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Review Article | DOI: https://doi.org/10.31579/2692-9392/218
Assistant Vice President for Clinical Education Development, A.T. Still University.
*Corresponding Author: Leonard B. Goldstein, Assistant Vice President for Clinical Education Development, A.T. Still University.
Citation: Jordyn Yokoyama, James Keane, Leonard B. Goldstein, (2024), Health Equity for the Homeless Population: A Review of the Health and Social Disparities Faced by the Homeless Population, Archives of Medical Case Reports and Case Study, 9(3); DOI:10.31579/2692-9392/218
Copyright: © 2024, Leonard B. Goldstein. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Received: 30 October 2024 | Accepted: 06 November 2024 | Published: 13 November 2024
Keywords: psychiatric illness; elderly individuals; treatment; healthcare issue
Homelessness, a condition in which an individual lacks a fixed and suitable place to stay at night, is becoming an increasing cause for concern for the U.S. population. Trends predicting large increases in the number of elderly individuals and young children facing homelessness in the U.S. along with a similarly increasing trend of psychiatric illness and drug use amongst the homeless population make ensuring healthcare availability to these marginalized people a necessity. However, long-standing stigmatization and a lack of access to quality care have made receiving appropriate medical care increasingly difficult for these populations. The purpose of this review is to investigate the leading causes of the lack of health equity and social disparities amongst homeless populations and to propose potential solutions and programs to mitigate this public health and healthcare issue.
Clinical practice guidelines can improve the clinical and social care for marginalized populations, thereby improving health equity. People experiencing homelessness face health inequities including high rates of preventable all-cause mortality [1], and treatable morbidities, such as infectious diseases and chronic health conditions [2]. People experiencing homelessness are often marginalized and are known to face barriers to assessing acceptable and respectful healthcare services [3].
Healthcare services are experienced as stigmatizing and shaming particularly for patients with concurrent substance use/abuse. These negative experiences often lead to avoidance and abandonment of care.
Current accreditation standards of most health professions training programs recommend teaching that incorporates social determinants of health and vulnerable populations to address health disparities that will confront all future providers [4-7]. While educators have focused on exposing their students to a variety of vulnerable populations, including immigrants, the poor, non-English-speaking, and ethnic minorities; less attention is being paid to other marginalized groups such as the homeless/unhoused.
The homeless/unhoused have been shown to suffer increased morbidity and mortality in comparison to their housed counterparts [8]. As homelessness becomes a common social condition within urban and some rural settings [9-11], medical educators seek to include care for the homeless in the curricula to address health disparities.
“Street Medicine” [10] is the delivery of healthcare in a setting most acceptable to unhoused patients. Providing healthcare “on the streets” allows access to healthcare that is not traditionally available to the homeless. Intentional exposure to street medicine may have the potential to provide teaching about addressing disparities, compared to passive exposure to clinical rotations in ambulatory and hospital settings (12, 13).
This article will discuss health equity for the homeless population, and how and why it should be included in a health equity curriculum.
What is Homelessness?
Although a clear definition of homelessness has yet to be established in recent literature, homelessness is a complex condition in which an individual suffers from a lack of suitable or fixed housing [14]. The vast array of other definitions, which include couch surfing, caravans and women’s refuges [15], further exemplify that homelessness is not simple, and that the result of such living conditions looks different for many people. But while this definition appears to be, on the surface, a simple issue of not enough housing, homelessness is multifaceted. These people not only suffer from a lack of housing, but they also suffer from a lack of emotional, physical and spiritual support. Essential needs such as this that an individual requires in order to live a full, well-rounded life, are typically assumed to be provided by adequate and safe housing [16]. When such accommodation and protection is absent, these people are unable to thrive because their basic needs are not met.
Over 500,000 people between 2007 and 2019 lived on the streets in the United States [17], and while this number may be slightly lower than in former years, 1.8-3.1% of the U.S. population still suffer from homelessness [18]. In the United States, some of the leading causes of homelessness have been identified as substance abuse, mental illness and domestic violence [19]. These causes are not only the cause of the initial state of homelessness, but are also further worsened by the lack of consistent housing. And while substance abuse is not always the cause of an individual suddenly experiencing homelessness, the immense stressors that one experiences often lead to substance abuse in order to alleviate their pain, emotional or physical. Once a vicious cycle ensues of an individual starting to use either drugs or alcohol and using any money, they have to purchase these substances, it becomes that much harder to escape the situation.
An unfortunately less-talked about cause of homelessness, especially among women, children and displaced families, is domestic violence [20]. After the women’s movement in the 1960s [21], the first shelters for battered women were opened in 1973. But by the 1990s, shelters for battered women were at capacity, further demonstrating that domestic violence is a prominent cause of homelessness. Between 1987, where it was found that over 40% of those taking refuge in the homeless shelters of New York were abused women and children [22], and 2005, where half of interviewed mayors for various cities in the United States counted domestic violence as a leading cause of homelessness in their cities [21], the fact that domestic violence remains a leading cause of homelessness shows that the need for a potential solution to improve these numbers is necessary.
Other causes of homelessness have been linked to poverty, a decline in access to public services and a shortage of affordable housing [23]. In addition, evictions, prison and mental health problems [24] play a large role in the cause of homelessness. Chronic mental health disorders are among one of the leading causes of homelessness in the United States, with an estimated 33% of the homeless population as of 2012 suffering from untreated psychiatric illnesses [25]. In a study done in the San Diego County Adult Mental Health Services, 15% of their evaluated patients who were being treated for a mental health disorder were also homeless, with schizophrenia and bipolar disorder being the two most prominent psychiatric disorders amongst those suffering from homelessness [26]. Some studies have found that the homeless population amongst patients suffering from severe mental illness to be as high as 24%, despite being in an area with a well-established, well-funded mental health system [27].
What are the Demographics for Individuals Suffering from Homelessness?
Estimates have put the number of people experiencing homelessness at any particular day at 600,000 [28], with approximately ⅓ of these individuals spending their nights on the street. Issues with accurately estimating this number and those that are afflicted by homelessness has been a constant problem because of changing definitions of homelessness, the ever-changing economic status of the United States and newer trends that have come to light. Past studies have shown that the African American population is the most dominant ethnicity making up the homeless population, with some estimates as high as 50% [29]. The next most prominent were Caucasian (35%) and Hispanic (12%) individuals.
In 1985, single men were the dominant demographic of the homeless population, constituting about 21% of these displaced persons [29]. Since the early 2000s, these numbers appear to have evened out, with a more rapid increase in single women and single women with children being noted as newer and significant subgroups [30,31]. This rise in number is likely linked to the increased number of battered women’s shelters, which reached 700 shelters by 1983 [21]. The mean age of the homeless population has also increased from individuals in their early to mid-30s to around 39 years of age.
In more recent years, the number of younger and older people suffering from homelessness has increased. In 2016, it was estimated that over 50% of single homeless adults were older than 50, which is a nearly 40% increase from the same statistic in 1990 [32]. Some previous research suggested that this jump in age was linked to when these individuals were born: during the “baby boom” era between 1945 and 1964. Whether or not the increase in the homeless population with this age demographic was due to an increased number of young adults at the time suddenly facing housing issues or new socioeconomic problems brought about by the baby boom is up for debate [33]. This number was suspected to modestly increase between 201
0 and 2020, especially for adults aged 50 to 65 years old [34]. With the size of the elderly population estimated to double by 2050 and the consistent proportion of elderly facing economic strife, these factors are expected to exacerbate this potential problem.
On the opposite end of the age spectrum, children in families with children are one of the fastest-growing subgroups of the homeless population [35]. With the impact that homelessness can have on childrens’ education and well-being, especially those in low-income families, the urgency behind this statistic is large. Factors such as poverty, unaffordable housing, violence at home, financial strife and behavioral factors are some of the leading causes of childhood homelessness [36]. This constantly changing population has made it difficult to identify a specific number of afflicted individuals, however it is suspected that the numbers of homeless children and youth could be as high as hundreds of millions [37].
Large changes in the demographics of the homelessness population were also seen between 1992 and 2002, where periods of dramatic economic expansion were the primary cause of these changes [38]. In times of economic recession, more people are likely to experience homelessness because of greater income and housing loss, especially for those less-skilled and recently hired. The opposite is true during times of economic growth. Fluctuations such as this have also made gauging the general number of individuals suffering from homelessness in a given time period very difficult.
Stigmatizations that the Homeless Population Face?
Stigmatization, which has been defined as a combination of labeling, stereotyping and discrimination where power imbalances exist [39], towards the homeless population is one of the biggest barriers in either their access to care or willingness to seek it. Some policies that further this stigmatization is the legislation that criminalizes certain actions of the homeless, such as camping and panhandling [40]. Oftentimes, those without housing have no choice but to camp somewhere for the night, and having such actions made illegal further pushes the stigma that they are second-class citizens. Some have also reported receiving citations for minor offenses such as jaywalking and loitering, for which they likely wouldn’t have been cited for if they had not been homeless.
Some states, such as Orlando, Florida, have laws that even prohibit distribution of food in public parks. And even if it isn’t made completely illegal, such as in Raleigh, North Carolina, requirements to distribute food are made so difficult and expensive that distributing food may not be feasible for those that would like to give and absent for the homeless who need the resource [41]. Homeless individuals are also often taken advantage of because of their vulnerable states, such as being more prone to violent attacks, prostitution, human trafficking and sexual assault [39].
Societal attitudes towards the homeless can have a grave, negative impact on their well-being. Often labeled as useless or non-functioning members of society because these individuals do not usually work [42], such attitudes can lead to others ignoring the homeless population and making them feel even more marginalized. Dehumanization, which is the process by which a person is made to feel inferior to their human counterparts, has been reported amongst the homeless population [43]. Treatment such as this has led to these individuals feeling humiliated and demeaned. Some stigmatization has also been found to be focused on race, gender and political beliefs. For instance, unhoused black men have been found to be viewed as more dangerous, and more conservative, housed individuals appear to prefer greater distance between themselves and homeless populations.
Illness, be it physical or psychiatric in nature, has also been associated with greater stigmatization and discrimination amongst the homeless population. Individuals suffering from homelessness whose living conditions were caused by a pre-existing severe mental illness have been found to have less stigmatization directed towards them than if the mental illness resulted because of their homelessness [44]. Stigma directed towards individuals for illness such as HIV/AIDS and substance abuse reported incidences of internal and external stigma [45], which are defined as their internal belief in how stigmatized they are and how they are treated by those around them, respectively. Those with greater internal stigma are less likely to seek necessary medical help and more likely to have poorer health outcomes than those with lesser internal stigma. In addition, lack of access to affordable care often leads to these illnesses becoming worse, or even leading to early mortality rates.
What are the Most Prominent Health Concerns the Homeless Population Faces?
Correlating closely with being one of the leading causes of homelessness, mental health is one of the most prominent health issues that the homeless population faces. Along with cognitive impairment, the rates of mental health illnesses are greater in the homeless population than in the general population [46]. Those suffering from severe mental illness have been reported to have a risk of homelessness that is 10 to 20 times greater than the average person, with schizophrenia and bipolar disorder being some of the predominant severe mental illnesses diagnosed in the homeless population.
Especially amongst the homeless youth, some of the most prominent health concerns are addiction in the form of substance abuse, sexually transmitted disease and infection and psychiatric disorders [47]. Concerns for cognitive development amongst youth and young adults is especially concerning because this is the time during which rapid and/or full development of important structures occurs. For instance, myelination of the brain increases during adolescence [48], which allows for quicker and more efficient reaction times. The prefrontal cortex also matures through a person’s mid-twenties [48, 49], and since this structure controls executive functions such as critical thinking and decision-making, it is crucial that it develops properly. However, challenges that youth, adolescents and young adults face when they are homeless, such as mental health issues and poor nutrition, could potentially have a negative effect on the development of these structures.
Some of the most prominent medical problems faced by those suffering from homelessness include respiratory illness, dermatology-related issues, physical injuries and digestive problems [50]. All of these conditions are further exacerbated by alcohol consumption, drug use and obesity. While these actions and conditions are not unusual within the general population, they are often seen in greater rates in the homeless population. These individuals also have a higher incidence of chronic illnesses than the general population, with one study done in British Columbia, Canada reporting past head injuries, chronic hepatitis and migraine headaches as the most commonly reported chronic conditions at 38.8%, 34.6% and 29.2% respectively [51].
Other health concerns that are often a cause for concern are dental issues and obesity. In comparison to the 3% of the general population that suffer from 5 to 6 decaying teeth, approximately 25% of the homeless population suffer from this issue [52]. Severe dental problems such as this have been correlated to a poorer intake of food and nutrients [53,54], which could potentially lead to other health concerns such as vitamin deficiency and malnutrition. But in contrast, there is an increased chance of obesity because these individuals often suffer from food insecurity. During times of very little food, these people have to suffer through periods of starvation and malnutrition. But when food is available, individuals often binge-eat in order to consume as much food as possible while they can [55]. Because this way of food consumption is more focused on volume than ideal nutritional intake, this puts these individuals at greater risk of other related chronic illnesses, such as heart disease.
What are Barriers to Solving the Homeless Crisis in the U.S.?
While solutions to the homeless crisis in the United States may seem obvious, there are several barriers that exist that make finding solutions layered and complicated. One of the largest issues that the homeless population faces is a lack of access to services [56] and a lack of affordable housing. One of the largest issues with access to services is transportation and distance. With a lack of transportation, it has been found that those suffering from homelessness are more likely to access services that are in convenient locations. A lack of basic mental health services and healthcare for the homeless population also often leads to these individuals having to use emergency services for health issues that could be solved with primary care services [57] or health problems that are now incredibly severe that could have been prevented with earlier treatment.
Food insecurity continues to be a problem amongst the homeless population, with 68% of the homeless population in some areas reporting having to go at least a full day without food in the last month [58], despite increasing numbers of food pantries and soup kitchens. Services for underrepresented subgroups within the homeless population, such as youth who are part of the LGBTQIA+ community [59], single women [60] and women who have experienced domestic violence and/or physical or sexual abuse [61] are also lacking.
Interviews with members of the homeless population have also identified cost as a massive barrier to obtaining care and medications that they need [54]. For instance, some report being taken to the emergency department, and being released back onto the streets with only a few days-worth of medication. Without a means to pay for medications or sometimes no way to get to a pharmacy to obtain this medication, acute or chronic health problems often had to go untreated. Sometimes, a fear or dislike of hospitals was also a leading factor for individuals not seeking care, which could also potentially be linked to underlying stigmatization around homelessness and healthcare.
What are some Existing Initiatives or Programs that Help to Improve Access to Healthcare for the Homeless Population?
Some examples of potential solutions proposed to help improve the homeless crisis often involve changes in policy, housing options and novel options to increase access to health services. Examples of some policy changes that have been made have been in response to the growing concern of the impact on childrens’ education for those that are experiencing homelessness [62]. In 1987, the McKinney-Vento Homeless Assistance Act was passed in order to remove barriers that limited homeless childrens’ access to attend school. Another initiative called “Race to the Top” was implemented, which required schools to help address and provide for children either experiencing or at high-risk for homelessness so that they can attend public schools.
Providing temporary housing or permanent housing is also a large barrier to overcoming the homelessness crisis, especially for single women escaping domestic violence situations [63]. Emergency shelters are good temporary resources for these women and other people in need, however these shelters are often at full capacity. Transitional housing is a more stable option because it allows unhoused women to stay for periods of time up to one to two years. In order to help this situation further, programs such as the Housing Voucher Program have been created, which allow these women to have permanent residence in a house so long as they are able to pay their portion of the rent or are able to have that rent paid for them.
One way that some are attempting to improve the homeless situation is by implementing potential prevention programs that target individuals or families before they experience a state of homelessness [64]. Programs such as eviction prevention, community-based services and screening amongst others proposed programs have been conceived with the goal of reaching those that may be vulnerable to experiencing homelessness and connecting them to resources to help them find appropriate housing.
Because access to quality medical care is also a huge problem for the homeless population, the creation of street medicine programs, which bring medical care directly to unhoused individuals, is becoming utilized more and more [65]. With schools such as the Keck School of Medicine of USC developing services to help with street medicine consultation can potentially help mitigate the issue of access to medical care. In addition to street medicine, the use of mobile programs has also taken on new importance [66]. These mobile units can help provide primary care, social services and behavioral health services to these individuals, who would not be able to access these services otherwise.
The homeless public health crisis in the United States has continued to persist, despite actions and initiatives taken to attempt to improve the situation. With certain subgroups such as single women, single women with children and the elderly becoming more prominent concerns in the makeup of homeless demographics, it is becoming increasingly that applicable and viable solutions be found and made available to solve the homelessness crisis. 600,000 individuals still suffer from homelessness each day [28], and because these numbers have been seen to increase between 2017-2021 in some states [67], this problem is far from solved.
Especially because we are seeing a rise in the number of homeless youth and young adults, a time that is critical for important milestone brain and nerve development [48,49], having a better understanding on the impacts of homelessness on these individuals is important. Very few studies have been done investigating how homelessness affects the development of these important structures in homeless youth. Without a solid understanding of the potential adverse effects these individuals may suffer as adults because they suffered from homelessness in their youth, there is less backing for potential programs to take stronger action on mitigating this problem. We propose that longitudinal studies that specifically focus on the effects on the prefrontal cortex development and myelination in youth suffering from homelessness and how these affect their wellness and development in adulthood could help shed light on the long-term effects of homelessness on youth.
Prevention of homelessness will also be key to improving the homeless crisis because we can prevent more individuals from suffering from adverse effects of homelessness in the first place. One study has suggested that the use of interdisciplinary partnerships could have a positive impact on solving the homeless crisis [68]. Because experts in these respective fields can help contribute at various levels of organization, from community-based interventions to institutional levels, their combined efforts could help more fully address the main challenges faced by the homeless population. A case study done in Tallahassee, Florida suggested that a Tiny Homes initiative could be a potentially effective solution, though it needs further research and analysis of its outcomes to fully understand its effectiveness [69]. While certain challenges like funding are problems with initiatives like this, more permanent or transitional housing programs such as this could help families or individuals with children and victims of domestic violence adjust, recover and potentially avoid homelessness altogether. Screening processes to identify those at risk of homelessness could also help improve prevention initiatives.
Increasing the use of street medicine and mobile care can also be a potentially effective way to reduce the medical needs of the homeless population. Because point of care, health checks done during an appointment, have been shown to be beneficial for maintaining greater health in the homeless population [65], increasing the use of street medicine could help provide vital care to those who are unable to find transportation or face other barriers to receiving medical care. Mobile care units are able to provide a range of medical services to unhoused individuals [66], which makes their use even more significant. Because primary care and behavioral services can both be supplied by these mobile care units, they can also help to decrease the number of unhoused individuals who are forced to use emergency services for illnesses that may not be immediately life-threatening. For instance, if mobile care units can bring appropriate wound care services to the homeless, these individuals are less likely to contract life-threatening infections and will not have to travel to an emergency room for treatment. And with estimates up to 46,500 unhoused people losing their lives because of the challenges faced during homelessness that exacerbate their medical illnesses [70], the importance of their use cannot be underestimated.
Rising numbers in subgroups and increased incidence of physical and mental illness among the homeless population show that despite strides to mitigate this public health crisis, we are far from finding long-term, effective solutions. Increasing research on the developmental effects that homelessness has on youth and their wellness as adults can help shed light on how we can halt and improve the rising youth in the homeless population. In addition, increasing the number and use of street medicine programs and mobile care units can improve the medical needs of unhoused individuals without access to adequate primary care health services.
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