Examining the Intersection of Homelessness and Public Health Concerns

The assignment explores the intricate connections between homelessness and health by analyzing existing literature that addresses how these issues intersect and affect vulnerable populations. Key topics include the prevalence of multimorbidity among the homeless, mental health concerns such as PTSD and psychological distress, barriers to healthcare access like insurance coverage and stigmatization, and specific vulnerabilities faced by subgroups including youth, women, and racial minorities within the homeless community. Research articles from multiple sources highlight these issues, showing how public policy can either mitigate or exacerbate the challenges faced by homeless individuals. The summary underscores the importance of targeted interventions and comprehensive public health strategies to improve outcomes for this marginalized group.

Running head: Homelessness as a public health risk
Homelessness a public health risk
Name of the Student
Name of the University
Author Note

1Homelessness as a public health risk
Contents
Introduction:...............................................................................................................................2
Facts about homelessness:......................................................................................................2
Homelessness in UK:.............................................................................................................2
Importance of discussing public health challenges:...................................................................3
Literature review: Public health perspectives on Homelessness:..............................................9
What could be done to address the challenge?.........................................................................12
Provision of Service:............................................................................................................12
Preventative Measures:........................................................................................................12
Accommodation:..................................................................................................................13
Social Networking:...............................................................................................................13
Promoting individual well being:.........................................................................................14
Barriers and Recommendations:..............................................................................................15
Barriers:................................................................................................................................15
Recommendations:...............................................................................................................17
Conclusion:..............................................................................................................................18
References:...............................................................................................................................20

2Homelessness as a public health risk
Introduction:
Facts about homelessness:
Homelessness or lack of home can be a devastating, dangerous and isolating
experience, which can increase the risk of morbidity and mortality (due to the lack of security
and healthcare, as well as the risk of psychological trauma and suicide risk. It can be caused
due to socio-economic factors like a lack of affordable accommodation, poverty, lack of jobs,
and personal life events leading to homelessness, apart from mental and physical health
issues, addition issues and psychological trauma. Additionally, being homeless can further
increase risks for morbidity and mortality, and further complicate the health risks.
Homelessness can be categorized into three types: Rough Sleeping, Statutory Homelessness
and Hidden Homelessness (Crisis 2018). Rough sleeping refers to the individuals sleeping
rough on the streets, Statutory Homelessness refers to individuals who lack a secure place to
live, while hidden homelessness refers to individuals who have not approached or divulged
their lack of home to the authorities, and hence have not been listed homeless. United Nations
describes ‘absolute homelessness’ as a condition arising due to a lack of physical shelter,
causing people to sleep outdoors, in vehicles, abandoned buildings, or places not intended for
human settlement, while describing ’relative homelessness’ who have physical shelters that
does not meet basic health and safety standards (Hwang 2018).
Homelessness in UK:
Reports from November, 2017 shows that as estimated 307,000 (one out of every 200
people) people sleeping rough or lack adequate housing in the UK, with London having the
highest number of homeless people, and increasing problems of homelessness in places like
Broxbourne, Luton and Chelmsford (Butler 2017).

3Homelessness as a public health risk
Figure 1: Distribution of the 300,000 homeless people in Great Britain; source (Butler 2017).
The number of people sleeping on the streets have increased by 134% since 2011, and
is not considered as a ‘national crisis’, with the government investing One billion pound to
solve the problem (BBC News 2017). This has drawn strong criticism on the failure of the
government to tackle the issue properly.
The aim of the report is to identify the necessity of discussing homelessness and a
challenge to public health, keeping a view of the risks to mental and physical well being of
homeless people, and the factors contributing to their homelessness as well as exacerbating
its effects. It will also try to identify the key challenges in the provision of care for homeless
people, and approaches to overcome them.
Importance of discussing public health challenges:
Sreelakshmi and Anish (2013) points out that improvement in community health can be
brought about by an interaction between conventional health sector as well as other sectors.
While James (2018) mentions that active discussion is an essential element of collaboration
of efforts. Identification of the problem followed by the discussion about how the problem
affects public health can be a part of the community health improvement process (The

4Homelessness as a public health risk
National Academics of Sciences, Engineering and Medicine 2018). Keeping in mind such
considerations, this report will discuss Homelessness as a public health challenge in the UK.
It has been pointed that homelessness can increase the risk for different types of chronic
and acute health conditions. Inter relation between health and homelessness can be
categorized into three types:
a) Health conditions that can lead to homelessness
b) Health conditions that can occur due to homelessness
c) Challenges in the treatment of homeless individuals
(Comittee on Health Care for Homeless People INSTITUTE OF MEDICINE 2018).
Kelly (1985) pointed out that the risk of health issues like skin disorder, or trauma can
be greatly increased due to homelessness, and can also cause a rapid deterioration of a minor
health condition into a serious one. Other health risks can include malnutrition, oral health
issues, parasitic infections, degenerative diseases, cirrhosis of liver, venereal disease,
alcoholism, drug abuse and its related health issues. Studies by Queen et al. (2017) shows the
prevalence of long term health conditions among homeless individuals compared to the
general population in the UK, as shown by the figure below:

5Homelessness as a public health risk
Figure 2: Prevalence of long term health conditions among homeless and general public;
source (Queen et al. 2017).
Figure 3: Prevalence of Depression among general population compared to other homeless
cohorts, HHS-Homeless Health Services, a- clinically recorded data, b-Self reported data;
source (Queen et al. 2017).

6Homelessness as a public health risk
Figure 4: Prevalence of Hepatitis C among general population compared to other homeless
cohorts, HHS-Homeless Health Services, a- clinically recorded data, b-Self reported data;
source (Queen et al. 2017).
Figure 5: Relationship between domains of severe and multiple disadvantage experienced by
people and long term health conditions, SMD- severe and multiple disadvantage, PI-
prediction interval; source: (Queen et al. 2017).
Barnett et al. (2012), also showed that a poorer socioeconomic status (indicated by
10), is related to a higher prevalence of multi morbidity and mental health co morbidities,
compared to individuals from higher socioeconomic status (indicated by 1).

7Homelessness as a public health risk
Figure 6: Prevalence of multimorbidity by age and socioeconomic status; source: (Barnett et
al. 2012).
Figure 7: Physical and Mental health Co morbidity and the association with socioeconomic
status; source (Barnett et al. 2012).

8Homelessness as a public health risk
Figure 8: Selected co morbidities among people with four common health conditions
differentiated according to their socioeconomic status (most affluent to most deprived);
source: (Barnett et al. 2012).
Several health conditions like Hypertension, Depression, and other painful condition
have been shown to have a higher prevalence among homeless individuals, as shown by the
statistics above and supported by Queen et al. (2017). This highlights the necessity of
discussing homelessness as a significant health challenge, since it is related so several causes
of mortality and morbidity among people, and hence a risk of public health and well being.

9Homelessness as a public health risk
Figure 9: Different health conditions related to homelessness; source: (Queen at al. 2017).
Literature review: Public health perspectives on Homelessness:
Studies by Barnett (2012) show the following key facts:
1) A strong association of age and multi morbidity (Taylor et al. 2010).
2) A substantial prevalence of multi morbidity among young and middle aged
individuals from deprived areas (Mercer and Watt 2007).
3) There is higher prevalence of mental health disorders among individuals with multiple
physical disorders, and is effected by the social gradients (Gunn et al. 2012).
According to Wolff, Starfeild and Anderson (2002), people suffering from multiple health
conditions often have poorer functional status, quality of life, and health outcomes. This
therefore creates a significant health risk for homeless people, due to their higher risks of co
morbid and multi morbid conditions. The burden is further increased due to another

10Homelessness as a public health risk
significant challenge of the provision of care for the homeless individuals (Comittee on
Health Care for Homeless People INSTITUTE OF MEDICINE 2018). For example,
treatment of diseases like Diabetes, which requires daily injections of insulin, which needs
refrigeration, and specialized diets, both of which are hard to be availed by a homeless
person. Also, the lack of health insurance among homeless individuals makes them unable to
afford any or most forms of treatment in case of emergencies, further increasing the risks of
morbidity or mortality. Poverty is one of the crucial factors that lead to homelessness, and
studies have shown that poverty can have strong causal effect on both mental and physical
health of individuals (Marmot 2015). Bramley et al. (2015) also adds that poverty is also
related to the emergence of spatial concentration of drug abuse, and chronic offenses.
Studies by Woliski, Kidder and Fenton (2007) also showed the increased risks of HIV
AIDS among homeless individuals are found to be three to nine times higher among
homeless individuals compared to the general public (Allen et al. 1994; Culhane et al. 2001;
Estebanez et al. 2000). The prevalence of HIV adds to the health risks of the homeless
individuals as well as being a significant public health concern, due to its communicable
nature.
Kennedy (2007) pointed out that homelessness increases the incidence of exposure to
violence and lower rate of social support, also causing a negative attitude towards schooling
or participation in schools. This further reduces their chances of employability and therefore
affects their socioeconomic status. The increased exposure to violence can also cause mental
health issues, and even give rise to violent, erratic or deviant behaviour, which also can be a
significant concern for public well being. Mental health issues and violence are also
interrelated, as per several studies (Rogers and Pilgrim 2014). This view is supported by Tsai
et al. (2015) who pointed out that exposure to violence increases the psychological

11Homelessness as a public health risk
vulnerability, causing lower mental health status and an increased incidence of mental health
issues.
Figure 10: Overlap in exposures to physical, sexual, and emotional violence; source: Tsai et
al. 2015).
Statistics from 2013/2014 shows 83,000 young people who were reported as homeless
in the UK, which marked a 40% increase in the number of homeless youth since 2011/2012.
This is a serious concern regarding public health. This therefore exposes the youth to an
increased risk of violence as well as mental and physical health risks. Additionaly, the
multiple risks can further increase chances of mental health issues and deviant behaviour,
hence a significant publuic concern. Johnson, Scutella and Wood (2015) pointed out that
family can be an important buffer to homelessness, which can be strained by household
poverty (Johnsen and Wattis 2014). Hence poverty can cause depletion of social and material
capital, and can lead to circumstances that can cause homelessness, thereby highlighting the
inter relation between structural, personal and interpersonal factors of homelessness (Bramley
and Fitzpatrick 2017).

12Homelessness as a public health risk
What could be done to address the challenge?
Different strategies can be utilized to address the problems due to homelessness, as
pointed out by various studies. The strategies can include:
Provision of Service:
Provision of service and employment is an important strategy that can improve the
economic and socioeconomic condition of the homeless people, and allow them to afford
stable and long term accommodations.
Preventative Measures:
Preventative measures to reduce the adverse effects of homelessness need to include the
following considerations:
1. By a collaborative effort from educational institutes, healthcare services, youth
services, job centres and police to ensure a targeted effort to prevent homelessness.
2. Improvement of healthcare service and family support for young individuals and their
parents and careers, and to facilitate the usage of their services.
3. Availability of safe and emergency accommodations to help families and individuals
struggling with homelessness.
It can be assumed that by increasing employability, and support to individuals or families
at high risk of homelessness, as well through the providence of continued support, their
economic condition can be improved, which can further improve access and availability of
healthcare systems. This also can cause an improvement in the mental health condition of the
individuals, reducing the risks of exposure to domestic, physical and mental abuse.
Employment can also help to reduce social isolation and stigmatization faced by the
individuals. Training and skills development programs can also help the individuals to
develop skills necessary to seek and retain jobs. Additionally, supporting employers of such

13Homelessness as a public health risk
individuals to sustain their employability can help in the retention of the employment status
of the homeless people.
Accommodation:
Ensuring proper accommodation of the homeless individuals needs to address the
following concerns:
1. Addressing the gap in the provision of accommodation for homeless people with
complex needs, and having the need for a high level of support. This can be achieved
through small scale housing projects or supported lodgings, with hosts who are
trained and supported by professionals.
2. Sustaining an environment that takes into consideration the emotional and
psychological needs of the homeless individuals.
3. Provision of long term accommodations for individuals with low requirement for
support or minimum support needs, like shared accommodation, rented
accommodation, design and build option for housing, and refurbished empty
properties.
It goes without saying that provision of proper accommodation is the most effective
solution for homelessness that allows easy, affordable and convenient shelters for such
individuals, which can be the starting point in the improvement of their conditions, supported
by other services like employment and training programs and healthcare and social services.
Social Networking:
Developing social networks through community actions and community building can
help to foster social cohesion. Aldrich and Meyer (2015) states that community resilience can
help the members of the community to cope up with various stressors, and maintain normalcy
of life and livelihood. Social Capital is identified by Aldrich (2017) as vital to build

14Homelessness as a public health risk
community resilience. An effective way of building social capital has been proposed by
Kawachi and Berkman (2014), through cohesion and networking, involving individual
perceptions, individual participation, and group surveys. Social interactions can also help in
the providence of increased access to support and help to the homeless individuals.
Promoting individual well being:
Individual well being can also be promoted through volunteer work and community
actions. Several studies have proposed the beneficial role of volunteer work on the well being
of individuals and on their employability (Griep et al. 2015). While Stukas (2016) also added
that community involvement can support both physical and mental well being of individuals,
apart from developing self esteem, self efficacy, social cohesion and social trust. Hence,
involvement of the high risk individuals in different volunteer work can be effective way in
helping their social cohesion and development of employment and employability skills.
These in turn can help to improve the individual well being of the people.
Healthcare facilities and it’s utilization for Homeless people can also be improved by
the inclusion of health insurance coverage, and assisting connections with a regular source of
healthcare (Winetrobe et al. 2015). Supporting homeless individuals to seek healthcare is an
important measure since, their healthcare utilization is majorly affected due to the lack of
shelter or fixed residence, lack of social support, low daily mobility and lack of financial
resource.

15Homelessness as a public health risk
Figure 11: The Skylight model for ending homelessness; source
(Stats.learningandwork.org.uk 2018).
The skylight model devised by the Department of Work and Pensions, Scotland
involves the following strategies: Employability Services (involving specialized coaching and
training, maintaining well being at workplace, and assisting interpersonal learning); Rational
Learning (involving feedbacks). Additional steps can include job shadowing (by coaches and
trainers), improving stability in life, integrating employability services and increasing
awareness (Stats.learningandwork.org.uk 2018).
Barriers and Recommendations:
Barriers:
Different types of barriers exist in the provision of adequate and proper service for
homeless people. Studies by Canavan et al. (2012) identify different barriers towards the
providence of care for homeless individuals, like:
1. Chaotic and uncertain life and circumstances
2. Alcoholism and drug use

16Homelessness as a public health risk
3. Inability to comply with medications
4. Lack of interest or willingness to use services
5. Lack of trust on healthcare and healthcare professionals
6. Insurance problems
7. Admission and discharge from healthcare institutes
8. Lack of collaboration between homeless service with social service and mental health
services
9. Lack of mental health outreach
10. Prejudice of healthcare professionals
11. Lack of capacity and employment.
The barriers to end homelessness are mostly linked to the poor socioeconomic status, and
lack of employment options, which increases risks of mental and physical health issues, lack
of education, and social seclusion or stigmatization, which further reduces their employability
options. The chaotic life and lack of residence also reduces their accessibility to different
services aimed towards public welfare, and further pushes them into a state of perpetual
deprivation. Children born under such circumstances additionally face challenges like health
problems, lack of education and violence, which affects the mental and physical well being of
the children, affects their educational process and their employability, thereby causing even
more deterioration of the economic condition, that can cause homelessness in the future.
Olufemi (2002) points out those negative, unsympathetic and rejecting perceptions of
the general public as well as healthcare professional towards the homeless people as another
significant barrier in the provision of their care. Weisz and Quinn (2017) studies the relation
between the stigmatization of homelessness with physical health, psychological distress and
service avoidance, showing that stigmatization adversely affects the health outcomes and can
also cause avoidance of services.

17Homelessness as a public health risk
Recommendations:
Canavan et al. (2012) suggested the following recommendations for healthcare
professionals, social workers and support groups who aim to assist the homeless people, to
overcome the barriers identified by their studies, including:
1. Building of trusting relation
2. Being un intrusive and respectful of the client
3. Keeping regular contact
4. Assisting homeless individuals to have health insurance
5. Assisting admission procedures
6. Improving collaboration between concerned authorities (like homeless service with
social service and mental health services)
7. Providence of stable accommodation
8. Providence of employment opportunities
9. Accessibility to mental health services, specially on the streets
Improving collaboration between concerned authorities can help in an efficient provision
of help to the homeless people, involving the homeless service, social welfare and mental
health services in a collaborative effort to reduce homelessness. Provision of mental health
services can also help to identify and mitigate mental health issues among the homeless
individuals, and focusing the help and support to people at high risk. Additionally, having the
outreach on the streets can improve accessibility of their services by homeless people, also
living on the streets. Assistance to solve housing problems can ensure the homeless
individuals are able to relocate to new homes, and thereby end their homeless status.
Addressing the concern of stigmatization, especially by healthcare professionals is
crucial to encourage the homeless individuals to seek assistance more proactively. It is

18Homelessness as a public health risk
important therefore for the healthcare professionals to build a trusting relationship with the
clients, being respectful of their situation or condition, and maintaining regular contact.
Conclusion:
Homelessness is a significant risk factor for different types of mental and physical
health conditions causing mortality and morbidity among people, apart from having a
significant impact on their socioeconomic status. The high prevalence of homeless
individuals in the UK, places them in the high risk group for developing health issues, and
hence is an important consideration for healthcare and social care worker, as well as
concerned authorities. Furthermore, since homelessness can also cause an increase in
violence, and deviancy, addressing such concerns is of high importance to maintain public
well being. Providence of support for homeless people needs to address the various
challenges and barriers in commitment and action, and involve working closely with these
people, enabling them to develop skills and abilities to improve their economic status and
hold jobs. Assistance with placements, along with the providence of safe and affordable
accommodations can be effective measures, apart from encouraging them to avail these
services more. However, such can only be possible through active participation of the
concerned authorities, and by maintaining an environment that does not discriminate and
stigmatize the homeless people, and keeping an aim to assist them to lead a better life. An
effective strategy reducing homelessness has been shown by the skylight model, as well as by
the studies by Canvan et al. (2012) (Stats.learningandwork.org.uk 2018). Improvement of
their conditions in a sustainable way is to ensure that the homeless individuals have access to
employment options, healthcare systems, accommodation assistance, and educational or
training services, which in a collaborative effort can break the vicious cycle that creates
homelessness and poverty. Since poverty is a significant precursor to homelessness,

19Homelessness as a public health risk
alleviating the conditions of poverty and deprivation can be an effective preventative
measure.

20Homelessness as a public health risk
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