government action.

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In many parts of England, demand for housing is causing prices to go up and beyond what a large percentage of the population can afford. In turn, this increases pressure on the sectors of rented housing and effectively raising prices, which culminates into more citizens applying for social housing. However, the large number of applications overwhelms the availability. The local councils offer assistance to persons who meet the criteria described as statutory homelessness or meet the priority need requirements as described by the homelessness Act. However, those who do not meet the criteria and are not eligible for help are referred to as intentionally homeless and are only covered by the provisions of non-statutory homelessness. A key test aspect used in determining whether a homeless person without children may be considered as having priority need to be housed under the homeless Act is vulnerability. In terms of homelessness, vulnerability implies that a person would be more exposed to harm in the event that they become homeless than other homeless persons. To pass the vulnerability test, one is required to prove that homelessness would be of a greater injurious impact on them than it would on the typical homeless persons. Whoever is can prove that their homeless status is unintentional, are eligible for public funds and have a connection to the locality will possess priority need. In England, such persons include those aged between 16 and 17 years; those below 21 years and were previously under the care of local authorities while aged between 16 and 18 years; those aged 21 years and over and are vulnerable because of getting out of care by the local authority; those made vulnerable by leaving prison or the armed forces. In Wales, more preference is given to women with dependent children or pregnancies; those facing risk of sexual or financial exploitation; and those exposed to domestic violence (Wilson 2013). However, the Department for Transport and Local Government has regularly opined that local authorities should offer assistance and advice to all its homeless subjects under their areas of jurisdiction regardless of whether they qualify under priority needs or not (DTLG 2002).

The Homelessness Act of 2002, applicable in England and Wales makes reforms to the Housing Act of 1996 regarding homelessness and how social housing accommodation is allocated, which has been subjected to wide consultations (Harding 2004). All local housing authorities are required by law to formulate and implement strategic approaches suitable to tackle homelessness within their jurisdictions since it is a devolved service. Local authorities are charged with six obligations which are strengthening help to the homeless and those at risk; develop strategic approaches to fight homelessness; encourage new reactions to fighting homelessness; reduce the staying in hotels by homeless families that have children; sustain more than two-thirds of a reduced rate of rough sleeping; and ensure that opportunities for decent homes are available for all (Irving 2011). Through such initiatives, improved protection is supposed to be available to the homeless who are in such situations through other means than their own fault. This is achievable through the strengthened duties the local councils owe homeless persons by the removal of some strict restrictions in the procedures of acquiring council assistance (UoY 2007). The councils are also given more authority by the Act to give assistance even to those who do not meet the criteria for priority need. Such provisions were framed with an acknowledgment of the need for the integration of policies on allocating housing and combating homelessness, and were summarized in the Housing Green Paper, chapter nine, under “Quality and Choice” (Wilson 2013).

The legislation prioritises the fight against rough sleeping and provided £400 million to partners in the voluntary sector and local councils for the cause to run between 2011 and 2015. Through these laws, the government initiates efforts to tackle homelessness by offering access to job training and advice, with the intention of enabling citizens to secure jobs and qualify for affordable housing. The government has also previously fronted prevention initiatives such as rent deposits (through the voluntary sector partners) that help citizens secure tenancies by renting from the private sector (UoY 2007). Further, there have been moves to solve family disputes and cases of violence that often end up in ejecting family members. These two factors have been cited as a major cause of single, homeless persons. Another key effort is the collaboration with money advisors and lenders to make home repossession necessary only as a final resort (Wilson 2013).

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However, not all the provisions of the homelessness Act are being implemented or working as effectively as required and, therefore, contributing negatively to government efforts. The enduring benefit cuts are giving rise to increased statutory homelessness, with a concentration on the most disadvantages and poorest classes of society (Irving 2011). It also affects families with children disproportionately. These groups lack the social and financial equity to handle relationship and work crises without ending up homeless. Statistics show that homeless families increased in number between 2009/2010 and 2011/2012 by over 10,000 from 40,000 53,000, with central London being the most affected. It is expected that the long term effect will be a growing number of central-London families driven to parts of the country with cheaper housing (Wilson 2013).

The most recent study by Crisis shows that by the next summer in 2014, over 8,000 children will be faced with homelessness as the benefit cuts will leave their parents unable to afford rent ( Ian 2012). Larger families will be the worst hit, and some of them have already resorted into temporary accommodation as they wait to be relocated elsewhere. The same study by Crisis has shown that such temporary accommodation ends up being more expensive in the long run, especially for those who wait for the relocation for considerably long. The monthly cost of administering the benefits cap by officials is £1.3 million, which leaves a monthly saving of £1 million. However, with the risk of the saving being used up by costs of temporary housing for the homeless, it appears as if the government is spending more money to increase the occurrences of homelessness (Wilson 2013).

Department for Transport and Local Government (DTLG) 2002, More than a roof – a new approach to tackling homelessness.
Harding, P 2004, Making it work: the key to success among young people living independently, The Policy Press, Bristol. Ian, A 2012, No more leaning on lamp-posts, London School of Economics, London.
Irving, H 2011, Homelessness, pathways to exclusion and opportunities for intervention, Northumbria University, London. Tania, B 2001, ‘Rough sleepers unit is fixing figures.’ The Guardian, London.
The University of York (UoY) 2007, Homelessness statistics September 2007 and rough sleeping-10 years on from the target, Author, London.
Wilson, W 2013, Homelessness in England, House of Commons Library, London.

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Florida is seeing an increase in homelessness. A Republican bill could make it worse

‘Inhumane’ legislation on Governor Ron DeSantis’s desk will require cash-strapped counties to build remote camps

W hen Diana Stanley and her team at The Lord’s Place, one of Palm Beach county’s largest and longest-established homelessness charities, opened a new engagement center last year, she figured a few dozen people would show up in search of help.

Now, almost 200 people a day are relying on the facility just for lunch. Staff are overwhelmed by the demand for residential accommodation from families, veterans and the elderly in particular.

“There’s no question there’s an increase in homelessness,” Stanley, the organization’s chief executive, said, her anecdotal evidence supporting a federal study published in December reflecting a 12% rise in just one year of people lacking permanent sheltered accommodation nationally.

“We’re seeing more and more families experiencing homelessness for the first time. And I would be remiss if I didn’t talk about the older adults, later in life, losing housing due to affordability, and being homeless at an age of 60 plus. It’s not a good situation right now.”

And things could be about to get much worse, Stanley and numerous other advocates for the unhoused warn. That variable relies on Florida’s Republican governor, Ron DeSantis, signing an “inhumane” bill currently on his desk that seeks to sweep the state’s sizable unhoused community from public view.

The new law will require counties and municipalities without sufficient existing capacity to establish homeless camps , with state oversight, far away from more prominent facilities such as parks and waterfront spaces, and impose penalties if they allow or authorize rough sleeping outside of them.

Equally concerning to critics is that there is no mention of increased funding for substance abuse and mental health treatment promised by DeSantis when he promoted legislative proposals to “combat homelessness” in a February press release. It has fueled suspicion that the true intent of the law is to hide the problem rather than try to tackle it.

“True to form, DeSantis didn’t offer a palette of humane solutions,” the veteran social justice advocate Barrington Salmon wrote in an opinion essay for the Florida Bulldog.

“He spoke of the issue in stark, unsympathetic terms characterizing homelessness in purely negative terms, blaming them for contributing to the erosion of the quality of life of others lucky to not be sleeping on the street.”

Stanley, whose organization housed more than 430 individuals and families in residential homes and shelters last year, and offered support and resources to hundreds more, concurs.

“We should be coming together to come up with solutions, not taking punitive approaches,” she said.

“It’s really disheartening for someone like myself, who’s given over 40 years to serving the poor and the homeless, and it’s a statement that we’ve stopped caring about our brothers and sisters: ‘If we can’t see them then we don’t have to help them’.”

Stanley says the “vagueness” of the law is another clue to its purpose. The bill’s wording insists it “fulfills an important state interest of ensuring the health, safety, welfare, quality of life, and aesthetics of Florida communities”, and makes “adequate provision for the homeless population of the state”.

Notably, it places the financial and logistical burden of setting up accommodation solely on municipalities and counties. It also offers few specifics other than the camps can operate for only up to a year, must have restrooms and running water, and cannot depress surrounding property values.

“There are too many uncertainties, too many gray areas, and it does absolutely nothing to address the root cause of homelessness, the lack of affordable housing,” said Stanley, who fears it will create further pressure on already limited shelter accommodation.

“When Covid happened money came down from the feds and the state to help with rental assistance, but that drying up, coupled with a lack of affordable housing, is going to equal homelessness.

“No family decides on a Friday night, ‘You know what? We’re just going to go out and camp out on the street,’ so it’s hard not to see this bill as a direct attack on those experiencing homelessness.”

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One of its Republican sponsors, state senator Jonathan Martin, insisted it was a safety issue, and that his bill was sympathetic to unhoused persons.

“Insufficient shelter beds and insufficient permanent housing solutions result in unsheltered sleeping and camping in public places, places that we want our kids and grandkids to enjoy, like the parks,” he told a Florida Senate hearing earlier this month.

“This bill is a compassionate response to the shortage of shelters and supportive housing by providing an alternative to sleeping in the streets.”

Martin also said Florida’s 2024 state budget included $30m in new grants for local municipalities to provide mental health and substance abuse services, and short and longer-term shelters.

Other experts see the bill as a criminalization of homelessness, and taking away funds that are sorely needed to address such services.

“It’s telling jurisdictions they’re going to have to build these encampments, they’ll have to provide security facilities, wraparound services, the encampments can’t impact property values, so I’m not sure where they’re going to be,” said Amy Donley, professor of sociology at the University of Central Florida, and co-author of the book Poor and Homeless in the Sunshine State .

“But all of it, if jurisdictions want to comply with the law, requires funds to be put there, and those funds right now are already being taxed with the increase in people experiencing homelessness, many of them for the first time.”

Donley also points to places where sanctioned encampments have failed, such as Dignity Village, a city-operated tented camp in Gainesville that was originally intended to accommodate more than 350 unhoused persons, but was closed and dismantled in 2020 amid growing problems with violence, theft and drugs.

“Having jurisdictions focus on building these encampments instead of increasing housing demonstrates a lack of understanding of the problem,” she said.

“I work with a shelter with families qualified for rapid rehousing, but there’s just nothing available. If they could move into affordable housing, that would free up room for people currently on the street. So that’s where the focus should be, helping people into housing, not encampments.”

Ron DeSantis
Homelessness

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Homelessness Policies in the UK and Their Effects
The New Policy Institute conducted research on this issue in 2003. They estimated that there are currently anywhere between 310,000 and 380,000 hidden homeless people within the United Kingdom. Current legislation on homelessness can be accounted for in the Housing Act of 1996 and the Homelessness Act of 2002, both of which attempts to deal ...
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The number of people experiencing homelessness in the UK has dramatically increased since 2010. In the autumn of 2018, 4677 people in England were estimated to be sleeping rough, a worrying increase from 1768 in 2010.1 Although these numbers almost certainly underestimate the total number of people affected, the trends in these data are important and unsurprising, given that one in five bed ...
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Record numbers of people are living in temporary accommodation in England, according to the UK government's latest reported figures. Statistics on statutory homelessness show that in March 2023 ...
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The definition of homelessness under English law is that of a person who either has no accommodation, or someone who finds their current accommodation unsuitable for further habitation (National Audit Office [NAO], 2017, p. 5). According to two recent reports by the England charity Shelter, by December 2018 there will be 320,000 people in the ...
Homelessness in the UK: who is most at risk?
Data sources. We draw on three complementary sources of quantitative data on experiences of homelessness in the UK. While all three data-sets have strengths and weaknesses for our present purposes, in combination, they allow us to explore the contribution of a wide array of the potential causal factors identified in the literature review above, including individual-level factors (e.g ...
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Homelessness in the UK Homelessness, as a socio-economic issue, has been prevalent in much of humanities history and continues to present itself as an... read full [Essay Sample] for free ... Causes, Effects, and Solutions Essay. Homelessness is a complex social issue that affects millions of individuals worldwide. According to the United ...
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3.1 Homelessness Prevention 23 3.2 Rapid Rehousing 30 3.3 Ending Rough Sleeping 39 Chapter 4 - Wider reforms needed to achieve the solutions to end homelessness 47 4.1 Homelessness legislation 47 4.2 Migrant homelessness 59 4.3 Making welfare work 65 4.4 Housing solutions 73 Chapter 5 - Costs and benefits of ending homelessness 84
Homelessness in the United Kingdom
Homeless population. The UK homeless charity Shelter estimated in 2019 that the number of people in England who were entirely homeless or in temporary accommodation was 280,000. Rough sleepers are only a small proportion of the homeless. Crisis estimates there are roughly 12,300 rough sleepers in the UK and also 12,000 people sleeping in sheds, bins, cars, tents and night busses.
PDF No Fixed Abode: Life and death among the UK's Forgotten Homeless
UK's Forgotten Homeless London: Picador, pp.361 Paul Moran & Frances Atherton (2019) The Philosophy of Homelessness: Barely Being London: Routledge, pp.184 Introduction No Fixed Abode and The Philosophy of Homelessness are impressive and innova - tive additions to the established body of ethnographic work on homelessness. Both
Full article: Youth Homelessness in Austerity Britain: "We Can't Help
The growth of homelessness in the UK has been attributed to government led economic reform, beginning with the election of David Cameron in 2010, who promised to significantly reduce the UK's welfare bill. We argue that these welfare reforms have adversely affected vulnerable young people and placed key services beyond their reach.
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People experiencing homelessness in the UK were unconditionally offered housing (and support) from the beginning of the first lockdown in March 2020. For many, that meant '(re)entering' the support system and having a chance to 'move on' to longer-term housing. This beneficial effect of some of the policy reactions to the pandemic on people experiencing homelessness was unexpected.
The Social Problem Of Homelessness
Structural causes of homelessness are mostly social and economical in nature often outside the control of individual or family concerned. These may include poverty, lack of affordable housing, unemployment and the structure and administration of housing benefit. According to the shelter (2007) the number of households found to be homeless by ...
Homelessness set to soar in England amid cost of living crisis
Core homelessness in England - a concept which captures the most acute forms of homelessness - is estimated to have totalled 203,400 in 2020, down 5% on 2019 levels. This was primarily due to ...
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In the UK, it's estimated almost 136,000 young people aged 16-24 were homeless or at risk of homelessness in the UK in 2022/23. Homelessness is difficult to measure, and official figures don't include everyone. There are the 'hidden homeless', who are getting by in informal arrangements. These young people sofa surf, sleep on floors, or ...
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Given the enormous costs of homelessness, upstream interventions that help those who would become homeless stay housed can be highly cost-effective (Evans, Sullivan, and Wallskog 2016; Rolston, Geyer, and Locke 2013; Goodman, Messeri, and O'Flaherty 2016). Keeping people in their homes prevents the trauma of homelessness and allows housing ...
Homelessness and Public Health: A Focus on Strategies and Solutions
Globally, the problem is many times worse, making homelessness a global public health and environmental problem. The facts [ 1] are staggering: On a single night in January 2020, 580,466 people (about 18 out of every 10,000 people) experienced homelessness across the United States—a 2.2% increase from 2019.
Homeless people and health: a qualitative enquiry into their practices
Homeless people live substantially shorter lives, spend a much greater proportion of their life in poorer health, 5 and have higher health and social care needs than the general population. 2 In the UK, the life expectancy of a homeless person is 47 years, compared to 77 years for the general population. 6 This difference in outcomes is related ...
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Case studies of homeless families in Sacramento County /. Project (M.S.W., Social Work (Child and Family Services)--California State University, Sacramento. Ralph E. Johnson, Chairperson. PDF ...
Analysis Of The Impact Of Homelessness On The Health Of ...
Mental health issues can be caused by the stress associated with being homeless, research by Homeless Link 2009 found that 32% of clients of homelessness services in England have mental health and 14% have personality disorder. Broadway 2009 found that rough sleepers are 35 times more likely to commit suicide than the general population.
Homelessness in England Essay Sample, 1320 Words, 4 Pages
Statistics show that homeless families increased in number between 2009/2010 and 2011/2012 by over 10,000 from 40,000 53,000, with central London being the most affected. It is expected that the long term effect will be a growing number of central-London families driven to parts of the country with cheaper housing (Wilson 2013).
The vulnerability of young homeless people
have used new strategies of data linkage to bridge part of this research gap. In their study, published in The Lancet Public Health, they retrospectively examined associations between homeless shelter contact and police-recorded crime victimisation using population-level linked administrative records in Denmark.They effectively tracked 1 182 749 individuals aged 15-35 years across 9 831 776 ...
Causes of Homelessness
An event such as a family breakdown leads to loss of home or family support, which triggers a response such as substance misuse, loss of self-esteem and motivation (Butcher et al 2007). There are also a series of "risk factors" or indicators that confront the homeless or potentially homeless (Jones and Pleace 2005).
Florida is seeing an increase in homelessness. A Republican bill could
W hen Diana Stanley and her team at The Lord's Place, one of Palm Beach county's largest and longest-established homelessness charities, opened a new engagement center last year, she figured a ...
Is the most powerful teachers union in America overreaching?
The trouble is there is no more money. This year the budget amounts to $29,000 per pupil. Such spending is possible only thanks to a huge slug of federal covid-relief funding.
Homelessness
It provides emergency night shelters and short stay hostels. Their research shows that more than 80% of the young people who turn to Centrepoint for help are homeless due to family breakdown, abuse or eviction. Some young people become homeless following the death of a parent. It seems a double blow to be bereaved and homeless.

Homelessness in England has reached record levels – here’s why, and how to fix it

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COVID-19 homelessness and care

Methods and participant involvement

Multiple exclusions: substance use, complex needs and digital shortcomings

Addiction hurts, at least twice, during COVID

Digital care? talk of the future…

Privacy needed, particularly for women

Technological barriers

Learnings: provide more specialised care and accelerate the right digital services towards an integrated system of care

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Homelessness and Public Health: A Focus on Strategies and Solutions

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Article Contents

Homeless people and health: a qualitative enquiry into their practices and perceptions

Participant recruitment

Data collection

Data analysis

Becoming homeless

Perceptions and understanding of health

Health issues for homeless people

Managing health

Social networks and health

The relationship between health and living environment

Primary and secondary healthcare services

Experiences of mental health (and substance misuse) services

Main finding of this study

What is already known on this topic

What this study adds

Limitations of this study

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Homelessness in England Essay

Florida is seeing an increase in homelessness. A Republican bill could make it worse

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