sample literature review on homelessness

Homelessness, health and the policy process: A literature review

Affiliations.

• 1 University of Sydney Menzies Centre for Health Policy, Faculty of Medicine & Health, Sydney 2006, Australia. Electronic address: [email protected].
• 2 University of Sydney Menzies Centre for Health Policy, Faculty of Medicine & Health, Sydney 2006, Australia.
• PMID: 31522758
• DOI: 10.1016/j.healthpol.2019.08.011

Homelessness has serious consequences for the health of people experiencing homelessness, and presents a challenge to the provision of quality care by health services. Policymaking to address homelessness, as with other social determinants of health (SDH), is complicated by issues of complex causation, intersectoral working and the dominance of biomedicine within health policy. This paper investigates how policies addressing homelessness have been explored using formal policy process theories (PPT). It also examines how health (as an actor and an idea) has intersected with the issue of homelessness reaching policy agendas and in policy implementation. A systematised search of academic databases for peer-reviewed literature from 1986 to 2018 identified six studies of homelessness policy change from Australia, Canada, France and the United States. PPT were able to articulate the interplay of actors, ideas and structures in homelessness policymaking. When the health sector was involved, it tended to be in terms of healthcare service utilisation rather than a broader public health framework emphasising structural social determinants of homelessness. Tensions between differing the priorities of local homelessness actors and a biomedical evidence-based policy paradigm were noted. Future policy action on homelessness requires new models of intersectoral governance that account for the complexity of health determinants, a health workforce enabled to engage with the SDH, and meaningful inclusion of those with lived and living experience of homelessness in policy formulation.

Keywords: Homelessness; Intersectoral working; Policy process; Political science; Social determinants of health.

Copyright © 2019 Elsevier B.V. All rights reserved.

Publication types

• Research Support, Non-U.S. Gov't
• Government*
• Health Policy*
• Ill-Housed Persons*
• Intersectoral Collaboration
• North America
• Policy Making*
• Public Health
• Social Determinants of Health*

• Open access
• Published: 25 April 2022

A qualitative systematic review on the experiences of homelessness among older adults

• Phuntsho Om 1 , 2 ,
• Lisa Whitehead 1 , 3 ,
• Caroline Vafeas 1 &
• Amanda Towell-Barnard 1  

BMC Geriatrics volume  22 , Article number:  363 ( 2022 ) Cite this article

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Adults who experience homelessness for an extended period of time also experience accelerated ageing and other negative impacts on their general health and wellbeing. Homelessness amongst older adults is on the rise, yet there are few systematic reviews investigating their experiences. Thus, this review classifies and synthesises qualitative research findings of studies published between 1990 to 2020 that have examined the needs and challenges of homeless older adults to elucidate their journey of homelessness. Seven papers met the requirements for inclusion. Three main themes were identified in the review: - (1) Pathways to homelessness, (2) Impact of homelessness, and (3) Outcomes and resolutions. This review collates current evidence on what is known about the experience of homelessness among older adults. In this study, homeless older adults identified a wide range of challenges associated with the experience of homelessness.

Peer Review reports

The population globally is ageing. Although, ageing is truly a triumph of development, this demographic change presents both advantages and challenges. The concept of successful ageing is to “add life to years” rather than adding days to life and is about maximizing wellbeing and happiness for the older adult [ 1 ]. The risk of developing physical and mental health issues among older adults along with associated costs are linked to a higher demand for health and social care [ 2 ].

Theories on ageing have been developed with the goal of understanding the ageing process and how best to support “healthy ageing at home” and “ageing-in-place” [ 3 ] however these do not consider older adults who do not live in a supportive environment or adults who are homeless. The home setting can be a place associated with poor subjective well-being and some older adults may feel compelled to leave the home setting as a result [ 4 ].

There is no consistent definition of homelessness, rather it has been confined to socio-historical, geographical, and cultural contexts from which the term is drawn [ 5 ]. Homelessness can be defined by a range of categories: absolute and or hidden with homelessness defined as sleeping in parked cars or parks, in emergency shelters, or in temporary shelters (couch surfing) with no or minimal health and safety requirement standards, and risk to personal safety [ 6 , 7 , 8 ]. This includes people residing in sub-standard housing such, as single-room occupancy hotels, or cheap boarding houses, as well as low-cost tiny, lodgings with minimal amenities [ 9 , 10 ].

There is an increasing rise in homelessness among older adults and older homeless adults have been identified as the “new homeless”, a “forgotten group” and a “hidden group” [ 9 , 11 , 12 ].

The reasons for homelessness amongst older adults are diverse. These can include: the impact of natural disasters; the availability of affordable housing, including rising rental costs, a decline in social welfare and support programs; financial insecurity; a lack of social amenities; and increasing rates of mental health issues, combined with various addictions, including gambling [ 2 , 9 , 11 , 12 , 13 , 14 , 15 , 16 ]. In addition to this, family relationship breakdowns, or the death of loved ones, can cut people’s social connections, resulting in older adults experiencing homelessness for the first time. This displacement of older more vulnerable adults can lead to deprivation including the basic need for a place they can relate to as home, subsequently leaving them homeless [ 3 , 7 , 15 , 17 ].

Molinari, Brown and Frahm et al. (2013) found homelessness was unanimously perceived as a humiliating experience by homeless older adults [ 13 ]. According to a survey conducted by the United States Department of Housing and Urban Development, over 15% of 634,000 homeless individuals were 50 years or older, where the number of homeless people aged over 65 has been projected to double by 2050 [ 13 ]. The same survey reported that in the United States alone, adults as young as 50 years of age were facing challenges of homelessness, effectively accelerating ageing processes. Further to this, homeless older adults face a greater threat of age-related disease burden, where they are more likely to experience: functional, auditory, visual, and neurological impairments, frailty, emotional distress, and urinary incontinence, at higher rates than in the general community [ 18 ].

Similarly, van Dongen et al. have reported within a longitudinal cohort study, that older homeless adults, unlike their younger counterparts, reported a higher incidence of cardiovascular disease and visual problems, as well as reporting limited social support from family and friends or acquaintances, and limited medical or hospital care use in the past [ 19 ].

However, there is limited published research identifying the distinct needs of homeless older adults. This is a critical gap in the literature, where a deeper understanding of the experiences of older adults who have been or are currently homeless is required.

The main aim of this qualitative systematic review is to synthesise the evidence on the experience of homelessness of older adults.

Using Joanna Briggs Institute (JBI) guidelines, a meta-synthesis of global qualitative evidence was undertaken. Studies with titles and abstracts that met the analysis goals were retrieved and chosen, based on inclusion and exclusion criteria. These studies were further appraised to evaluate methodological validity by analysing evidence relevant to viability, appropriateness, meaningfulness, and effectiveness [ 20 ]. Qualitative and mixed-method studies with ample qualitative data in their results sections to allow secondary data analysis met the inclusion criteria. The sample comprised of older adults aged between 45 and 80 years that had experienced homelessness for at least one period. The search was restricted to studies that were published in English and available in full-text form, where studies with participants below 45 years, older adults in housing facilities, and aged care residents were excluded.

Search methods

This analysis followed the Joanna Briggs Institute (JBI) method for systematic reviews [ 20 ]. A qualitative assessment and review instrument (JBI-QARI 10 item tool) [ 20 ] was used to facilitate the meta-synthesis. Results from the studies were extracted, categorised, and synthesised. Searches were conducted in PsycINFO, Web of Science, Google Scholar, Medline, PubMed, and CINAHL using appropriate search terms. Additionally, important citations were searched from reference lists of relevant articles. Searches were limited to published studies from 1990 to 2020 (see Fig.  1 ).

PRISMA flowchart

Quality appraisal

Two reviewers independently assessed 21 articles for methodological quality in their design, conduct and analysis using the JBI-QARI 10 item tool [ 20 ]. Any discrepancies were discussed within the team. Out of the 21 articles, seven were included in the synthesis. Each selected study was re-read several times, discussed within the review team and data were abstracted for interpretation.

Data abstraction

Findings relating to both current and past experiences of homelessness among older adults were extracted from the seven selected studies. A total of 56 findings were extracted. Each finding was reviewed and further compared and manually coded to identify themes. Table  1 lists the author and year, sample size, design, setting, and participant characteristics of the selected studies.

Analysis of the seven reviewed articles was carried out using the qualitative evidence synthesis method [ 20 ] developed by JBI (2014). Qualitative findings from each study were first read and reread, followed by an identification of common themes. Recurring themes across studies were then grouped together in a meta-synthesis of the findings. This process comprised critical appraisal, data extraction, analysis, and a meta synthesis involving organisation and categorisation through decoding and encoding of the extracted data to produce a final summation of the findings. The qualitative evidence summation and synthesis were deliberated, cross-checked, and then reviewed by all the authors.

Of the seven studies identified for review (see Table 1 above), four studies directly explored pathways to homelessness amongst older adults. Individual study sample sizes ranged from 14 in Reynolds, et al. (2016) [ 21 ] to 60 in Viwatpanich (2015) [ 24 ]. Three studies applied in-depth face to face interviews, with three studies using semi-structured interviews, and one study conducting focus groups to collect data. The studies were conducted in three countries: Canada, USA, and Thailand.

Data synthesis commenced using open descriptive coding to search and identify concepts and finding relationship between them. Next using an interpretive process, the meaning units were categorised within each domain using labels close to the original language of the participants. The categorization of the data for each case was then followed by a cross-case analysis that examined the similarities and differences. Following categorisation, themes were conceptualised for each category. An overarching theme was identified: ‘the journey of homelessness’. Within this context, three core themes were identified: 1) Pathways to homelessness; 2) impact of homelessness; and 3) outcomes and resolutions, where each of these 3 themes had relevant sub-themes. (see Fig.  2 ).

The Journey of Homelessness Model

The conceptual model depicted in Fig. 2 represents the overarching theme of the ‘journey to homelessness,” and key concepts and relationships between variables from the synthesis of the literature. Unlike other conceptual models that involve causal and directional relationships, this model is both directional and non-hierarchical. The model illustrates the pathways to homelessness, the associated impacts of homelessness and the outcomes of homelessness. The following section explores the three themes and sub-themes in more detail.

Theme 1. Pathways to homelessness

The causes of homelessness were shown to be multifaceted, where pathways to homelessness revolved around a combination of individual, social, and structural factors. The reviewed data suggested that becoming homeless involved two distinct pathways: one that was gradual and one that was rapid.

Sub-theme 1.1: gradual pathway to homelessness

Findings from six studies contributed to this subtheme. This sub-theme captured the factors contributing to gradual pathways into homelessness amongst older people. These factors were identified as accelerated ageing, poverty, rising housing costs, failing and uncommitted social security systems, a lack of social programs and services, social distress, rural-urban migration, substance abuse and addiction, as well as estrangement from family or lack of living relatives [ 13 , 14 , 21 , 22 , 23 , 24 , 25 , 26 ].

The following quotations from these studies illustrate both estrangement from family and the impact of a lack of support from social services:

Many conflicts we had at that time, we never talked … never talked in normal way … nothing clear between us, emotion never came clear...they did not want to talk to me, not even to look at my face … I could not stand it, I surrendered. Beating and scolding by descendants is not in our tradition, no respect, if they did not want me to stay with them, I moved out [ 24 ] .

I submitted applications for low-income housing, I’ve been on the waiting list, seven years is a long time, especially at my age [ 22 ] .

Personal vulnerability to difficult familial relationships, neglected needs and unstable housing were the most cited causes of homelessness amongst these older adults [ 3 , 9 , 14 , 25 ].

Two studies [ 15 , 21 ] described a pathway to homelessness as related to alcoholism and drug abuse, as highlighted in the following quotation:

I got into crack cocaine, I got into hooking, I got into anything you could think of I guess . . . So it was my addictions that brought me down, and unhealthy relationships [ 25 ] .

Feeling ‘homeless at home’ [ 27 ] due to loneliness was noted by some older adults as their reason for ‘living on the streets’. For example, homeless older adults that experienced social rejection and conflicts with housing management, neighbours, and roommates, noted this to ultimately lead them to homelessness. For example, one participant stated, “I have lived alone and never really felt at home, because to me home is a place that includes other people, your family” [ 23 ].

Sub-theme 1.2: rapid pathway to homelessness

Some older adults described the process of homelessness as ‘rapid’. A rapid pathway to homelessness was associated with abrupt life changes such as losing a loved one, divorce, and the impact of these losses on their lives. The two quotes below highlight rapid pathway process:

Losing them, let’s just say it evaporates over time. It’s the fact that I wake up like I am here that I can’t accept … homeless … in the street. I sold everything, every single thing! I never thought I’d end up like this. It’s like starting from zero [ 23 ].

I had a wife, then she died, I did not know where to go, what to do, I turned homeless [ 24 ] .

Older adults that faced a series of losses and a rapid deprivation of social support systems noted the experience of disrupted circumstances. Accordingly, they noted their fear of losing their independence and ‘sense of self’ resulted in their resistance to any help that was offered, in turn contributing to their homelessness.

Theme 2. Impact of homelessness

Findings from five studies contributed to this subtheme. Homelessness and ageing were presented to form a ‘double jeopardy’ where homelessness aggravated the challenges of old age [ 15 , 21 , 22 , 23 , 24 ].

This theme included the subthemes of: unmet needs, coping strategies, and the realities of housing availability.

Sub-theme 2.1: unmet needs

‘Unmet needs’ amongst older homeless adults were categorised as involving physical, emotional and social needs leading to despair and destitution. As this quote below highlights:

I’m supposed to get a pneumoscopy, but where am I, where do I stay? How can they get a hold of me? I don’t have money to get around [ 15 ] .

Sub-theme 2.1.1: lack of physical wellbeing

Findings from six studies [ 14 , 15 , 18 , 21 , 22 , 24 ] contributed to this subtheme. Physical decline and physical disability were described as exacerbated by the experience of being homeless. Participants described a relationship between age and frailty, fatigue, poor physical health, and impaired mobility while homeless, as these quotes demonstrate:

Ah! Walking all day, for me, it’s very hard on the body, ok. Sleeping outside on a park bench, that’s very, very hard on the body. The bones, the humidity. Just leaving in the morning and then not going to work. … You’re always faced with the outdoors, and always faced with walking, walking. It’s not easy walking from downtown [ 15 ] .

My health was very poor. I was very prone to pneumonia. I was taken out of the shelter in the ambulance and it was later determined that I had actually contracted tuberculosis [ 22 ] .

At that time, I got Psoriasis, I knew that it was disgusting … . It looked scary. I am much too old. It is so difficult to find a job … nobody needed me … so I decided to stay and sleep here [ 24 ] .

Homelessness in later life was shown to often be linked to a multitude of health problems. Most studies described older homeless people as living with physical health problems including chronic diseases such as hypertension, diabetes, bone and joint diseases, respiratory illness, and skin diseases [ 14 , 21 , 22 ]..

Sub-theme 2.1.2: lack of emotional wellbeing

Findings from five studies contributed to this subtheme. Accordingly, homelessness was described as contributing to poor emotional health related to social exclusion and isolation amongst older adults. Further, homelessness was associated with cognitive impairment, stigma, shame, stress and anxiety, as well as depression amongst homeless older adults [ 15 , 21 , 24 , 25 ]. Homelessness was described as a humiliating and degrading experience, as evident in these quotes:

At my age, I don’t see life ahead of me anymore. You see, I don’t know, I don’t see the end of the tunnel, … … It’s as if I wanted to erase myself [ 15 ] .

All I could think about was suicide. How did I end up here? When I think a lot to myself, what the hell am I doing? [ 23 ] .

Feelings such as shame, demoralisation, and loss of dignity were described and these impacted on emotional health.

Opportunities to improve emotional wellbeing were rarely described, however one example stood out as an exception and this was related to volunteering:

One thing I didn’t expect was when I helped people with whatever issues they were having on their bicycle, I really enjoyed that. It gave me a chance to teach someone [ 25 ] .

Examples such as these were rare, with social exclusion and the lack of opportunity to contribute and connect with others more commonly described.

Sub-theme 2.1.3: lack of social relationships

Findings from four studies contributed to this subtheme. Social relationships were described as central to creating a life that had meaning and familial interactions. Disconnection from loved ones was associated with feelings of unhappiness [ 13 , 15 , 27 ], while companionship was shown to improve wellbeing [ 25 ]. Social relationships were shown to decline, leading to the experience of social exclusion and isolation.

I am a walking dying woman. I walk until I can’t walk anymore, and then I sit. The busses pass me by. We are untouchables and I do not think anybody’s going to do anything about it [ 25 ] .

At my age, I don’t see life ahead of me anymore. Because everywhere I go: “Ah! He’s homeless.” It is as if I wanted to erase myself. I think that it’s more “society,” as such, that rejects homeless people [ 15 ] .

I think that living homeless, you exclude yourself, and a lot of other people exclude you. I was on the other side before becoming homeless. So, you know, the perception that people have, it plays a big part. … So that together makes it so that, if you don’t have family either, let’s say, you don’t have … close friends or a strong social network. Well, you experience all that, you live with loneliness and isolation [ 15 ] .

Sub-theme 2.2: impaired coping strategies

Findings from four studies contributed to this subtheme. Older homeless adults described a range of factors as impacting their ability to cope. These included moving to shelters, challenges to adapt to their unique requirements, limited housing options, limited income supports, social exclusion, isolation, and a lack of coordination and access to community health and support services [ 13 , 15 , 23 , 25 ].

As the quote below shows, there were expressions about the fear of homelessness and how long it will last:

Struggling to get your basic needs met, scrounging, just trying to get by as best I can, and feeling desperation, humiliation, despair, a shocking feeling, full of fear, and turmoil. What’s tomorrow gonna bring? Why am I in this situation? How do I get out of it? [ 13 ]

Coping with the harsh realities of homelessness in later life was described as being increasingly challenging for most older adults because older homeless individuals experience mental health disorders and acute or chronic physical illnesses.

Sub-theme 2.3: realities of housing availability

Findings from three studies [ 13 , 15 , 23 ] described the challenges experienced in accessing housing services and fulfilling requirements for safe, secure, and affordable housing. This theme captured impacts of poor coordination and communication between homeless veterans and housing intervention providers in regard to information for service availability, gaining access to homeless shelters and a lack of training and education by some housing providers especially with regard to homelessness.

He … got this rule book and threw it at me. Find a place! [ 13 ]

You know, I’m 60, I’m not 20 anymore. So that’s what makes you tired, you get stressed. So, after that, they give you pills as a solution. I told the doctor, sorry I didn’t come here for pills, I came for housing [ 23 ] .

I submitted applications for low-income housing, I’ve been on the waiting list, seven years is a long time, especially at my age [ 23 ] .

I want a space where I can be well. I wasn’t well when I was young. I’ve never been well anywhere. I need a simple place … where I can have peace, and quiet … but not be all alone [ 15 ] .

Older homeless adults described a need to create stability and escape homelessness through the provision of services, and in particular, housing. Older adults described how oscillating in and out of shelters prevented senses of safety, stability, or autonomy.

Theme 3. Outcomes and resolutions

In four studies [ 13 , 15 , 21 , 24 ] homeless older adults described how the outcomes and resolutions of homelessness involved overcoming both complex challenges and habituations. This theme encompassed the finding of directions and strengths to improve difficult situations and overcome challenges that occurred at the intersection of homelessness and ageing.

Three subthemes were identified within this theme: building resilience, strength, and hope; seeking spiritual meaning; and exiting the cycle of homelessness.

Sub-theme 3.1: exiting the cycle of homelessness

Some older adults moved out of the phase of homelessness and described facilitators and barriers to this transition whilst other described choosing to stay homeless until the end of their lives.

Sub-theme 3.1.1: factors facilitating the exit

Two studies [ 13 , 15 ] contributed to this sub-theme, where older adults described means of overcoming challenges and establishing priorities in order to exit homelessness in later life. The results suggested that the creation of autonomy, flexibility, and privacy helped people feel belonging and often this meant living in a place where they could continue to drink and/or occasionally use drugs, have access to a health system to manage health problems; and have access to food and shelter facilitated exits.

They listen to you and they help you with . . . your transition, your program. You sit down and you work the program out with them;” “If you have a question, you can walk in anytime and ask them what’s going on [ 13 ] .

In the next couple years, I hope to find myself an apartment for the few good years I have left, before the big pains of “aging” come [ 15 ] .

Fulfilling financial support, housing and health care services was identified facilitate older adults exiting homelessness.

Sub-theme 3.2: remaining homeless

Some older adults experienced homelessness at a younger age and described continuing to be homeless in older age, where they oscillated between living in shelters and on the streets.

I am used to being in this way, moved from place to place … me alone, without father and mother since childhood … it become normal and I feel happier, than to stay with others [ 24 ] .

It’s just a continual cycle. I just got sucked down into it, you know. It’s hard to describe because when I found myself there, I was just like, wow. How did I get here? [ 21 ]

Participants described the chronic nature of homelessness as involving a challenge of disentangling themselves from the cycle of homelessness. A lack of tailored intervention programs to respond to homelessness in later life also prevented older adults from exiting homelessness.

Sub-theme 3.2.1: perceived barriers to exiting homelessness

In two studies [ 21 , 24 ], older adults described experiences of vulnerabilities and challenges to exiting homelessness. Shelters were described as constraining and not being able to adapt to the unique needs of older adults. Where limited housing options were seen as available, income supports were described as limited, with a lack of coordinated and, accessible community health and social support services, impacting on participants’ ability to ‘feel in place’.

My health pretty much stayed the same as when I was homeless. The conditions I have aren't gonna improve [ 22 ] .

It’s harder to keep a place, especially when you keep falling back in the same circle and you’re in the same crowd. I am finding out today, you keep falling back in the same circle, the same circle is not gonna change [ 21 ] .

One participant described the difficulty of obtaining employment as a barrier to exiting homelessness:

You know being 50 years old, it’s going to be really difficult to be able to reintegrate into the workforce [ 21 ] .

Housing facilities and transition to housing shelters were shown to present challenges for homeless older adults. A lack of privacy, autonomy, rigid rules, and challenging interpersonal relationships within housing and shelter programs were identified as leading older adults to feel homeless at home.

Sub-theme 3.3: building resilience and strength

This sub-theme captured the life lessons, resilience, strength, and hope of older homeless adults, described as having formed through experiences and skills developed whilst living on the streets. This theme also suggests how individuals cope with difficult symptoms related to social support and, addiction, relying on positive things learned while living with other homeless people on the streets. Some older adults chose to stay homeless accepting homelessness as their fate.

In the next couple years, I hope to find myself an apartment for the few good years I have left, before the big pains of “aging” come. I really want a normal life, get up in the morning, go to work, think about vacation. Hang out with other people … I don’t have a girlfriend but would like to start a life with someone else [ 15 ] .

What does ageing mean to you, getting older on the streets? A: Experience. Q: Ok. A: Wisdom. Q: Getting older on the streets, that’s how you see it, it’s the wisdom that you have gained. A: Yeah, that’s where I learned to be wise. Because there are several people who told me I am wise [ 15 ] .

I think because of karma … I accept it as punishment from bad deeds in my former life, but only in this life okay! Next life I am looking forward for a normal life, like others [ 24 ] .

Most studies [ 3 , 8 , 13 , 17 ] cited that wisdom, experience, and optimism were necessary in order to help older adults exit homelessness. Optimism instilled future hope and self-worth back into the self-esteem of homeless older adults.

Sub-theme 3.3.1: seeking spiritual meaning

In two studies [ 24 , 25 ], older adults described finding meaning in life through adopting and accepting religious faith with a belief to achieve higher self-actualisation.

I want to be closer to Dhamma (Buddhist teaching), I want to be a monk till I die [ 24 ] .

Meditate, just being by myself. Living the night, just being alone and listening to my music, that makes [my pain] feel better. I like jazz but I just listen to my music, just go away to myself. That makes me feel - I like being alone. I love being alone [ 25 ] .

When I feel [anger over my situation] I go to the water and I pray hard. I just start praising God until I can feel the spirit come over me to comfort me. I pray until He comes and allows his spirit to wrap his arm around me; I feel a lot better. A psychiatrist can’t tell me what’s wrong with me. For someone to try to help would mean a lot. I do not have nobody but to trust God. He’s my only psychiatrist [ 25 ] .

Homeless older adults recognised and confirmed that psychosocial and existential symptoms caused as much distress as physical symptoms triggering negative changes in personality, energy, and motivation. Some homeless older adults viewed their age as a source of strength, wisdom, and experience in learning to manage their symptoms, describing themselves as survivors who had overcome significant hardships. Higher levels of wellbeing were likely to be achieved when older people sought spiritual meaning through religion, socialising, reading, meditating, volunteering, and introspection practices.

This review synthesised evidence generated from qualitative studies to provide a glimpse into the experiences of homeless older adults. The review has shown that while drivers related to entry into homelessness were diverse, two distinct trajectories underpinned the experience of becoming homeless amongst older adults. Older people that faced a sudden series of losses that completely overturned their circumstances fell into the ‘rapid pathway’ to homelessness. Participants on a ‘gradual pathway’ were shown to become homeless due to a range of factors, for example - addiction problems, physical and mental health issues, relationship break-ups, foster care, poverty, unemployment, and greater housing instability [ 13 , 24 ]. Further to this, homeless older adults were shown to include a significant percentage of separated, divorced, or single individuals [ 28 ]. Likewise becoming single in later life was shown to be associated with homelessness amongst older people. Other studies found that ageing, its associated factors and a lack of stable housing were prominent reasons for homelessness [ 15 , 22 , 23 ].

Housing was perceived to offer a sense of security and a stable environment conducive for safe ageing. Further, housing was identified as offering protection from harsh weather and other dangers. Similar accounts relaying how the health of homeless older adults declined during episodes of homelessness was also reported [ 9 ]. Stable housing played an influencing role in physical health and general wellbeing. Although homeless older adults expressed satisfaction with life, they linked secure housing with healthy dietary habits, proper sleep patterns, enhanced self-care and reduced feelings of stress and anxiety [ 22 ]. In addition, this review found that most homeless older adults were more able to prioritise their health care needs when other necessities such as food and shelter were met. However, research has also suggested that living in scattered-site apartments can reinforce the process of social exclusion, and thus they are not appropriate for older adults living alone, with regard to their additional health and social needs [ 3 , 10 , 28 ].

Ageing intensified the adversities of homelessness experiences and presented a twofold risk where homelessness aggravated the challenges of old age and vice versa [ 15 ]. Old age and its associated conditions intensified older adults’ perceptions of homelessness later in life, including feelings of shame, anxiety, and worry. Studies by Cohen [ 9 ], Kwan, Lau and Cheung [ 29 ], and Molinari et al. [ 13 ], have unanimously shown older adults to perceive homelessness as a dehumanising experience. Homelessness was described as: struggling “to get your basic needs met,” “scrounging, just trying to get by as best I can,” and feeling “desperation,” “humiliation,” “despair,” “a shocking feeling,” “full of dread, turmoil,” “what will tomorrow bring? why am I in this predicament and how can I get over it?” [ 13 ]. For most participants, homelessness was not a preferred option.

The limitations of this review include the predominance of data collected in North America which may reduce the generalisability of the findings. Another drawback is that it presents only a cursory review of issues related to gender, race, and ethnicity. Finally, the qualitative data analysis applied by the majority of studies here is subjective, where outcomes could be affected by authors’ personal biases.

Despite these limitations, the review has conceptualised two divergent pathways into homelessness in later life, as well as the impacts of homelessness, drawing attention to a greater understanding of homelessness experienced by older adults.

The review sought to provide insight into the needs of homeless older adults. Awareness of the complexities faced by homeless older adults need to be acknowledged if policy and research are to support the population and improve access to resources and support. The review has highlighted areas for future research to expand knowledge and understanding of the unique needs and challenges of homeless older adults.

Synthesis of seven studies resulted in the identification of an overarching theme relating to the ‘journey of homelessness’ and three major themes, each with subthemes, to describe older adults’ experiences of homelessness. A broad range of diverse settings, cultures, and countries with a particular focus on homelessness in later life were included. The review has revealed homogeneity of experiences amongst homeless older adults, with the need for access to appropriate and affordable housing and adequate support systems.

The findings have identified pathways to homelessness require different prevention and support measures. People in the study who described a gradual pathway needed social support to address distress, which might have helped them avoid losing their homes. Those individuals with rapid pathways unanimously concluded that homelessness could have been avoided if independence and self-sufficiency were less regarded as a norm by society.

Availability of data and materials

The authors declare that all data generated or analysed during this study are included in this published article.

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Acknowledgements

We would like to acknowledge Lisa Webb, Librarian, Edith Cowan University Library for her support in the literature search and Dr. Michael Stein, HDR Communication Advisor, Edith Cowan University for editing.

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PO, LW, CV, and ATB substantially contributed to the conception and design of the article. All authors critically appraised the searched literature, discussed each item in the appraisal instrument for each study included in the review and interpreting the relevant findings. The primary author PO drafted the article and LW, CV and ATB revised it critically for important intellectual content. The author(s) read and approved the final manuscript.

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Om, P., Whitehead, L., Vafeas, C. et al. A qualitative systematic review on the experiences of homelessness among older adults. BMC Geriatr 22 , 363 (2022). https://doi.org/10.1186/s12877-022-02978-9

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Homelessness during COVID-19: challenges, responses, and lessons learned from homeless service providers in Tippecanoe County, Indiana

Natalia m. rodriguez.

1 Department of Public Health, College of Health and Human Sciences, Purdue University, West Lafayette, Indiana USA

2 Weldon School of Biomedical Engineering, College of Engineering, Purdue University, West Lafayette, Indiana USA

Alexa M. Lahey

3 Department of Pharmacy Practice, College of Pharmacy, Purdue University, West Lafayette, Indiana USA

Justin J. MacNeill

Rebecca g. martinez.

4 Department of Anthropology, College of Liberal Arts, Purdue University, West Lafayette, Indiana USA

Nina E. Teo

Yumary ruiz, associated data.

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

The COVID-19 pandemic laid bare some of the United States’ most devastating health and social inequities faced by people experiencing homelessness. Homeless populations experience disproportionate rates of underlying health conditions, stigma and marginalization that often disenfranchise them from health and social services, and living conditions that potentiate the risk of COVID-19 transmission and adverse outcomes.

Guided by the socio-ecological model, this community-based participatory research study examined the impacts of the COVID-19 public health crisis on people experiencing homelessness in Tippecanoe County, Indiana, and the ways in which homeless service providers prepared for, experienced, and responded to the pandemic. Eighteen (18) semi-structured interviews were conducted with representatives of 15 community-based organizations, including shelters and other homeless service providers.

Qualitative content analysis revealed myriad challenges at the individual and interpersonal levels faced by people experiencing homelessness as a result of the pandemic, and multilevel responses for COVID-19 impact mitigation in this community. Many of the emergency measures put in place by homeless service providers in Tippecanoe County, Indiana created opportunities for innovative solutions to longstanding challenges faced by homeless populations that are informing better service delivery moving forward, even beyond the COVID-19 pandemic.

Conclusions

Community-based organizations, including homeless shelters, are uniquely qualified to inform pandemic response and disaster risk mitigation in order to respond appropriately to the specific needs of people experiencing homelessness. The lessons learned and shared by homeless service providers on the frontline during the COVID-19 pandemic have important implications to improve future disaster response for homeless and other vulnerable populations.

The COVID-19 pandemic has exposed and amplified the rampant health disparities and weaknesses of our public health system that inequitably impact marginalized and underserved populations in the United States (US), including people experiencing homelessness (PEH). Herein, we refer to homelessness not as a defining trait of an individual, but instead as a state that is experienced, one that is transitory and amenable to intervention. PEH face disproportionate rates of underlying health conditions and substance use disorders, stigma, and marginalization that often disenfranchise them from health and social services, and social living conditions that lead to a heightened risk of infection and adverse outcomes of COVID-19 [ 1 – 3 ]. Pandemic-related lockdown measures caused a sudden disruption in access to public spaces, restrooms, and other resources that PEH typically rely on to meet basic needs. Additionally, because of the economic consequences of the pandemic, growing rates of domestic violence [ 4 ], and the release of prisoners without social support or housing options [ 5 ], many communities throughout the US experienced increases in homelessness and demand for shelter beds. Homeless shelters throughout the country were reportedly overburdened and under-resourced to respond to this crisis, with drastic shortages of supplies and volunteers [ 6 – 8 ]. Furthermore, standard COVID-19 prevention guidelines, such as practicing social distancing, maintaining regular personal hygiene, and mask wearing can be difficult in congregate settings, placing homeless shelter guests, staff, and everyone they interact with at increased risk of infection.

Recognizing that PEH are particularly susceptible to COVID-19 infection and pose increased risk for community transmission, effective pandemic response efforts must prioritize these marginalized groups. Previous studies following natural disasters have found that PEH were often overlooked in disaster planning and response [ 9 , 10 ]. Federal policy and funding were directed almost entirely towards homelessness prevention efforts and assistance for newly displaced individuals and families, leaving critical gaps in resources, communication and outreach programs for those who were already homeless prior to the disaster [ 9 , 10 ]. While numerous resources rapidly become available for disaster response, homeless service providers generally lack a formal role in disaster planning and often lack established mechanisms to access relief resources or to assist PEH in doing so. Similarly during the COVID-19 pandemic, homeless service providers have been minimally involved in federal disaster planning, and coordination and reimbursement processes between government entities on disaster response is lacking [ 11 , 12 ]. Four months after Congress passed the Coronavirus Aid, Relief, and Economic Security (CARES) Act, less than 30% of the $4 billion allocated to support homeless populations had actually reached those in need [ 13 ]. Furthermore, despite CDC recommendations for frequent COVID screening in shelters, most continuums of care across the US reported little or no testing capacity [ 14 ], and insufficient data to know who was getting sick and where [ 15 ].

At any given time, there are nearly 600,000 people around the country experiencing homelessness who sleep in temporary shelters or on the street [ 16 ]. The US Interagency Council on Homelessness estimated approximately 15,000 COVID-19 cases and 250 deaths among PEH in 2020 [ 17 ], but these are rough and incomplete estimates, and the full impact is largely unknown due to a lack of a centralized effort to track COVID-19 infections and deaths among the nation’s homeless population [ 15 ]. In Indiana, a point-in-time count in 2019 estimated nearly 5500 individuals experiencing homelessness in the state, although that number is reasonably underestimated because of the difficulties in the counting process [ 16 ]. To date, no statewide effort has been undertaken to track COVID-19 cases or deaths in Indiana’s homeless population specifically.

In Tippecanoe County, Indiana, a recent Community Health Needs Assessment Report cited homelessness and housing instability as community issues of highest concerns, with estimates of up to 900 homeless individuals in the county over a year, including an average of 180 homeless children reported by the Tippecanoe and Lafayette School Corporations [ 18 ]. In response, a growing number of community-based organizations and local programs have aimed at addressing these concerns, including a non-profit homeless engagement organization that serves as an initial point of entry for PEH in Tippecanoe County, which provides shelter, housing services and case management, three meals per day, and access to showers, phones, and toiletries to PEH, which they refer to as their “guests”. In partnership with this organization, an ongoing community-based participatory research (CBPR) [ 19 ] study is examining the challenges and impacts of the COVID-19 pandemic on PEH and homeless service providers in Tippecanoe County, Indiana. Guided by the socioecological model (SEM) [ 20 ], the findings presented herein document the challenges faced by PEH from the perspective of homeless service providers and the ways in which these providers prepared for, experienced, and responded to the pandemic for this vulnerable population.

In congruence with the essence of CBPR, our community partner, a non-profit homeless engagement organization that serves as an initial point of entry for PEH in Tippecanoe County, contributed to all aspects of the study from formulation of research questions to identification of potential participants to the analysis and dissemination of findings. Our community partners were assumed most capable of providing the best accounting of influential homelessness service providers. As such, from July 2020 through January 2021 participants were recruited using quasi-snowball sampling [ 21 ], which involved initial contact with an existing community partner organization who provided a partial and initial list of relevant and established community-based organizations (CBOs) engaged with people experiencing homelessness in Tippecanoe county. As interviews were conducted, interviewees recommended additional local organizations and individuals of various levels of authority, whom were contacted and interviewed by the research team.

Academic and grey literature was reviewed to gain insights into the COVID-19 response among communities working with PEH and to identify knowledge gaps that could be addressed by the local CBO interviews. Informed by the SEM and the literature review, an initial interview guide was developed to understand multilevel challenges and responses to supporting PEH during the COVID-19 pandemic, from the perspective of local homeless service providers. Our community partner organization reviewed the interview guide and suggested additional questions and probes. The final interview guide included questions such as: “In your view, how did the day-to-day lives of PEH change as a result of the pandemic?”; “Did COVID-19 change the services or resources your organization typically provides?”; “Did your daily interactions and communication with PEH change as a result of the COVID-19 pandemic? If so, how?”; “Do you feel your organization was prepared to handle the pandemic?”; “Did COVID-related policy changes affect your organization? If so, how?”

In total, 18 semi-structured interviews were conducted with representatives of 15 organizations, including local government officials and a diverse array of CBOs within Tippecanoe County, Indiana. This included organizations that participated in the extended housing of the chronically homeless, emergency shelters for acute care, specialized homelessness services to those suffering from domestic violence, rapid re-housing and housing support programs, rental and foreclosure assistance programs, food banks, soup kitchens, mental healthcare, and other social service providers.

Interviews were performed virtually by trained research assistants who were involved in formulating the research questions and in the grounded theory and associated constant comparative analysis; moreover, each interviewer had no prior association with any interviewed subject that could have biased the line of questioning or content of any given interview. Interviews were recorded and transcribed using Otter.ai, a digital scribing platform. Transcribed interviews were reviewed and edited for accuracy. Each interview was coded by multiple coders and subsequently discussed as a group to ensure intercoder consistency [ 22 ]. Utilizing a combinatorial approach of deductive and inductive coding, data was thematically analyzed [ 23 ] using NVivo, a qualitative coding software [ 24 ]. Guided by the SEM, themes were organized across individual-, interpersonal-, organizational-, community-, and public policy-levels. (Fig.  1 ).

Socio-ecological model framework for multilevel challenges and responses to supporting PEH during the COVID-19 pandemic

As part of the CBPR approach, preliminary findings that highlighted the strengths, opportunities, and challenges of the community-based responses to COVID-19 were shared with the primary community-based partner, as well as a local network of homeless service provider organizations to incorporate their feedback and insights and ensure community involvement in all aspects of the research and analysis. This study was approved by Purdue University’s Institutional Review Board (protocol IRB-2020-1005).

Individual-level challenges

Organizational staff provided powerful examples of the concerns they had for homeless clients. They discussed their clients’ poor health and the pre-existing conditions that magnified their risk for COVID-19: “ Especially with this population, like not only do they not have homes, they all have horrible health … while [other organizations] have a kind of targeted criteria for those that are like at high risk for COVID; well that’s almost everybody in my day room. ” Staff also worried about the impact of prolonged shutdown periods and disruption to routines on clients’ mental health, “ in general, the population was a lot more stressed... services weren’t necessarily available to them. The isolation is a huge problem [and] all their regular places to hang out were kind of shut down and dispersed. The isolation really had a negative impact on their mental health.” Staff also expressed concerns related to reductions in access to substance addiction treatment services and counseling and how these circumstances negatively impact their clients’ mental health, substance use, and even relapse. “We work closely with an organization that provides mental health care. But during this whole pandemic … they weren’t coming to the building … mental health care is a critical piece of programming, quite frankly, and to have that go away, coupled with all the changes and challenges, it was awful … we saw a lot of behaviors that were a result of [clients] not being able to access that care … the substance use is out of control … ”.

In regards to COVID-safety measures, staff members described how difficult it was for clients’ to engage in basic hygiene practices like handwashing due to lack of access to showers and washrooms, “those living unsheltered really needed access to like hygiene stations because a lot of … businesses and places that [homeless] people normally go … were not available during the pandemic.” Closures also resulted in the loss of other critical resources such as clothing, meals, and food donations and as a result, “ … they just ran out of places to go. There wasn’t many places for people to be and feel safe, be and feel comfortable …” Living in congregate shelter settings impeded adoption of COVID-safety practices, “… they’re all together, they all share cigarettes, they all share food, they’re all touching each other.” Also, general disbelief and low COVID risk perception heightened individual’s risk, “… they just don’t pay any attention to it. They don’t think it’s real. We even had the health department come down here. You know and talk to them, but I don’t know, they just don’t think that it’s going to affect them.” Staff explained that their clients’ fears of being confined, alone, or separated from their social group led many to reject quarantine practices, “ the period of time where we were locked down and they really couldn’t go anywhere, you know, they weren’t supposed to be going to the convenience store or anything like that, they did not like that. They don’t like being confined …” This was further illustrated by another staff member who shared, “[some] … could have used the shelter [but] chose not to because they didn’t like the idea of quarantine to begin with and then to do it in a hotel, they didn’t really like that idea either because you’d have to be separated from friends and family for two weeks. And so they just figured out a way to quarantine some other way. ”

Even when restricted or adapted services became available, clients continued to face challenges. For instance, a major early development was the provision of virtual services; unfortunately, barriers to accessing these modified services persisted for clients’ with poor telephone or computer access, “o nce COVID hit, it was very interesting to see our partners pivot, because they all shifted to work from home and they would do telehealth … Well our people don’t have telephones, they’re not calling and scheduling appointments. It was really awful.” Moreover, when efforts were made to provide clients phones, these same clients lacked access to settings that would allow them to charge or store the devices, “ we connected people to those resources so we help people you know get an email address, if they have the opportunity to have a computer, we help people get the free phones, so that people do have access to a phone to call people. But our people don’t have a place to charge them, and they don’t have a computer … the pandemic added a whole new set of challenges.” Staff also recognized that clients’ limited access to information created challenges, “ they’re not connected to the news and social media, the way we are. They don’t have Facebook on their phone, they don’t have Twitter, they’re not looking at all of that.” They went on to discuss the role organizations failed to play in providing clients information, “ we don’t have TVs or anything here so if they don’t have phones where they can get online and see what’s going on, they really don’t know what’s going on in the outside world and they really don’t care.”

Organizational-level challenges and responses

Several organizations had policies and procedures in place for natural disasters like tornadoes and earthquakes, armed intruders, bed bugs and lice, and flu outbreaks. However, most felt there was no precedent for this kind of pandemic response in homeless populations. “ With COVID there was no rulebook whatsoever … We had no idea what we were getting into, no one did .” Nevertheless, most participants felt their organizations were able to quickly respond, leaning on local partners and state guidance to adapt procedures and implement additional precautions in order to stay open and continue to serve the homeless community. “ I feel like no one was ready for this, right? But we were not completely flat footed. There was a pretty nimble response to the reality, in my opinion, and we didn’t miss a beat, never closed the shelter for a single moment. Everything continued .”

Staff described initial confusion and uncertainty around how best to implement COVID-19 safety measures in crowded homeless shelters. Some organizations implemented an initial shutdown where they did not let anyone new into the shelter for a period of time. Other organizations suspended services, which created challenges to reaching and staying connected to clients. “Well, for quite a long period of time, we were not allowed to [bring] people in our office … So we could get on the phone with them and they would be out at the front desk, but then there’s the whole privacy thing … If they’re not comfortable saying over the phone what they need to talk about, then, it was really hard to do anything. So, it did affect their services for a period of time.” Some organizational staff expressed concerns that these service changes would lead to negative outcomes such as health complications for clients who require on-going care. “ Basically, if we can’t see them, and they don’t have a phone, and we don’t know how to get a hold of them by phone. We couldn’t do med management with them. We couldn’t do therapy with them and we couldn’t do much for case management, so we didn’t. We didn’t do anything for some clients. I mean it put everything on halt for some people that had no other resources or couldn’t get here on their own.”

New safety procedures and reminders were implemented to promote physical distancing in the shelter and during meals. “One thing that we have continually had to emphasize is the number of people in our community space … social distancing in a really large day room, that’s a challenge … we had to frequently do reminders … constantly having to tell people to spread out, you need to be six feet apart.. we do our best to keep socially distant during meal times … we’ve staggered our seating and our tables and things like that. And we’ve also modified the way that we serve dinner, most things are now self-serve so there’s limited contact between volunteers and staff and the guests.” Moreover, organizational staff began to offer COVID-related communications including information related to new procedures and expectations for homeless clients through face-to-face group announcements in the shelter. “We try and make announcements out in our day room where everybody is … had a little town hall meeting with folks … you talk this through and try to explain what the situation is and why we have these expectations.” These modifications also necessitated that COVID practices be enforced which the staff found challenging. “We have people trying to sneak past the front desk and get their temperature taken and stuff like that.”

Staff discussed difficulties particularly around enforcing physical distancing and masks among homeless clients. “Trying to keep people apart here in our facility is pretty horrible, you know, keeping the mask on and keeping people six feet apart, that’s been a huge problem for us.” As a result, some organizations were forced to reduce or discontinue essential services such as meal services. “ It wasn’t [possible to have evening meal]. We weren’t able to have everybody six feet apart the whole time and you’re taking off your mask to eat and there’s 20 people in a room we’re not supposed to have a gathering at all. So, some of those things we just weren’t able to do.”

In response, some organizations implemented very strict mask policies, while others concluded that it would be too difficult to enforce and thus focused efforts primarily around requiring staff to wear masks. “We can’t discipline everyone … that’s not about who we are and what we do. So, our approach in general, pandemic or no, is to give people the opportunity to make a better choice tomorrow. So that’s how we roll. We take as many steps as we can … staff wearing masks and six feet apart and all of those kinds of things but if it comes down to people being here and not wearing a mask or people being on the street and not wearing a mask, we want them to be here where they’re receiving services.”

Limited options for screening and testing were discussed as key challenges to identifying cases and preventing further transmission. “Some of the challenges that we have encountered are getting our people tested. Right now, the only avenue that we have is to call an ambulance and have them tested through the emergency room. And then when they return, we have to isolate them until their test comes back … But a lot of our people have been sitting in the same room together … they’ve already been exposed to each other. Getting test results back has been a huge issue.” In response, some shelters implemented temperature checks and symptom screening at the door. They also relied on the health department and local hospitals to provide testing for homeless clients. “When people come in, their temperatures are taken … and if anyone has a fever that’s like over 100, we contact the health department to see if they need to go be tested for COVID [at a hospital] … And if they are positive, they will be taken to a hotel by the health department for however long their isolation period is, and then they come back.”

The crisis led to operational challenges due to declines in staff levels and available volunteers. “ Some organizations rely really heavily on, mostly volunteers, and a lot of volunteers tend to be maybe like older folks or retired folks who are then in high-risk categories. And so they lost pretty much their entire volunteer base.” Likewise, challenges emerged related to lack of organizational staff policies that “ … certainly affected our staff, because I didn’t we, we put into place, like a COVID sick time policy, so if you or a family member or your children are in school or if you have some compromised immune system, I expected you to work from home. You know what I mean like that’s the deal. Now did every one of my employees work eight hours a day from home? No, no. So that certainly was unfortunate.” In response, organizations implemented staffing reorganization plans to enhance staff safety and to offset the sudden lack of volunteers. “We also then split our staff team up into, initially it was three different groups, so we would do one week [at home] and three in the shelter. And that was including staff that don’t usually work in our shelter … because we couldn’t have volunteers anymore.”

Besides the strained staffing levels, many organizations faced serious financial challenges. At the start of the pandemic organizations lost donors, “ anytime there’s some sort of massive upheaval in the social fabric of the U.S., it’s always the nonprofits … that have the most sustained reaction to that because more and more people will continue to come into services. [However], fewer and fewer people will be in a position to donate.” This was further illustrated, “ our fundraiser in August is canceled. Our fundraiser in April didn’t do really well”. Organizations also experienced unexpected expenses associated with having to purchase COVID protection equipment and supplies for staff and clients. “ We had to get all the PPE, I mean I just bought 1000 masks yesterday, you know none of these things were ever in our budget before to buy plexiglass for 1000 bucks and I’ve got meals now being delivered from a hospital. We’re having meals catered from them, that’s another $4,000 expense a month. These financial strains were made worse as organizations attempted to adapt their services for a virtual platform, “to use a platform like [zoom] we [need] to get new computers new webcams new platforms.”

Amid this backdrop of operational challenges, homeless shelters also experienced pressures related to increasing demands and needs for beds. “You know earlier in COVID before that unemployment benefit kicked in, we were seeing more households than before. And in early COVID they were higher than they are now because people couldn’t go out and buy their own groceries. So, we are concerned that not receiving as much in income we’ll see more demand.” An organizational strategy to address this increased demand was to pay for hotel rooms for high-risk clients and those soon to be housed. “Our most at-risk population plus those that were on a path to housing, we just went ahead and paid for them to get out of here to just deconcentrate the day center … we put them into a hotel until they were able to leave the hotel and go into housing.”

Community-level challenges and responses

Most participants expressed that the community response to organizational- and individual-level challenges was overwhelmingly positive. Many discussed the tremendous support received from community members, faith-based organizations, local businesses, and donors. “We had a tremendous outpouring of support from local businesses and the United Way, and individual donors.” “We have a very big community of people that anytime we need anything, we just put the word out on Facebook, and we have multiple people that will bring things in, donate money, do whatever we need...”

Participants also described the support and guidance they received from established interagency relationships and collaboration. “In our community, we work well together, that doesn’t happen everywhere … we’re pretty lucky … the relationships that helped us early on were with each other …” “The Homeless Prevention Intervention Network, which is all of the agencies that have some touch with this population … we’re co-providing services, we share the same clients … there’s a monthly meeting and there’s pretty strong communication. We had been meeting monthly for years. So when all this was kind of coming down the pike, you know, we were already meeting, we were already talking.” One such coordinated effort among the agencies was the creation of a ‘Housing Instability Hotline’ to connect people economically impacted by the pandemic to rental assistance and other resources. “The hotline did not have any unique resources to … we have like 15 navigators that were trained on how to answer those calls, all of them are volunteers, all of them came from other agencies so all the agencies came together to create this pool of people to answer the calls … [this was] just a real important strategy I think at the beginning.” The existing interagency collaborations also enabled rapid coordination of efforts during outbreak-related shelter shutdowns. “When the shutdown happens, it prevents any new people from coming in. The community put together what’s called an Annex, a safe space [one organization’s empty gym], which provides shelter for people to come in at different periods throughout the day … they come in and they get snacks, they can take a shower, they’ve got cots that they can lay and rest on … The Annex is a cooperation between a lot of different agencies in Lafayette.” Participants also described strong partnerships with the local health department which provided a constant source of guidance. “We have a very good partnership with the Tippecanoe County Health Department and so they were here, often, and were informative … . we have been in constant contact.”

Policy-level challenges and responses

Participants expressed frustration over a lack of federal guidance, especially in the early days of the pandemic. “One of the frustrating things about it, in the beginning there was no clear guideline. So constantly watching our local government web pages, trying to reach out to those resources … using the information [from] CDC, different webinars and seminars, a lot of my time was devoted to researching and finding things on my own and kind of being in the know and joining group chats and countless zoom meetings to find out the latest information, because in the beginning, there was no clear protocol, and even now, things are changing daily.” Additionally, participants felt that several aspects of federal and state guidance, such as ‘stay at home orders’, was not appropriately aligned with the context and realities faced by homeless populations. “ It’s hard to enforce that with people living outside when they didn’t even have access to places to wash their hands, or use the restroom … those are really hard things, I think, too, to socialize and adhere to when you’re not living housed and you don’t have access to the same resources that people in housing do .” Moreover, many felt that most of the community-based organizations’ funding for pandemic response was from local sources and that there was an overall lack of federal response funding for the local homeless population. “It’s all local, so these are local donors like private individuals and companies. We have not received any federal money yet …”.

Where federal response and guidance were lacking, many participants felt that the state response stepped in to fill those gaps. “We had a lot of support from our local health department, but also at a state level, like in the early days of COVID advice from some of our state base and state housing organizations.” “The governor putting a hold on evictions and foreclosures was a good thing … we needed to take a minute to figure out, you know, what’s going on here. And I’ve been glad about that, that that happened.” The state of Indiana also coordinated regional safe recovery sites, where homeless individuals awaiting COVID-19 test results or needing to quarantine could stay, and encouraged inter-region communication, which many participants appreciated. “Inter-region communication has increased dramatically. We rarely talk to other regions … But we have weekly calls on the safe recovery site which includes all the regions … about what they’re doing in terms of homelessness, which has been really helpful … just hearing what those folks are doing and describing what they’re going through has been really helpful.”

Lessons learned and silver linings

In the midst of overwhelming challenges of the COVID-19 public health crisis, participants also shared important lessons learned in the process of quickly adapting their service delivery. In fact, many of the emergency measures put in place by homeless service providers created opportunities for innovative solutions to longstanding challenges faced by homeless populations that can inform better service delivery moving forward. Table  1 outlines some of the key lessons that community-based homeless service providers felt were important to implement for improved pandemic and post-pandemic response for people experiencing homelessness.

Key Lessons for Pandemic Response in Homeless Populations

This study examined the impacts of the COVID-19 pandemic on people experiencing homelessness in Tippecanoe County, Indiana and the experiences, challenges, and responses of homeless service providers. The socio-ecological model guided the analysis of multilevel challenges and responses for COVID-19 risk and impact mitigation for this homeless population.

Homeless service providers identified challenges at the individual level including the disproportionate risks and vulnerability of this population due to pre-existing physical and mental health issues, substance use prevalence, limited access to basic needs, healthcare services, and education. While many of these are social determinants of health indicative of structural issues and inequities, they were presented as individual-level challenges by our participants because they are experienced most directly by PEH. These identified challenges echo existing literature on homelessness and health [ 1 , 2 , 25 ]. The disruption of in-person services for mental healthcare and addiction recovery amplified many of these issues for this population. Providers shared that PEH have minimal access to technology or reliable communication channels that led to a lack of information and understanding of the pandemic. As a result, disbelief and low risk perception among homeless individuals led to an overall reluctance to comply with COVID-19 safety measures, as reported by shelter and other organizational staff. Moreover, provider perspectives offered insights into the need to understand how strategies and policies might further marginalize or traumatize this population. For instance, quarantining practices were rejected by clients because of confinement fears and concerns related to being separated from their social group not solely due to lack of compliance.

In alignment with numerous reports around the US [ 16 , 26 ], homeless shelters and other organizations reported increased demand for homeless services due to the pandemic, and numerous operational challenges including loss of volunteers and staffing issues, additional unbudgeted expenses for PPE, and difficulty deconcentrating spaces or enforcing masks and social distancing. Community-based homeless service organizations described frustrations around lack of federal guidance and challenges navigating emergency relief resources and funding. Guidelines around reduced shelter capacity and frequent testing were largely infeasible for many organizations that lacked additional resources or mechanisms for shelter diversion or rapid testing. Additionally, federal guidance lacked adequate regard for this population’s vulnerability, context, and ability to adhere to recommended COVID safety measures.

These challenges were not unique to this community or to this disaster, and our findings provide further evidence of an overall neglect of homeless populations in disaster preparedness and response [ 27 ]. Whereas disaster response has often focused on homelessness prevention or on providing housing and assistance for those displaced during the event, it has often overlooked individuals and families who were already homeless prior to the disaster [ 27 ]. The experiences shared by Tippecanoe County homeless service providers further support these reports.

Despite numerous reported challenges, participants also shared the myriad ways this community came together to respond to this unprecedented public health crisis for a vulnerable homeless population. Organizations leaned heavily on each other to share experiences and best practices. Interagency collaborations enabled rapid implementation of coordinated response efforts for community assistance, resource navigation, and continued provision of basic services during periods of shelter shutdowns. Participants stressed the importance of these strong multisectoral partnerships as being key to effective pandemic response for this vulnerable population because the challenges spanned issues related to housing, health, law enforcement, among other sectors.

Unlike major homeless shelter outbreaks reported elsewhere [ 2 , 3 , 7 , 28 ], as of February 2021, the total number of confirmed positive COVID-19 cases among people experiencing homelessness in Tippecanoe County was estimated to be less than 30, and no COVID-related deaths were reported among homeless individuals in the county. Overall, homeless service providers were able to meet the basic needs of homeless individuals while avoiding major outbreaks or total shutdowns. The lessons they learned in the process are invaluable to informing future pandemic response for homeless populations. Furthermore, many ways in which they adapted their practices could improve service delivery for homeless populations long after the COVID-19 pandemic.

While the unique perspectives of the service providers in this study offer key lessons for pandemic response in homeless populations, a limitation of this present study is that it does not include the perspective of people experiencing homelessness. Future work will focus on homeless community member narratives around their individual experiences during COVID-19, including their awareness and perceptions of the disease, risk factors, and prevention measures, their perspective on local response efforts, what they believe their own needs are, and how they believe those needs should be met.

The particular vulnerability of PEH and consequently the increased risk for PEH to contribute to community transmission of COVID-19 should have prioritized these populations in pandemic response and relief efforts. This has not been the case in most communities throughout the U.S., and one reason for the exclusion of these groups in general health promotion programs has been a common inability to engage these ‘hard-to-reach’ populations [ 9 , 29 ]. Robust evidence regarding the ability to engage with homeless communities is essential to inform policy and practice to improve public health outcomes and to inform targeted pandemic response efforts in the future. To effectively reach these populations, initiatives should be based on the voices of the affected and the guidance and input from community-based organizations and leaders who have knowledge of the needs and available resources within vulnerable communities.

Community-based organizations, including homeless shelters, are uniquely qualified to inform, and should be included in planning efforts for, pandemic response. Homelessness is a result of varying circumstances for a wide range of people, thus there is no one-size-fits all approach and pandemic response and impact mitigation strategies must be tailored to specific local contexts [ 30 ]. Disaster response in general must be more inclusive and recognize the unique circumstances of PEH within the context of public health disasters in order to respond appropriately to their needs. The lessons learned and shared by CBOs on the frontline during the COVID-19 pandemic have important implications to improve future disaster response for homeless and other vulnerable populations.

Acknowledgements

The authors are grateful to homeless service and other community-based organizations in Tippecanoe County, Indiana who gave so generously of their time and whose insights informed all aspects of this work.

Abbreviations

Authors’ contributions.

NMR conceived and designed the study, secured funding, and contributed to data collection, analysis, and writing of the manuscript. AML contributed to study design, data collection, analysis, and writing of the manuscript. JJM contributed to study design, data collection, analysis, and writing of the manuscript. RGM led project management and data analysis, and contributed to writing of the manuscript. NET contributed to study design, data collection, analysis, and writing of the manuscript. YR contributed to study design, data analysis, and writing of the manuscript. The author(s) read and approved the final manuscript.

This work was supported by the Purdue University College of Health and Human Sciences COVID Rapid Response grant program and by the Indiana Clinical and Translational Sciences Institute, funded in part by grant # UL1TR002529 from the National Institutes of Health, National Center for Advancing Translational Sciences.

Availability of data and materials

Declarations.

This study was approved by Purdue University’s Institutional Review Board (protocol IRB-2020-1005). Informed consent was obtained verbally by all participants prior to commencing research activities as approved by Purdue University’s Institutional Review Board. All methods were performed in accordance with the Declaration of Helsinki on ethical principles for research involving human subjects.

Not applicable.

As of January 2021, NMR is a member of the board of directors of a non-profit homeless service organization in Tippecanoe County. AML, JJM, RGM, NET, and YR declare no competing interests.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

The psychological impact of childhood homelessness—a literature review

• Review Article
• Published: 01 June 2020
• Volume 190 , pages 411–417, ( 2021 )

Cite this article

• Saskia D’Sa   ORCID: orcid.org/0000-0003-3016-9299 1 , 2 ,
• Deirdre Foley 1 , 2 ,
• Jessica Hannon 1 , 2 ,
• Sabina Strashun 3 ,
• Anne-Marie Murphy 1 , 2 &
• Clodagh O’Gorman 1 , 2 , 3  

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In August 2019, 3848 children in Ireland were faced with emergency homelessness [ 1 ]. In recent years, lack of affordable housing, unemployment and shortage of rental properties have been the primary driving factors for the potentially devastating impact of familial homelessness in our society [ 1 ]. Our aim was to evaluate current knowledge on the psychological impact of homelessness in children. Using the PRISMA model, we performed a review of the currently available literature on the psychological impact of homelessness on children. This concept was explored under two different categories—‘transgenerational’ and ‘new-onset homelessness’. Hidden homelessness was also explored. Our literature review revealed several psychological morbidities which were unique to children. This includes developmental and learning delays, behavioural difficulties and increased levels of anxiety and depression [ 66 , 77 , 40 , 81 , 42 ]. This has been demonstrated by poorer performance in school testing and increased levels of aggression. Anxiety in children within this cohort has been shown to peak at time of dispersion from their stable home environment [ 67 ]. Our study highlights violence, aggression and poor academic learning outcomes to be just some of the key findings in our review of homelessness in childhood, worldwide. Unfortunately, there has been minimum research to date on paediatric homelessness within the context of the Irish population. We anticipate this review to be the first chapter in a multipart series investigation to evaluate the psychological morbidity of paediatric homelessness within the Irish Society.

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D’Sa, S., Foley, D., Hannon, J. et al. The psychological impact of childhood homelessness—a literature review. Ir J Med Sci 190 , 411–417 (2021). https://doi.org/10.1007/s11845-020-02256-w

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A Literature Review of Homelessness In The United States

Homelessness in the United States 

The homelessness crisis is a highly prevalent issue that the entirety of our country is facing. For reference, in an article written by Emo Zhao from the International Journal of Sustainable Development & World Ecology, she expresses that in the US between the years of “2007 and 2019, there were over half a million homeless people per night living on the streets” (Zhao). In a research article written by Deborah Finfgeld-Connett it was indicated that per year roughly “3.5 million Americans experience homelessness” (Connett). Across the board, rhetoric expresses that the homelessness crisis is multifaceted in nature, as a number of different factors have caused the problem to occur. In tandem with the catalyzation of the problem, varying approaches have been taken to address homelessness. In order to research the topic of homelessness further, this literature review explores the common attributes that play a role within homelessness. This review will focus on where homelessness stems from: unaffordable housing, the mental health crisis, the foster care system, as well the notion of unstable home environments. 

Unaffordable Housing

Across the United States, the cost of living is not equitable given the wages that people are paid; the surge in housing prices has pushed not only individuals but families into homelessness. In turn, the lack of affordable housing has caused those who are already homeless to have an increasingly difficult time finding and sustaining housing (Lind). In an article written by Diana Lind from the Architectural Record, she explains that the lack of affordable housing has pushed the inequality gap in our society to an increasingly far extent (Lind). A research paper in the Journal of Social Distress and Homelessness written by Diane Joy Irish & Stephen W. Stoeffler supports this claim by arguing that the inequality gap can be evidenced through the “19 million families” who are “cost burdened” in the US as a result of spending “50% or more of their income” on their place of residence. Irish and Stephen go on to dictate that, in spending half of their earnings on housing, families are having a challenging time affording other necessities leaving them financially insecure. Emo Zhao explains that the cycle of stress pertaining to housing insecurity is very grueling. In fact, living in poor-quality environments has been evidenced to lower one’s overall well-being, both mentally and physically. Zhao goes on to write that the impacts on individuals’ health creates problems that last for an extended period of time, and given the number of homeless individuals this is a major concern for the state of our public health in the United States (Zhao). In the research paper written by Irish and Stoeffler from the Journal of Social Distress and Homelessness, they detail that states are failing to recognize that as the cost of housing continues to rise, the wages people are paid needs to rise as well. Minimum wage jobs not paying nearly enough to sustain the cost of living in states in the United States. Because of  a failure to recognize this gap, those who are homeless are left stuck, and those who are struggling to pay for living, are met with insecurity of what their future will look like.  As a result of the non-livable wages individuals and families experience housing insecurity (Irish and Stoefller). 

Mental Health Crisis

As a result of the level of instability and a lack of access to resources, the mental health crisis among the homeless population in the United States is and has been exacerbated. Thus, when a person is homeless they are more susceptible to becoming mentally ill. Debroah K. Padgett wrote an article in the BJPsych Bulletin that was later published by Cambridge University Press in which she demonstrated that when compared with those who had stable housing, homeless individuals have disproportionately suffered from mental health struggles such as depression, suicidal ideation, misuse of substances, and trauma. Padgett explained that the exposure to the “natural elements” is a grueling experience and can be linked back to a lack of mental wellness among the homeless population (Padgett). In the study mentioned previously, done by Ema Zhao with International Journal of Sustainable Development & World Ecology, the research that the study conducted aimed at assessing the “key factors pertaining to the persistence of homelessness”. The study concluded that mental illness can be worsened and or onset when in the presence of homelessness. Zhao’s findings also added the notion of homelessness being difficult to “escape” when a person is struggling with mental illnesses (Zhao). These sources reckon that the mental health crisis disproportionately impacts the homeless community as a result of their living conditions.

Foster Care System and Growing Up in Unstable Home Environments

The foster care system and growing up in unstable home environments are both precursors for homelessness within the United States. Within the foster care system, there is a lack of resources available for young people when they “age out” of the system. With a lack of resources, youth are not given the level of support needed to successfully engage with society independently. Not only is homelessness impacting teens aging out of foster care but this problem has destructive effects on a larger population of young people. Those who have grown up in unstable home environments are at a higher risk of being homeless as well. The Gale Opposing Viewpoints Online Collection wrote that, “4.2 million US adolescents, teens, and young adults experience at least one period of homelessness each year” (Gale). They go on to write that, young people in foster care, are provided with care up until they are an adult however, once they reach a legal age they are often left to fend for themselves. An article written by Shah MF, Liu Q, Mark Eddy J, Barkan S, Marshall D, Mancuso D, Lucenko B, Huber Ain, the American Journal of Community Psychology  dictates that there between “11% and 37% of youth aging out experience homelessness one or more times in the years following their transition”. Beyond that, “an additional 25–50%” of youth “experience housing instability”(Shah MF). The article by the American Journal of Community Psychology goes on to argue that as a result of not being equipped with a support system that most of their peers have, these young people are made to navigate challenging situations on their own (Shah MF, Liu Q, Mark Eddy J, Barkan S, Marshall D, Mancuso D, Lucenko B, Huber). Another journal which was written by JoAnn S. Lee, Gilbert Gimm, Maya Mohindroo, and Louise Lever from the Child and Adolescent Social Work Journal wrote that “the transition to adulthood is especially difficult for youth who age out of the foster care system because they lack the normative social and financial support of family” (Lee). Thus, all of these sources express that as a result of there being limited resources, the foster care system does not effectively provide sufficient tools or support for these young people to live successfully on their own, making homelessness a higher risk for this population of young people. Among teens who are not in foster care, the article written by the Gale Opposing Viewpoints Online Collection expresses that the nature of teen homelessness results from “family conflict, exposure to abuse or trauma, substance abuse, mental health problems, and low levels of academic achievement”. They go on to write that adolescents who identify within communities of color, particularly black, hispanic, and LGBTQ+ youth are at an additional space of vulnerability. Once the teens are homeless, they are in jeopardy of being exposed to “low levels of academic achievement, delinquency and contact with the criminal justice system, substance abuse, mental health concerns, and sexual exploitation,” ( Gale Opposing Viewpoints Online Collection ). This puts these teens in an agonizing cycle. Homeless youth, both those who have aged out of foster care and those who end up homeless without ever having been in the system, are a population that needs more attention and support because of the risk levels that they are exposed to.

Homelessness in the United States is a growing issue that impacts millions of people across the country. With the prominence of unaffordable housing, a society that struggles from mental health issues, a broken foster care system, and a high rate of teens who are at risk because of their unstable home environment, it is evident that the homelessness crisis is out of hand. The concerning aspect of this review is that it only touches upon the tip of the iceberg.

Works Cited

Finfgeld-Connett, Deborah. “Becoming Homeless, Being Homeless, and Resolving 

Homelessness among Women.” Issues in Mental Health Nursing , vol. 31, no. 7, 2010, pp. 461–469., https://doi.org/10.3109/01612840903586404.

Irish, Diane Joy, and Stephen W. Stoeffler. “The Structural Nature of Family Homelessness: A 

Critical Analysis of the Intersection of Unaffordable Housing, Housing Insecurity, Non-Livable Wages, and Eviction.” Journal of Social Distress and Homelessness , 2023, pp. 1–10., https://doi.org/10.1080/10530789.2023.2187521.

Lee, JoAnn S., et al. “Assessing Homelessness and Incarceration among Youth Aging out of 

Foster Care, by Type of Disability.” Child and Adolescent Social Work Journal , 2022, https://doi.org/10.1007/s10560-022-00817-9 .

LIND, DIANA. “Living in the U.S.: At What Cost? Rising Housing Prices Are Outpacing Wage 

Increases Nationwide, Threatening a Living Standard That Once Seemed an Inalienable Right.” Architectural Record , vol. 206, no. 10, Oct. 2018, pp. 80–83. EBSCOhost , search.ebscohost.com/login.aspx?direct=true&AuthType=shib&db=a9h&AN=132093266&authtype=sso&custid=s3818721&site=ehost-live&scope=site.

Padgett, Deborah K. “Homelessness, Housing Instability and Mental Health: Making The 

Connections.” BJPsych Bulletin , vol. 44, no. 5, 2020, pp. 197–201., https://doi.org/10.1192/bjb.2020.49.

Shah, Melissa Ford, et al. “Predicting Homelessness among Emerging Adults Aging out of 

Foster Care.” American Journal of Community Psychology , vol. 60, no. 1-2, 2016, pp. 33–43., https://doi.org/10.1002/ajcp.12098 .

“Teen Homelessness.” Gale Opposing Viewpoints Online Collection , Gale, 2019. Gale In 

Context: Opposing Viewpoints , link.gale.com/apps/doc/PC3010999079/OVIC?u=usfca_gleeson&sid=bookmark-OVIC&xid=e2f048c5. Accessed 30 Mar. 2023.

Zhao, Emo. “The Key Factors Contributing to the Persistence of Homelessness.” International 

Journal of Sustainable Development & World Ecology , vol. 30, no. 1, 2022, pp. 1–5., https://doi.org/10.1080/13504509.2022.2120109.

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Good Literature Review About Homelessness

Type of paper: Literature Review

Topic: Literature , Leadership , Education , Youth , Students , Teaching , Teenagers , Homelessness

Words: 2250

Published: 06/14/2021

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Introduction

Homelessness is a substantial and systemic problem, as it provides people with the fewest resources even less of a chance to better themselves and escape the cycle of poverty. Homeless youth, in particular, face particular problems, being offered substantially fewer chances to succeed compared to other youth of the same age who are not homeless. There are many reasons for youth to become homeless; in many cases, homeless children have homeless parents, or have been tied up in the system without a concrete family structure (e.g. orphans). One substantial phenomenon is the homeless LGBT child; despite the many social advances that gay rights advocates have managed to achieve in recent years, a substantial number of teens are kicked out of their homes because of their sexuality by angry parents who reject them (Leitsinger, 2014). Because these teens have nowhere to go, they are forced to turn to homelessness, often engaging in prostitution and drug use in order to survive and cope with these conditions. Homeless youth also have a high rate of mental problems and traumas given their extreme level of poverty, and are given few avenues for escaping from this endless cycle of destitution and lack of education. Because of these circumstances and more, it is especially important that homeless youth be provided with avenues to get out of their entrenched systems of poverty.

The issue of homelessness is a substantial one, particularly in the case of homeless youth; school-aged homeless youth find it uniquely difficult to get an education. There are often issues of transiency, of not staying in the same place, not being able to afford the basic resources required for attending school, and so on, creating a matrix of factors that make it particularly difficult for these students to get a comparable level of education to other students, if any education at all. As education is a significant resource by which individuals can uplift themselves out of poor socioeconomic conditions, it is doubly imperative that homeless youth are given the chance to receive a quality education. To that end, the issue of providing educational resources to homeless youth must be given high priority in the field of education.

In addition to the basic utilities of an education, teacher-leaders have a unique position to provide particularly helpful guidance and support to these impoverished, homeless children. As homelessness often leads to a daily life devoid of structure and largely removed from the niceties of modern society, homeless youth live their lives without the psychological and emotional coping mechanisms and support system they need to survive and achieve their potential. Homeless youth education may be one of the only avenues by which many homeless youth receive a concrete level of guidance and support, making it especially vital that teachers convey not only knowledge from their curriculum, but a transformational, charismatic leadership style that will inspire students and assist with their personal development. This component to teaching is often said to be helpful in a normal classroom setting, but the motivational elements of a transformational teacher-leader is even more crucial to homeless youth given their erstwhile lack of guidance.

In this literature review, homelessness and its various types and causes will be described and defined, particularly as they relate to homeless youth. Two major themes will be addressed: first, there is the effect of educational leadership on academic experiences of homeless youth. This theme will be further explored under three subthemes:

1) components of effective leadership in the education sector;

2) significance of educational leadership in ensuring the success of teachers and students alike

3) solving education challenges through the tenets of educational leadership. By researching this topic through the existing literature, the ways in which educators can provide a good and influential presence for underserved children in education will be elucidated and further points of study can be found.

The second theme to be explored in the literature review are the education opportunities currently available to homeless students. The three subthemes of this second theme include

1) effectively integrating homeless students into the standard education system;

2) providing appropriate education resources to students of all kinds

3) providing psycho-social support to homeless youth of student age. Through this exploration of these issues based on an overview of the existing literature on these fields of research, a concrete direction for our study may be discerned.

Given the information explored in this literature review, the underlying tensions that accompany the phenomenon of homeless youth in education involve the factors of substance abuse, history of trauma, and lack of structured social and economic framework that exist within homeless populations. These tensions make it difficult for homeless youth to interact well in a structured school environment, as well as prevent school leaders from communicating effectively with them.

It is theorized that communication strategies such as transformative leadership will help to instill in underprivileged students a sense of belief in their education competencies, which may help to alleviate these tensions and provide a greater support system for these students who would otherwise have no support system to speak of (Devono & Price, 2012). These strategies and more must be explored as concrete, potential avenues for including homeless and transient youth students into the education system, as that will provide them with the opportunity to gain the knowledge and skill sets needed to receive gainful employment and work their way into systems that will take them off the streets. One substantial tension found in the literature is the role of the teacher in creating a proper learning environment, which is question generally found in any education context regardless of the presence of disadvantaged youth. Issues and factors like educational leadership and metacognition are found to be highly influential in creating the circumstances by which students improve; students benefit most from teachers who are involved, highly specific in their treatment of their students, and who act as a motivator for students to learn in the first place. School administrators also play a substantial part in this endeavor, as they are responsible for allocating and acquiring the proper school resources necessary. The exact responsibilities that administrators and teachers have alike is a continued cause for concern, and a possible subject of future research.

Homeless youth must be addressed not just as students, but as people, the school system they enter into presumably having a larger responsibility for their emotional and physical wellbeing; to that end, existing literature has explored the varying services that schools can provide for students who are homeless. Government agencies, school counseling and other such programs are usually responsible for caring for these homeless youth, depending on whether or not they are in school. Psychosocial risk assessment is an important component to consider when integrating homeless youth into a classroom, given the special cases that homeless youth can often bring up. School counseling, in particular, has proven to have positive outcomes in improving the performance of homeless youth students, emphasizing the need for homeless youth to be cared for to a greater degree than is usually expected of non-homeless students in these contexts.

Another substantial tension is the challenge of inclusive education – typically utilized in the context of students with disabilities, here it can be applied to the disadvantages of homeless students as well. Inclusive education, regardless of content, comes with a complex set of challenges for teacher and student alike, balancing a whole classroom of students with their own varying needs and requirements into a curriculum that serves all of them effectively. Homeless students experience unique challenges that leave them underequipped to handle the structures and rigors of an education setting, particularly in a classroom with non-homeless youth.

Issues of discrimination, uneven study skill allotment, and comparatively low incentive to learn can make an inclusive classroom with homeless youth students particularly troublesome for students and teachers alike. Combining classrooms of students who are both economically stable and unstable may lead to tensions and a distinct lack of motivation on the part of the homeless youth population to engage in learning. If inclusive classrooms are to be a potential solution for these populations, strategies must be developed to specifically acclimate homeless students with a classroom in an inclusive setting.

One proposed issue is to set up education interventions in homeless shelters, but the extent to which these interventions are effective remains to be seen. While some interventions to promote literacy in homeless shelters have been initiated, the extent to which they would be effective remains to be seen (Bolland & McCallum, 2002). Furthermore, there are issues of occupancy to consider as well: homeless youths as a population may be too numerous for homeless shelters to handle a concise, comprehensive education program (MacCillivray, Ardell & Curwen, 2010). Because of the logistical issues of maintaining a full education program within homeless shelters for a proportionately few number of occupants, as well as the potentially disruptive nature of a mixed population of homeless youths and adults, inclusive education in traditional schools may well be a more effective solution.

There are certain gaps in the existing literature that may help to alleviate these particular problems. The effect of transformational leadership and the teaching of appropriate learning strategies, perhaps through metacognition, on homeless youth attending school has yet to be researched in sufficient depth. Currently, homeless students suffer substantially from a lack of motivation, a tendency toward disruptive behavior, and a lack of respect for authority – all factors that can hinder learning in a structured classroom environment (Groton, Teasley & Canfield, 2013).

Transformational leaders are also said to provide social justice in education, providing homeless youth in classrooms with a better sense of belonging and integration into a normal classroom setting, which can in turn help these students cope better with life among more affluent students, and vice versa. As the literature indicates that these strategies may lead to better learning outcomes, substantive research on the subject is necessary to determine the extent to which this occurs.

Another issue to be addressed is the effect of equitable education opportunities on homeless students; as legislation such as the McKinney-Vento Homeless Assistance Act and No Child Left Behind is still in its infancy, studies on their effect on the homeless student youth population in particular are still forthcoming. It is theorized that, if legislation protecting homeless youth and promoting equality in education is integrated into normal classroom operations more quickly, homeless youth might more effectively transition into student life and achieve higher academic and social outcomes. To that end, further research on how government legislation and specific attempts to curb the issue of homelessness are effecting youth education is necessary to enact more targeted, accurate interventions on this underserved population. Only through determination of the interventions’ effects on homeless youth can structured implementation of programs for homeless youth students be accurately and effectively created.

This particular study is new and unlike anything done previously in this particular schema of education research given its focus on transformative and educational leadership and its effect on homeless youth. Because of the unique social problems inherent to homeless youth, including crime, drug and sexual abuse, and unemployment, it is more important than ever that teachers in education settings provide not only an educational value for these youth, but they must also instill character and emotional coping mechanisms they may not necessarily receive on the streets. As school counseling has been shown to have a positive effect on homeless youth, the further application of emotional and cognitive reinforcement in an active classroom setting may help to further improve gaps in learning and emotional coping that can come with the status of homelessness (Daniels, 2002).

This study will add scholarly value by exploring how these well-worn theoretical frameworks apply to an underserved and unexplored population of student youth. These specific models have not been thoroughly applied to this specific population and setting in current education research; therefore, this study may inspire further research that continues the avenues that have been explored preliminarily by this existing literature. As homeless youth of school age are a difficult population to maintain and keep in contact with due to their transient nature, studies like these may be difficult to implement in other climates. The study of these theoretical constructs of transformational and educational leadership in the context of homeless youth attending school may help to determine the effectiveness of homeless youth outreach in education. If the outcome of the study is successful, the resulting literature may offer a potentially useful framework for interacting with this underserved population.

This literature reviewed the two major themes related to homeless youth in education: the effect of educational leadership on academic experiences of homeless youth, and the opportunities for education currently available to homeless students. Given the literature reviewed in this section, it is clear that educational leadership plays an important part on homeless youth academics, but that there are not as many education opportunities available as there should be for this underserved population – the development of transformational educational leadership may enhance what interventions are there to make teachers more valuable to homeless students. Furthermore, the role of teachers as a transformative presence for homeless youth students in an inclusive classroom is worthy of further study, which will be outlined in the study itself.

Leitsinger, M. (Aug 3 2014). Left Behind: LGBT Homeless Youth Struggle to Survive on the Streets. NBC News.

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Literature Review: Aging and Homelessness

by AHadmin | Apr 10, 2014 | Literature Review | 0 comments

NOTE: The following report can be downloaded  here .

******************************

Literature Review: Aging and Homelessness  

conducted as part of the SSHRC project:

“Homelessness in late life: growing old on the streets, in shelters and long-term care” (project no 435-2012-1197)

Authors:  Amanda Grenier,  Rachel Barken, Tamara Sussman, David Rothwell, and Jean-Pierre Lavoie

With thanks to: Victoria Burns, Laura Henderson, Sebastien Mott, and Malorie Moore

Co-Investigators: Amanda Grenier (PI), Tamara Sussman, David Rothwell, and Jean-Pierre Lavoie

October 2013

Aging and Homelessness (Phase I Literature Review)  

Introduction

This report reviews the state of literature on aging and homelessness. A substantial literature spanning several decades explores homelessness and the programs designed to address this issue (Lee, Tyler, & Wright, 2010; Shlay & Rossi, 1992; Toro, 2007; Trypuc & Robinson, 2009). However, present knowledge and practices about homelessness tend to focus on youth, younger adults, and young families, with far less attention to older people (Beynon, 2009; Burns, Grenier, Lavoie, Rothwell, & Sussman, 2012; Cohen, 1999; Crane & Warnes, 2001; Gonyea, Mills-Dick, & Bachman, 2010; McDonald, Dergal, & Cleghorn, 2004). Older people who are homeless are depicted as an ‘invisible population’ (Gonyea et al., 2010), but with demographic shifts the numbers of older people experiencing homelessness can be expected to rise (Edmonston & Fong, 2011). Population aging calls for research and policy attention to aging and homelessness.

This report focuses on the intersections of aging and homelessness. We draw on international and Canadian research to provide an overview of the circumstances, statistics, and programs that exist in this area and a general understanding of what homelessness means, specifically for older people.

This report is organised according to four relevant areas that contribute to current understandings of homelessness among older people:

• The first section reviews the terminology, definitions, and distinctions that exist in the field, including the age at which homeless people are considered to be ‘old’;
• The second section reviews the available statistics and estimated prevalence of homelessness, and in particular older homelessness, in Canada and Quebec;
• The third section reviews the major pathways into homelessness across the life course, including distinctions between ‘aging on the streets’ and becoming homeless for the first time in later life;
• The fourth section reviews variations that exist between subsets of the homeless population or according to diverse social locations. Gender, immigration status and geographic location, health status, substance use, and violence/abuse are considered to differentially impact experiences of homelessness, both across the life course and in later life. We finish by addressing the unique needs older homeless adults.

Methodology

The purpose of this research was to compile the literature on aging and homelessness, with a focus on prevalence, pathways to homelessness, and variations according to diverse social locations. We began by locating relevant literature reviews and identifying key sources. A formal literature search was conducted through Web of Science and AgeLine database (1978 – 2004), followed by a search on Google Scholar. Search terms included: ‘elder’, ‘elderly’, ‘older adult’, ‘senior’, ‘homelessness’, ‘programming’, ‘support’, ‘shelter’, ‘Quebec’, and ‘Canada’. We discuss homelessness broadly in this report, but pay special attention to research on older homelessness, on differences between younger and older homeless populations, and on the Canadian context. We also drew on grey literature, which was found using Google and the same keywords listed above.

Summarizing the existing literature, and arriving at more general understandings of homelessness and aging, is challenging due to variations in methodologies and samples. Studies have different research populations and foci and refer to different locations; making it difficult to separate the impacts of geography, service availability, and individual differences. Results are also constrained by challenges in accessing homeless people. The transitional and unstable nature of homelessness makes it difficult to maintain contact with these individuals (Greenwood, Schaefer-McDaniel, Winkel, & Tsemberis, 2005), and some of them are less likely to be participants in research studies because they are cautious of authority and bureaucracy (O’Connell et al., 2004).  Despite limitations in research data and access, this report is a best attempt to compile what is known about homelessness in later life, with the aim of creating a research agenda and developing best practices for care.

The State of the Literature on Aging and Homelessness

Section One: Defining Aging and Homelessness

What is ‘homelessness’? 

Definitions and categories of homelessness vary among sources and between programs. The Canadian Homelessness Research Network (2012) provides a comprehensive definition, describing homelessness as “the situation of an individual or family without stable, permanent, appropriate housing, or the immediate prospect, means and ability or acquiring it” (1). They identify four living circumstances that fall under the umbrella of homelessness:

1) Unsheltered, or absolutely homeless and living on the streets or in places not intended for human habitation;

2) Emergency sheltered, including those staying in overnight shelters for people who are homeless, as well as shelters for those impacted by family violence;

3) Provisionally accommodated, referring to those whose accommodation is temporary or lack security of tenure, and finally,

4) At risk of homelessness, referring to people who are not homeless, but whose current economic and/or housing situation is precarious or does not meet public health and safety standards

(Canadian Homelessness Research Network, 2012,1).

Although people who are provisionally accommodated or at-risk fall under the umbrella of homelessness, the typical image of a homeless person is someone who lives on the streets or in shelters. It may be particularly challenging to identify the provisionally accommodated and the at-risk because they may not use services, such as shelters, which are typically associated with homelessness (Mott, Moore, & Rothwell, 2012).

In the literature there are distinctions between types of homelessness, including transitional or temporary, episodic or cyclical, and chronic homelessness (Culhane & Metraux, 2008; Echenberg & Jensen, 2008; Kuhn & Culhane, 1998). Some researchers write that individuals who are homeless for three full months fall into the chronic category (Trypuc & Robinson, 2009) while others explain that people who are repeatedly homeless for more than a year are chronically homeless (McDonald et al., 2004). People who are chronically homeless often use shelters as a means of housing, rather than an emergency service (Mott, 2012). Chronically homeless people tend to be older, persistently unemployed, and are more likely to be disabled or experience substance use problems. By contrast, cyclically and episodically homeless people are typically younger (Mott, 2012). A less frequently used category is ‘rough sleepers’, which refers to homeless people who tend to avoid shelters and outreach services (Crane & Warnes, 2000; Johnsen, Cloke, & May, 2005; O’Connell et al., 2004). Research suggests that a small proportion of the homeless population, referred to as ‘heavy shelters users,’ accounts for over 50% of overall shelter use (Mental Health Commission of Canada, 2012).

What is ‘older homelessness’?

There is an acceptance that homelessness among older people is on the rise, but differences in life trajectories and health status make it difficult to determine what constitutes the older homeless population. While 65 —the dominant age of retirement — is the most widely accepted marker of old age, it is deficient where later life homelessness is concerned. Older adults living on the street tend to exhibit mental and physical health issues that are more consistent with non-homeless people who are approximately ten years older than them (Cohen, 1999; Gonyea et al., 2010; Hibbs et al., 1994; Hwang et al., 1998; Morrison, 2009; Ploeg, Hayward, Woodward, & Johnston; 2008). People who live on the streets also have higher rates of early mortality than the general population (Cohen, 1999; Hibbs et al., 1994; Hwang et al. 1998; Morrison 2009), with the average age of death for a homeless person in Canada cited as 39 years (Trypuc & Robinson, 2009).

Attempting to find an appropriate marker for later life among homeless people is not as simple as subtracting ten years from the general age classification of 65. Aging is a process that takes place across the life course and in relation to institutional structures, practices and experiences (Grenier, 2012). For example a study of older homeless people in Toronto finds that those over 50 subjectively consider themselves “old” (McDonald et al., 2004). As a result, the general trend in research is to consider persons who are above 50 or 55 years as “older” (Cohen, 1999; Garibaldi, Conde-Martel, and O’Toole, 2005; Gonyea et al., 2010; McDonald, Dergal, & Cleghorn, 2007; Ploeg et al. 2008; Shinn et al., 2007). For this reason, we suggest that 50 is an appropriate and inclusive threshold for considerations of homelessness and aging. We recognise, though, that health and personal trajectories across the life course—not just chronological age—define the experience of aging.

Section Two: Statistics and Estimated Prevalence  

How many homeless people are there in Canada?

Homelessness is a global issue, with an estimated 100 million people considered homeless worldwide(United Nations Organization, 2005). Canada does not gather comprehensive data on homeless individuals (Trypuc & Robinson 2009). The information collected by Statistics Canada is based on the number of persons living in shelters, with a category that includes “persons lacking a fixed address, shelters for abused women and children, and other shelters or lodging with assistance” (Statistics Canada, 2012). This, combined with the realities that homeless people live in transition and often lack a fixed address, means that it is difficult to gather general estimates of the homeless population (Mott et al., 2012). Different understandings of the living circumstances that constitute homelessness, and different counting methods, further complicate this issue. Some studies use a point prevalence count to estimate the number of homeless people at a specific time. They do this by conducting a survey of shelter users and counting the number of individuals in ‘homeless hotspots’ on one night. Other studies use a period prevalence count to estimate the homeless population over a given duration (Hulchanski, 2000). Using administrative data, such as the recorded number of people using a shelter over a given length of time, is an example of the period prevalence method

Estimates suggest that Canada’s homeless population ranges from 150,000 to 300,000 (Laird, 2007; Mental Health Commission of Canada, 2012). The lower number is a conservative estimate government sources give, and the higher number, proposed by advocates and non-governmental sources, accounts for the rapid growth in municipal homeless counts and persons who may not use homeless services (Laird, 2007). Approximately 20,170 individuals (.05% to .06% of the population) lived in shelters between 2001 and 2011 (Statistics Canada, 2012) and in 2008 there were 1,128 shelters in Canada (Echenberg & Jensen, 2008). Data on shelters and shelter users gives some information on homelessness, but it does not accurately capture the entire homeless population. Discrepancies in estimates of Canada’s homeless population are indicative of insufficient data on this issue.

While national data is sparse, some urban centres collect information on homelessness. Toronto has the largest number of homeless people in the country, but cities in Alberta seem to have significant homeless problems (Gaetz, Donaldon, Richter, & Gulliver, 2013). Available information collected by point prevalence methods outlines that there were approximately 5,086 homeless people on a single night in Toronto in 2008 (representing 0.19% of the city population); 1,602 on one night in Vancouver in 2012 (representing 0.27% of the city population); and 3,190 on one night in Calgary in 2012 (representing 0.29% of the city population) (Gaetz et al., 2013). Comparable data for Montreal is not available, but a survey conducted in 1996-1997 found that approximately 28,214 people in Montreal used shelters, soup kitchens, and day centers for homeless people over a one-year period. Of survey respondents, 12,666 lacked a fixed address in the previous year (Chevalier & Fournier, 2009). Although a reliable estimate of homeless prevalence has not been produced since then, Montreal’s homeless services have seen an increase in the number of users  (RAPSIM, 2010). From 2008 to 2009, the Old Brewery Mission (OBM), a service for homeless men and women in Montreal, witnessed a 34% increase in admissions to its transition services, from 708 to 1,077 people (Old Brewery Mission, 2009-2010).

Age is similarly difficult to assess with available data. Research suggests that 75% of Canada’s homeless population is between the ages of 25 and 55 (Social Planning and Research Council of BC, 2005). A 2001 reports finds that families with young children and youth are the most quickly growing group of homeless people in Toronto and Ottawa (Eberle, Kraus, & Serge, 2001). Approximately 6% of the visible homeless population in Canada is considered to be over the age of 65 (Stuart & Arboleda-Flórez, 2000) and 9% are over the age of 55 (Social Planning & Research Council of BC, 2005). Older adults are a minority among homeless people—perhaps due to higher mortality rates in this population—but a Vancouver-based study found that older people spends more time in shelters than their younger homeless counterparts (Serge & Gnaedinger, 2003). Adults over the age of 55 represent 14%-28% of shelter users in Canada (Stergiopoulos & Herrmann, 2003). With a lack of viable housing alternatives for older adults and over-crowding in acute hospitals, there is pressure on shelters to fill the gap in convalescent care by accepting elderly and unwell patients who can no longer care for themselves (Serge & Gnaedinger, 2003). The number of older adults who are homeless is increasing, and they are considered to be particularly vulnerable (Stergiopoulos & Herrmann, 2003).

Section Three: Pathways into Homelessness

What are the major pathways into homelessness?

Pathways into homelessness among youth are more clearly articulated than those of later life. Research finds that homelessness often occurs when cumulative difficult circumstances and triggers events, rather than a single incident, make homelessness the only (or the preferable) option. Psychological disorders, connected with traumatic events in childhood or adolescence (Martijn & Sharpe, 2006), as well as family breakdown and/or the death of a parent (Padgett, Smith, Henwood, & Tiderington, 2012), are associated with homelessness in earlier parts of the life course. As such, the literature on the accumulation of events points to the importance of treatment such as psychological counselling for trauma experienced in childhood (Padgett et al., 2012) and the importance of teaching youth coping and resilience skills to prevent breakdowns and decrease the risk of homelessness (Kennedy, Agbenyiga, Kasiborski, & Gladden, 2010; Padgett et al., 2012).

The literature on pathways into homelessness in adulthood and later life is less definitive. Research indicates that gradual declines and/or trigger events (Shinn et al., 2007; Gonyea et al., 2010), as well as various individual and structural factors, contribute to later life homelessness. While there are complex interconnections between these pathways, in this section we try to untangle structural conditions, cumulative circumstances and risk factors, and trigger events. Our goal is to give readers a better sense of diverse conditions, operating at different levels, associated with later life homelessness.

Macro-level forces that disadvantage particular groups of older adults may increase risks of homelessness. A report comparing 21 OECD countries suggests that Canada’s social policy expenditures are relatively equally distributed among people under and over 65  (Lynch, 2001). Still, structural issues associated with homelessness include inadequate affordable housing; fewer available jobs, leading to competition for employment and poverty among some older adults; and policies that limit certain individuals’ access to health, disability and pension benefits (Gaetz et al., 2013; Lee et al., 2010; Tully & Jacobson, 1994). Since the 1990s, the rising cost of housing in Canada has also resulted in increasing numbers of citizens living below the low-income cut-off in both urban and rural areas (Skaburskis, 2004). Asset poverty research shows that 28% of adults 66 and older do not have sufficient financial assets to survive at the low-income threshold for three months (Rothwell & Haveman, 2013).

In this context, individuals may experience a gradual decline into homelessness. Conditions associated with a gradual decline include precarious employment and/or diminishing finances leading to poverty, poor mental and/or physical health, decreasing social connections (Morris, Judd, & Kavanagh, 2005; Shinn et al., 2007), psychiatric conditions (Barak & Cohen, 2003), and alcoholism (Crane, 1999; Dietz, 2009). Education, work history, and incarceration are also associated with homelessness. People with lower levels of education are at greater risk (Rank & Williams, 2010), and persons released from prison are more likely to be homeless than those who have never been incarcerated (Kushel, Evans, Perry, Robertson, & Moss, 2003; Metraux & Culhane, 2006). Other findings indicate that those who experience higher levels of victimization and poverty when younger are more likely to be homeless later in life (Browne & Bassuk, 1997; Koegel, Melamid, & Burnam, 1995; North, Smith, & Spitznagel, 1994; Stein, Leslie, & Nyamathi, 2002; Toro, 2007), as were those who experience traumatic life changes if they have limited social and family networks (Morris et al., 2005).

People who experience these vulnerabilities may lack the skills or resources to cope with emergency situations. In turn, these situations may trigger homelessness (Crane & Warnes, 2005). Trigger events include loss of accommodation; death of a spouse, relative, or close friend who may have provided care; domestic violence, and/or family breakdown (Crane & Warnes, 2005; Gonyea et al., 2010). For example, a Toronto study found that 70% of people over 50 became homeless between the ages of 41 and 60 as a result of family breakdown, eviction, and/or a loss of employment (McDonald et al., 2004).

There is no single pathway into homelessness, but older adults typically experience one of two types of homelessness: they are either chronically homeless throughout their lives and continue this pattern as they age, or they become homelessness for the first time in later life. The literature suggests that the second pathway is increasingly common. Research conducted with older homeless individuals in the United States, England, and Australia found that two thirds had not experienced homelessness earlier in life, while the other third had been homeless before (Crane et al., 2005). Similarly a New York City study of 79 homeless adults over 55 finds that half of the participants lead what they considered ‘conventional lives’ prior to becoming homeless. The other half was more likely to have experienced homelessness throughout their lives (Shinn et al., 2007). In addition to representing a new population, the duration of time an individual spends homeless is typically longer for older adults than younger people because they are less likely to reintegrate into the workforce (Caton et al., 2005). Evidence of new homelessness in late life underscores the urgent need to understand later life pathways to homelessness.

It is difficult to reach conclusions about the ways older people become homeless because studies in this area are often qualitative with small sample sizes. The literature suggests, though, that accounting for life course trajectories can lead to better understandings of pathways and potential solutions to homelessness. Understanding the pathways in and out of homelessness throughout the life course also can assist when developing treatment plans for older homeless individuals. This is especially the case where questions of decades of impoverishment and victimization may be concerned. An approach that balances income security and affordable housing in late life with counselling and psychological services may be a way to address the complex factors contributing to later life homelessness.

Section Four: Variations Among Subsets of the Homeless Population

This section addresses noteworthy variations in the homeless population. Although not meant to be comprehensive, the following section outlines major trends that exist regarding diverse locations including gender, immigration status and geographic location, health, and substance use. The section ends with a discussion of the unique needs of older homeless people.  

Gender . Research on gender and homelessness suggests that men outnumber women about 4 to 1 among all homeless adults (Cohen, 1999), with the gender gap narrower among older people (McDonald et al., 2007). These numbers reflect that men are more likely to use shelter services and are thus more visible in the homeless population (Rich & Clark, 2005). Homeless women’s invisibility makes it difficult to provide precise information on gender differences. The number of older homeless women is likely under-reported, particularly among those who are leaving abusive situations (Kosor & Kendal-Wilson, 2002). The research that does exist, however, points to differences in the pathways and experiences of men and women. Men are more likely to be homeless and/or precariously housed throughout their lives (Hecht & Coyle, 2001). Where men’s homelessness is often connected to loss of employment (McDonald et al., 2004), mental health problems, or addiction (Peressini, 2007), older women’s homelessness is often associated with a trigger event leading to homeless for the first time in later life (Hecht & Coyle 2001; Shinn et al., 2007; Toro, 2007). Two issues regarding older women’s pathways to and experiences of homelessness stand out in the literature: (1) poverty as a result of family circumstances and the structure of the pension system (Rahder, 2006); and (2) experiences of abuse (Kosor & Kendal-Wilson, 2002; Toro, 2007).

Women experience financial disadvantages throughout their lives (McDonald et al., 2004; Rahder, 2006) and this increases their risks of homelessness in later life. Women’s disproportionate involvement in unpaid care work may disrupt or take the place of labour force participation (Denton & Boos, 2007). Unpaid care work is uncompensated in Canada’s pension system; increasing women’s chances of poverty in later life (Wakabayashi & Donato, 2006). Women are also more likely to work for lower pay or on a part-time basis, and this limits their access to pension and health benefits. Women’s poverty can increase with age, when sexism and ageism in the labour market make it difficult for older women to find employment. Women are also more likely to become homeless due to family circumstance, such as becoming a widow or marital breakdown (McDonald et al., 2004). In these situations women may lose support from a spouse’s income or pension benefits (Denton & Boos, 2007). Eviction or loss of accommodation may result when women lack sufficient finances (Hecht & Coyle, 2001).

There are specific concerns regarding older homeless women’s experiences of abuse and violence. Kosor and Kendal-Wilson (2002) find that spousal abuse, family violence, and disputes with family and friends are major pathways to homelessness among older women in one American city. Other studies suggest that the number of women over 55 who are forced to leave their homes as a result of physical and/or sexual violence is increasing (Grossman & Lundy, 2003). There is a service gap between domestic and elder abuse; leaving few to no services for older women who are abused (Straka & Montminy, 2006). Older women leaving abusive situations are often forced to stay with family or friends or live on the streets. In the latter case, older women’s risks of abuse and victimization are significantly higher than men’s (Dietz & Wright, 2005; Grossman & Lundy, 2003; Wenzel, Leake, & Gelberg, 2001). There is a national shortage of shelters for abused women, and changes in funding for social housing has resulted in even fewer units available for them (Rahder, 2006).

Immigration status and race/ethnicity. Older adults belonging to minority racial/ethnic groups face unique challenges that impact their pathways to and experiences of homelessness. There are a disproportionate number of First Nations people in Canada’s homeless population (Canadian Institute for Health Information, 2007), with one study reporting that they are over-represented by a factor of 10 (Hwang, 2001). Immigrants are also over-represented in the homeless population. A study in Toronto (McDonald et al., 2007) finds that 55% of the recent older homeless population was born outside of Canada, compared with 29% of the long-term homeless. The high representation of immigrants among recently homeless older adults may be connected to Canada’s pension structure. Someone who moves to the country during his or her adult life has significantly less time to build a pension.  This results in a much lower retirement income and greater risks of poverty and homelessness in later life. Most people in McDonald et al.’s (2007) study were receiving some amount of provincial benefits, but social assistance is often inadequate given the high cost of rent in urban centres like Toronto. Gaps between services and benefits may hinder older homeless people’s access to housing (McDonald et al., 2007). Language is also significant barrier for older adults who cannot communicate well in English or French because speaking the dominant language is often necessary to access housing and support services (McDonald et al., 2007). Non-first language speakers often feel marginalized and isolated; particularly in institutional settings such as residential homes or hospitals (Saldov & Chow, 1994).

Geographic location . Geographic location is also implicated in experiences of homelessness and must be accounted for when considering the diverse needs of older adults across Canada. The majority of homeless people live in large cities (Statistics Canada, 2001), where services, such as shelters, are located. Shelter use is reportedly higher in Quebec, Alberta, Ontario, British Columbia, and Manitoba than in other provinces and territories (Statistics Canada, 2001). Homelessness is typically considered an urban problem, but homeless people who live outside urban areas face additional challenges accessing services and support (North et al., 1994). Here the intersections of poverty, new homelessness, and Northern or rural locations need further investigation.

Health and safety issues . Health problems experienced across the life course are both a risk factor for homelessness and an outcome of homelessness. People with mental health and/or addiction problems are more likely to become homeless (Mott et al., 2012). At the same time, people who lack stable housing face threats to their mental and physical health (Bhui, Shanahan, & Harding, 2006; Power & Hunter, 2001; Schanzer, Dominguez, Shrout, & Caton, 2007). Common health problems in the general homeless population include tuberculosis, HIV, arthritis, hypertension, diabetes, fungal infections, and parasites (Hwang, 2001). Traumatic brain injury is also relatively common among homeless people. A survey finds that 53% of people using homeless services in Toronto have experienced a traumatic brain injury (Hwang et al., 2008). Rape and assault are also health and safety risks associated with homelessness. Studies on violence and homelessness find that 40% of homeless men were assaulted, and 20% of women were raped, in the year prior to study (Crowe & Hardill, 1993; Kushel et al., 2003).

The literature on homelessness in later life suggests that older people face greater disadvantages than younger groups regarding physical and mental health (Bhui et al., 2006; Cohen, 1999; Dennis, McCallion, & Ferretti, 2012; Garibaldi et al., 2005; Gonyea et al., 2010; Kim, Ford, Howard, & Bradford, 2010; Lipmann, 2009; Martins, 2008; Ploeg et al., 2008; Quine, Kendig, Russell, & Touchard, 2004). Garibaldi et al. (2005) find that those over 50 were 3.6 times more likely than the younger homeless population to suffer from a chronic medical problem, while Kim et al. (2010) find that the likelihood of having mental health problems doubles for homeless people over the age of forty-two.

Specific health issues among older homeless adults have also been documented. In a Toronto study, the most frequently reported ailments among this population were vision, arthritis, dental problems, and back problems (McDonald et al., 2004). There are gender differences, with women reporting greater difficulties with arthritis and bladder control while men are more likely to suffer from back and skin problems (McDonald et al., 2004). Older homeless men—particularly those who lose their jobs between the ages of 60 and 65—are also at a high risk of suicide associated with mental illness (Greater Vancouver Shelter Strategy, 2013). In some circumstances, health conditions are already present when one becomes homeless. In other cases, they manifest or become worse during periods of homelessness (Horn, 2008; Hwang et al., 1998). Canadian data on the health status of older homeless people is inadequate, with more accurate information needed to account for the discrepancies in conditions and services across the country (At Home/Chez Soi Interim Report, 2012).

Substance use . Drug and alcohol use is often associated with homelessness. In the general homeless population, substance use is reported to affect 49% of those who are transitionally homeless, 66% of those who are episodically homeless, and 83% of those who are chronically homeless  (Kuhn & Culhane, 1998). Homeless people use a range of substances, but alcohol is used most often. Between 53% and 73% of homeless people reportedly use alcohol (Frankish, Hwang, & Quantz, 2005; Podymow, Turnbull, Coyle, Yetisir, & Wells, 2006). That said, a Toronto study finds that others substances are also used frequently: 60% use marijuana, 52% use cocaine, 49% use crack, 25% use oxycontin, 18% use morphine, 14% use heroin, and 25% use other opiates (Khandor & Mason, 2008). Some differences in substance use among members of the homeless population are noted. Men are more likely than women to use drugs, and those with mental illnesses are more likely to use alcohol or drugs than those without documented mental illnesses (Blazer & Wu, 2009; Dietz, 2009).

There is little information on older people’s use of substances, and less on the impacts of drugs and alcohol as one ages. The literature on substance use among older homeless people presents mixed results that are challenging to interpret. Some research reports that substance use patterns are considered to differ between age cohorts and are thought to decrease with age (Blazer & Wu, 2009; Cohen, 1999). Other studies highlight that where younger and older groups of homeless people are equally as likely to report alcohol abuse (Dennis et al., 2012; Dietz, 2009; Hecht & Coyle, 2001), older adults are less likely to report drug use (Hecht & Coyle, 2001). Conversely, there is a literature suggesting that drug use among the elderly has been increasing and is expected to continue on this upward trajectory (Beynon, 2009; Proehl, 2007). For example, Garbibaldi et al.’s (2005) study of homeless people in two American cities finds that those over the age of 50 are 2.4 more likely to be dependent on heroine than those who are under 50. The reported increased rates of drug use among older people are likely a cohort effect: people tend to maintain drug habits throughout their lives, and the cohort of people entering their senior years reports higher rates of drug use than previous generations (Beynon, 2009). Research suggests that older people who have used substances across the life course will have co-morbidity issues as a result of prolonged use of drugs or alcohol (Beynon, 2009), but the paucity of relevant information and services leaves an already vulnerable population at risk (Blazer & Wu, 2009; Proehl, 2007).

  The unique needs of older homeless people. The research on homelessness among older people identifies a number of needs unique to this population. Needs that parallel those of younger homeless groups include stable housing, income, food, and health care. Needs specific to younger groups, such as job training and employment assistance, are often considered irrelevant for the older population (Garibaldi et al., 2005). This may need to be reconsidered where gender or immigration status limits older adults’ access to pension benefits. These individuals may also need assistance finding employment, especially in the years prior to qualifying for public pension and/or in cases where benefits are insufficient. Greater attention to employment may be necessary in the future. Aside from housing needs across the life course and in late life, which requires a separate review (see Crane & Warnes, 2007: McGhie, Barken, & Grenier, 2013; Serge & Gnaedinger, 2003), two of the more prevalent issues outlined in the literature are: (1) access to health and social services and (2) safety.

Older homeless adults often experience challenges accessing health and social services. Because they are more likely than their younger counterparts to have mental and physical health concerns, they may require access to specialized medical care beyond that which is available in shelters (Power & Hunter, 2001). Living without a home can be especially challenging in later life; making older adults’ needs to access housing particularly urgent (Abbott & Sapsford, 2005). Interviews with health care providers address how mental health conditions present challenges to generating continued engagement with older homeless people (Cohen, Onserud, & Monaco, 1992; Horn, 2008; Proehl, 2007). Due to memory problems, they sometimes forget to attend scheduled appointments and are unable to complete programs. Older homeless people have also reported discriminatory treatment and stigmatization in health care settings, demonstrating a need for medical staff to become more sensitive in the way they treat this population (Martins, 2008; Lipmann, 2009; Quine et al., 2004).

Difficulties navigating government services, not just financial restrictions, can be a barrier to accessing government assistance and health services. Most older homeless people do not receive the full amount of government assistance for which they qualify (Ploeg et al., 2008). There are also concerns regarding the appropriateness of services available for older homeless adults. One Canadian research project found that there is a gap in services for homeless people aged 50-65 (McDonald et al., 2006). In this study clients reported frustration because neither the services offered, nor the programs created for the general homeless population, suited their needs (McDonald et al., 2006).

Older homeless adults have unique needs regarding safety. They encounter violence on the streets and in shelters (Cohen et al., 1992; Lee, 2005; North et al., 1994). Older adults face higher threats to safety than their younger counterparts because they are more likely to be in poor health and because they are seen as easy targets (Dietz & Wright, 2005). Older women and transgendered people face higher risks of victimization, but homeless men still experience high risks of physical abuse (Cohen, 1999; Dietz & Wright, 2005; Gonyea et al., 2010; Grossman & Lundy, 2003; Lee, 2005; North et al., 1994; Tully & Jacobson, 2008). The literature is unanimous in pointing to older homeless adults’ unique challenges.

Conclusion: Knowledge Gaps

This report has reviewed extant research on aging and homelessness in four key areas. There are notable knowledge gaps in each of these areas. First, with regard to definitions and distinctions in research on homelessness, it is necessary to reach a consensus regarding the age at which homeless people reach ‘later life.’ Based on research on physical and mental health in homeless populations as well as homeless people’s subjective perceptions of old age, we suggest that 50 is an appropriate threshold for considerations of homelessness and aging. Second, better estimates of the number of homeless people and their age distribution in the Canadian population are necessary. Third, we suggest that a life course perspective could be fruitfully applied to understand major pathways leading to homelessness, particularly risk factors and trigger events, and their prevalence across the life course. Fourth, greater attention to intersecting inequalities when exploring locations of risk is necessary (Brotman, 2003; Klodawsky, 2009). Some studies focus on gender and others on ethnicity, but research considering the impact of multiple marginalized categories on older homeless adults’ experiences is necessary. Another notable gap in the literature is the impact of sexual orientation on older adults’ life courses and risks of homelessness. Future studies should be designed to fill these knowledge gaps and to generate a more comprehensive understanding of aging and homelessness. 

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