Ongoing armed conflicts and poor economic conditions are daily increasing the ranks of the homeless in the world through the creation of refugees and immigrants. The level of increase in the homeless population worldwide can only be estimated because of the continuous fluctuation of this population. However, the World Health Organization as well as nongovernmental agencies managing the homeless around the world confirm that there are greater numbers each year.
In the United States, the increase in the number of homeless became a subject of local, state, and national concern in the 1980s, with the profile of the homeless changing from that of an older male with alcohol addiction to that of young men and women (21–39 years) who often entered homelessness accompanied by their young children (National Coalition for the Homeless, 2002). In 1987 the federal government, in the Stewart B. Mc-Kinney Act, initially enacted legislation providing limited funding for health care for the homeless via the federally funded community health centers.
Since the number of homeless continued to increase, this funding was reapproved in 1994. In this act a homeless person is defined as one who
lacks a fixed, regular, and adequate night time residence; and...has aprimary night time residency that is (a) a supervised publicly or privately operated shelter designated to provide temporary living accommodations...(b) an institution that provides a temporary residence for individuals intended to be institutionalized, or (c) a public or private place not designated for, or ordinarily used as, a regular sleeping accommodation for human beings. This definition does not include individuals incarcerated by federal or state governments. (42 U.S.C. & 11302(c)
Currently the Urban Institute estimates that in the U.S. the number of individuals experiencing homelessness at some time within a given year is 3.5 million, with 39% (1.5 million) of this group being children (Urban Institute, 2000). This estimate is flawed and minimal as it reflects only the homeless counted by agencies servicing the homeless.
The homeless who are not included in this estimate are those who do not seek services from homeless shelters and reside outside, in abandoned buildings or autos, or with relatives or friends. Homelessness and health are interrelated in three major ways: health issues may lead to homelessness; being homeless may predispose an individual to health threats; and homelessness can impact health by limiting one’s access to health care. Health status can easily lead to homelessness. When an individual with physical or mental illness or drug/alcohol addiction is unable to maintain employment and housing—homelessness results.
Being homeless in a shelter setting exposes the individual to health threats (communicable diseases) from living in close quarters with others (primarily respiratory, gastrointestinal, and dermatological health threats) and exacerbates common health problems (colds, extremity swelling, foot lesions, etc.) due to shelter restrictions which require residents to rise early and leave the premises. Being homeless also makes access to health care more difficult since most homeless individuals do not have health insurance, and most shelters do not have onsite health care providers or access to cost-free medications.
Consequently, the homeless seek care for acute episodes of illness at their peak and do not seek preventive care. Nurses and nurse researchers around the world have been in the forefront studying the health care needs of the incoming homeless (refugees and immigrants). The U.S. nursing literature focuses primarily on the health of homeless U.S. citizens who have descended into homelessness for various reasons (eviction, substance abuse, release from prison, domestic abuse, etc.). Early research in this area was directed primarily at gathering demographic information related to the homeless, such as age, sex, reason(s) for homelessness, health care needs, etc. (Lindsey, 1995) and providing reports of the healthcare needs of this population from newly developed nurse-managed clinics. Although reporting of demographic information has continued, in the last 5 years nursing research in this area has evolved in new directions.
Qualitative studies to better understand the lives of the homeless and the homeless experience have been published (Rew, 2003; Huang & Menke, 2001; Morrell-Bellai, Goering, & Boydell, 2000). New research instruments have been developed and validated with various subgroups of this population, and new theoretical frameworks have been offered to better explain the phenomenon of homelessness in particular homeless subgroups (veterans, single mothers, substance abusers, domestic violence victims, adolescents, etc.). These research studies have expanded the base of nursing knowledge through examining areas unique to this population, such as the relationship of early childhood trauma and abuse to adult homelessness; identification of the stressors and coping behaviors of individuals (adults, mothers, and children) who are homeless; identification of the personal strengths of the homeless; and identification of the meaning and value of pets for the homeless. Through these studies unique factors impacting the physical, mental, and spiritual health of subsets of the homeless have been identified and nursing interventions proposed to utilize this new knowledge in addressing their health issues.
Nurse researchers have also been active in developing mechanisms to include the homeless and their nursing care needs in nursing school curricula through service learning projects, faculty managed care centers, and clinical homeless shelter rotations (Wilk, 1999). New research instruments have also been used in studies with the homeless. Some have been adapted and validated for use with the general homeless population and others developed and validated specifically for use with subgroups of this population, such as homeless sheltered women (Hogenmiller, 2004).
In the future, nursing research related to the health of the homeless will expand on current new directions to include: (a) identification of how to incorporate preventive health activities for individuals in the homeless state, (b) empowering the homeless to become competent health care consumers, (c) identification of the unique elements and health care needs of second-generation homeless, (d) identification of a continuum of health care strategies for individuals with recurrent homeless episodes, and (e) development of cost-analyses and cost sharing models with other health care institutions to pro-vide needed health care that is cost effective.