Primary Prevention and Social, Behavioral, and Environmental Factors in Homelessness
Abstract
The goal of this research paper is to identify primary factors that causes homeless and lead to the prevalence of homelessness. By identifying these causes, strategies can be implemented by governments and institutions that can improve conditions for those that are susceptible to falling homeless. When evaluating these conditions this research paper will look at the social, environmental, behavioral strategies for intervention to help alleviate the suffering of the homeless. Also discussed will be the imperative of a public health response.
Tackling homeless is a difficult problem. Many mentally ill people become homeless because of their mental illness. Others because of drug and alcohol abuse. Also some people become homeless strictly because of financial insufficiency. But after becoming homeless all are exposed to significant trauma which makes helping this population even more difficult.
When trying to help this population an understanding of all the variables involved with homelessness must be identified, only then can interventions be designed which will help get them off the street. It is an imperative that public policy help this group as this population suffers most of all populations, falling victim to the highest rates of morbidity and mortality.
In this research paper I will identify the causes of homelessness. I will document different causal factors that lead to homelessness and finally I will offer some strategies of primary prevention for a problem that has so far been resistance to change. It is the hope of this writer that in understanding the varied causes of homelessness including genetics, poverty, mental illness, discrimination, some proposals can be put forward to help this underserved population.
Homelessness can not be isolated in one primary cause. If it could then primary strategies would be more easily implemented and homelessness would be minimized. Unfortunately the causes of homelessness are varied and therefore finding a singular strategy that fits all is useless. Because of the nature of homelessness being the result of a myriad of causes, the treatment regimen whether implemented environmentally, socially, or behaviorally has proven to be bordering on impossible. To look only at one factor is like trying to see the haystack by looking at a hayseed. My project will involve examining the causes of homelessness. In order to do this an attempt will be made to determine what are the primary factors involved. Only then can these primary factor be addressed.
Environmental and Social Determinates of Homelessness
The lack of success in preventing homelessness is evident. Homelessness is a problem around the world. While the homeless in earlier times were hidden from it's citizens, in the US homeless homelessness is more evident with the deinstitutionalization of the mentally ill, disbanded by mental health facilities. To focus on one risk factor of homelessness one must gloss over the history of failure to address the needs of this burgeoning population.
Buhrich notes the high incidence of schizophrenia. He attempts to estimate the percentage of a homeless populations prevalence of schizophrenia. The expanded Brief Psychiatric Rating Scale (BPRS-E) was used on two hundred and ten homeless men and women residing at or visiting the seven largest refuges in inner-Sidney Australia. An attempt is made to ascertain if with deinstitutionalization there was an increase in the homeless population. The results indicate that deinstitutionalization has not resulted in an increase in the homeless population at the homeless refugee centers. Yet measuring schizophrenia rates is difficult because those that participate underrepresent the homeless population who are less accessible (Buhrich, N., Hodder, T., Teesson, M., 2003). This result may be misleading.
Getting those that are homeless to participate in studies is difficult because of their lack of stability in their lives. They have no residence, no phone, no car and often little of no money. Those that are institutionalized are better able to be followed. Also many of those institutionalized may have been misdiagnosed and may not end up homeless. Therefore the deinstitutionalization of the mentally ill may have in fact increased the number of people on the street (Buhrich, N., Hodder, T., Teesson, M., 2003).
When looking at the conditions of homelessness one finds "As is true of homeless people in general, homeless substance abusers and mentally ill persons are characterized by extreme poverty; underutilization of public entitlements; isolation from family, friends, and other support networks; frequent contact with correctional agencies; and poor general health"(Fischer, P., Breakey, W., 2002) . The health care outcomes of the homeless are abysmal as demonstrated by the following report on a homeless man who sought care from a mobile clinic. It illustrates how the best intentions are often for naught. The homeless schizophrenics are less likely to avail themselves of care, and when their needs are addressed the untreated problems tend to be more advanced. Followup is minimal because of the mental disorganization of the homeless schizophrenic.
When attempting to help the homeless with health needs the provider must be cognizant of the possible lack of adherence to the treatment regimen because of mental illness or potential distrust of the provider. The homeless suffer an increased risk of mortality double of comparable housed patients. Homeless populations have a high prevalence of substance abuse and mental illness. Mental illness decreases the likelihood of receiving proper care. "Compared with controls having depression, homeless schizophrenic adults have fewer medical visits and fewer documented medical problems and are less likely to receive preventative care" (Hastings, J., Zulman, D., & Wali, S 2007).
Helplessness seems to be a constant theme of homelessness. This helplessness manifests itself not only by the homeless person being unable to take care of themselves but also finding themselves unable to navigate the problems presented by societal interaction. Some studies focus on the behavioral factors that decide homelessness (psychological factors) others focus on environmental factors (poverty). Once again this malady is not easily isolated. Schizophrenia has for a long time been thought to be genetic with environmental trigger but the mechanism by which this works is unknown. The schizophrenic homeless comprise a complex and intractable program.
The risk to the health of the homeless is clear and cannot be qualified. "Homeless people have a greatly increased risk of death. Compared with the general youth population of Quebec, mortality rates among street youth in Montreal are 9 times higher for males and 31 times higher for females. Among men using shelters for the homeless in Toronto, mortality rates are 8.3 times higher than the mean for 18-24 year olds, 3.7 times higher than the mean for 25-44 year olds and 2.3 times higher than the mean for 45-64 year olds" (Hwang, 2001). Governments have a moral obligation to address the problem of homelessness.
Looking at it from a narrower perspective is Baxter, tying the social impacts with the individual effects. "The causes of homelessness include unemployment, insufficient decent low-cost housing, and the mass deinstitutionalization of mental patients. The immediate event which precipitates homelessness may include eviction, conditions in prior residences, failure of aftercare provisions for discharged mental patients, withdrawal of familial supports, and loss of income" (Baxter, 1981).
It is found in this study that individuals with schizophrenia are overrepresented in the homeless population. Kelly talks about structural violence. People with schizophrenia are often victims of structural violence. These are the environmental factors that impact behavior negatively. One example of structural violence is that those with schizophrenia are also overrepresented among the prison population. Further structural violence occurs because incarceration increases stigma.
Schizophrenics are marginalized and don't have the option for participation in civic or social life. This population is unable to gain employment, accommodation, and unable to access medical and social services. "This structural violence may be understood by literature looking at socio-economic determinants, homelessness, migration and forensic psychiatry. By looking at the individual experience one can gain first hand knowledge of structural violence" (Kelly, 2005).
Yet the idea that the homeless, especially the mentally ill homeless, are not able to live in independent housing it not always clear. "Given that all study participants had been diagnosed with a serious mental illness, the residential stability demonstrated by residents in the Housing First program–which has one of the highest independent housing rates for any formerly homeless population–indicates that a person's psychiatric diagnosis is not related to his or her ability to obtain or to maintain independent housing" (Tsemberis, S., Gulcur, L., & Nakae, M. , 2004).
If it is true that the homeless are able to live in independent housing but are unable to acquire adequate housing, dislocation must be the result of social and environmental factors that preclude it. "A cohort study of homelessness among patients with schizophrenia in China using a logistic regression model. Significant predictors included a shabby and unstable house or shelter, positive family history of mental disorders, lack of income of the patient; and unmarried, divorced or separated. Multiple risk factors increased the likelihood of homelessness. Evidence indicated that unstably housed patients with schizophrenia would experience multiple psychosocial problems, had few supports and were significantly more likely to be literally homeless." (Ran, M., Chan, C., Chen, E., Xiang, M., Caine, E., Conwell, Y, 2006).
It is difficult to determine whether those that suffer from mental illness who are in dilapidated housing are there because of their inability to circumnavigate societies demands or whether this poor quality of life decreases social functioning. Those that are not considered to be classically mentally ill may find themselves on a downward spiral because of environmental pressures ultimately resulting in extreme dislocation
Behavioral Factors in Homelessness
Rather than looking at homelessness as simply a social problem, others look inside the homeless' psyche to find the answer. "Life circumstances have significant direct effects on depression…,[y]ounger persons, the chronically homeless, the street-based homeless, the sick and the less educated are also more likely to experience depression" (Gory, M., Ritchey, F., Mullis, J., 1990). The psychological effects of losing one's home and entering the ranks of the homeless are less well understood. "Given the suggestive research evidence presented the implications of psychological trauma theory, may result in many homeless individuals and families may be suffering both short- and long-term psychological devastation wrought by homelessness itself" (Goodman, L. A., Saxe, L., & Harvey, M. , 1991).
The psychological implications of homelessness is apparent. "People who are dually diagnosed with severe mental illness and substance use disorders constitute 10–20% of homeless persons" (Drake, R. E., Osher, F. C., & Wallach, M. A. , 1991). "An attempt is made to understand why some of those who are mentally ill become homeless while others do not. It was thought that schizophrenic men who became homeless would have poorer pre-illness social functioning, higher levels of the positive and negative symptoms of schizophrenia, greater abuse of drugs and alcohol, and more antisocial personality disorder. Also the homeless tend to have greater familial disorganization in childhood. It was thought the homeless would receive less help from the mental health system in finding housing and followup care. Using a case-control study it is shown that there are significantly higher levels of drug abuse, higher rates of antisocial personality disorder. It was shown that those that ended up homeless had not had access to therapy prior to becoming homeless. An association is shown between family disorganization in childhood and poor family support in adulthood. The study identified three domains of risk. Severity of mental illness, family background and prior mental health service use. Standard practice for discharging the homeless to shelters or streets functions to perpetuate the homelessness as this interrupts an mental health intervention because of the vicissitudes of the street" (Caton, C., Carol L. , Shrout, P., Eagle, P., Opler, L., & et al, 1994). It was thought that Xie "that by measuring behavior before the advent of homelessness one can decide what the risk of homelessness is for the individual studied is. Three groups were conceived forming a continuum beginning from milder symptoms to more severe. The mild group was referred to as the early-recovery group. This group was characterized by less severe substance use disorders at baseline and by use of Clozapine. The late recovery group took longer to adhere to treatment but when they did progress was made. This group had more serious substance abuse problems than the early recovery group. The no-recovery group was the largest group of the three. Lack of recovery referred to only substance abuse disorders in the no recovery group" (Xie, 2009).
Homelessness with those that were dual diagnosis (e.g. both mentally ill and substance abusers) took the longest to recover in Xie's study and one would expect this result to be replicated in the general population where treatment regimens are difficult to conform to because of the transient nature of homelessness.
Public Health Intervention
Even if the homeless can solve their social, psychological and behavioral problems, there are other barriers that confront them and this is the stigma. Once identified as homeless this person becomes a sort of outcast like someone from the Indian untouchable caste. "The homeless man is blamed no less than the domiciled man and generally is stigmatized more severely" (Phelan, J., Link,B., Moore, R., Stueve A., 1997). Even if those that are homeless whose psychologically functioning may improve, their integration back into society may be stilted. In my opinion this may be because first of all the previous behavior of the homeless person may make them suspect. Also those that come in contact with the previously non-domiciled person, may not want to recognize their own potential for falling homeless. It brings the aspect of homelessness to the individual who could have been them.
One way that homelessness is commonly looked at socially is in alienation from society. Homeless people experience growing alienation "Given that homelessness stems, at base, from an inability to afford housing, we next consider the structural conditions of the economy, housing markets, labor markets, and related factors that influence people's ability to afford housing…we look at the ways in which the United States has chosen to address homelessness from the federal level" (Burt, 2001). Only through recognizing environmental factors that lead to homelessness can public health official help the potential homeless before it is too late.
Public health policy must be modified to more clearly reflect the true causes of homelessness. "The magnitude of the problem of homelessness is much greater than most previous attempts to enumerate homeless people have led us to believe. This finding requires reconsideration of inferences about the causes of homelessness that were derived from point-prevalence studies of currently homeless people" (Link, B., Susser, E., Stueve, A., Phelan, J., Moore, R., & Struening, E. ,1994). When attacking the problem of homelessness one must be fully aware of the breadth and and depth of the problem. Not only is the challenge of helping the homeless in general overwhelming due to their numbers but the complexity of the dislocation is difficult to address in the individual.
By early intervention, considering behavioral, psychological and social environmental factors, the rate of homelessness can be reduced. Youth that are substance abusers must receive counseling early, those that suffer from mental disorders must also have professional psychological intervention, especially to prevent dual diagnosis that results in the potential to fall into homeless population. Public health policy must focus on social and environmental determinants. Problems such as poverty, abuse, discrimination, lack of access to medical care in order to help this disenfranchised population.
Discussion
When dealing with homelessness early intervention is vital. Only through primary interventions can this problem be solved. A multivariate approach must be implemented. Environmental, social and behavioral aspects that lead to homelessness must be addressed. After people become homeless, secondary intervention is difficult and may in fact be nearly impossible. Once deinstitutionalized or non-domiciled, reintegrating them back into society is very difficulty because of trauma they have faced being homeless. It is probably true that the longer one is homeless, the greater the trauma and therefore the more difficult to integrate them back into society. This difficulty of reintegration is a moot issue if they die prematurely. Because of the extreme difficulty of reintegrating the homeless back into society tertiary intervention almost become a moot issue.
With primary intervention mental health problems can be addressed early as mental health problems often manifest in the late teens or early twenties. But in order for there to be an effective primary intervention many variables must be addressed. While what follows is a wish list it would be helpful for example if those that were mentally ill received prompt treatment. This could be accomplished by having present in the schools and communities easy access to therapist who can help, be it in the schools or community health centers. Parent of teenagers and young persons in general must be made aware of the treatment options available to help. Maladies such as depression can be addressed early as well as more serious mental disorders such as those with manic-depression, schizo-affective disorder, and those with schizophrenia. The reason early intervention is necessary because if these serious cognitive disorders become apparent the less likely that a primary intervention will be effective because of increasing more severe dislocation over time.
In order for the mentally ill to be helped when they become ill a basic change would be needed to in society. Environmental, social and behavioral aspects that contribute to mental illness must all be addressed. In order to do this a more effective mental health delivery system would be needed and all of these mental health professionals would have to have access to both the economically privileged as well as the economically deprived. Only with an effective delivery system can homelessness be avoided, but it remains to be seen if it is more likely than not the case that this political will exists for such a change.
Not only must accessibility to mental health services be available in a timely manner but also those who struggle with adverse environmental pressures must be helped so as to be able to cope with the problem. As evidence seems to indicate, there are genetic factors that can lead to mental illness, there are also considered to be in some cases environmental factor. Finding genetic precursor to mental illness could provide a clue to those who might need help although their anonymity would need to be protected to prevent discrimination. Physical and psychology health of the family is vital for good mental health. Perhaps with much support with this fundamental strength that exists in the family, will the children be able to resist becoming susceptible to environmental pressures. Even with the genetic component if resilience in the face of environmental pressures can be achieved mental illness hopefully can be avoided.
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