research paper veteran homelessness

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Homelessness Among U.S. Veterans: Critical Perspectives

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Homelessness among Veterans has been of major public concern for over three decades. Tens of billions of federal dollars have been spent to prevent and end veteran homelessness. Substantial knowledge and progress has been gained from the many service providers, researchers, administrators, and policy makers around the country who have and continue to battle Veteran homelessness. This accumulated wealth of knowledge, lessons learned, and developed solutions need to be widely disseminated and shared to benefit the field. This book provides an overview on a range of multidisciplinary topic areas related to Veteran homelessness and highlights recent research and services that have been developed for this population. Areas that are covered include epidemiology; mental illness and substance abuse; primary care; housing models; criminal justice; money mismanagement; special subpopulations such as female veterans, Iraq/Afghanistan veterans, and aging veterans; and technology-based solutions. Together, this book underscores the collective work and progress made by those who serve the Department of Veterans Affairs and other organizations dedicated to homeless veterans around the country.

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• Introduction
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USICH, US Interagency Council on Homelessness.

eTable. Demographics of the Homeless Population From 2015 and 2022 PIT Counts

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O’Toole TP , Pape LM , Kane V, et al. Changes in Homelessness Among US Veterans After Implementation of the Ending Veteran Homelessness Initiative. JAMA Netw Open. 2024;7(1):e2353778. doi:10.1001/jamanetworkopen.2023.53778

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Changes in Homelessness Among US Veterans After Implementation of the Ending Veteran Homelessness Initiative

• 1 US Veterans Health Administration, Washington, DC
• 2 Providence Veterans Affairs Health System Center for Innovation in Long Term Services and Support, Providence, Rhode Island
• 3 Division of Medicine and Biology, Alpert Medical School at Brown University, Providence, Rhode Island

Question   What were the trends in homelessness among US veterans after implementation a Veterans Health Administration program to rehouse veterans experiencing homelessness?

Findings   In this cohort study using a mixed-methods analysis of 13 years of program data, during implementation of the Ending Veteran Homelessness initiative, there was a 55.3% decrease in homelessness among veterans compared with an 8.6% decrease for the general population.

Meaning   These findings suggest that health systems can play an important role in addressing community homelessness.

Importance   Homelessness is a persistent and growing problem. What role health systems should play and how that role is incorporated into larger strategic efforts are not well-defined.

Objective   To compare homelessness among veterans with that in the general population during a 16-year study period before and after implementation of the Ending Veteran Homelessness Initiative, a program to rehouse veterans experiencing homelessness.

Design, Setting, and Participants   This national retrospective cohort study using a mixed-methods approach examined annualized administrative (January 1, 2007, to December 31, 2022) and population data prior to (2007-2009) and during (2010-2022) the Ending Veteran Homelessness initiative. Participants included unhoused adults in the US between 2007 and 2022.

Exposure   Enrollment in Veterans Health Administration (VHA) Homeless Program Office components providing housing, case management, and wrap-around clinical and supportive services.

Main Outcomes and Measures   Point-in-time (PIT) count data for unhoused veterans and nonveterans during the study period, number of Section 8 housing vouchers provided by Housing and Urban Development–Veterans Administration Supportive Housing, number of community grants awarded by Supportive Services for Veterans and Families, and total number of veterans housed each year. Semistructured interviews with VHA leadership were performed to gain insight into the strategy.

Results   In 2022, 33 129 veterans were identified in the PIT count. They were predominantly male (88.7%), and 40.9% were unsheltered. During the active years of the Ending Veteran Homelessness initiative, veteran homelessness decreased 55.3% compared with 8.6% for the general population. The proportion of veterans in this cohort also declined from 11.6% to 5.3%. This change occurred during a shift to “housing first” as agency policy to create low-barrier housing availability. It was also coupled with substantial growth in housing vouchers, grants to community partner agencies, and growth in VHA clinical and social programming to provide homeless-tailored wrap-around services and support once participants were housed. Key respondent interviews consistently cited the shift to housing first, the engagement with community partners, and use of real-time data as critical.

Conclusions and Relevance   In this cohort study of the federal Ending Veteran Homelessness initiative, after program implementation, there was a substantially greater decrease in homelessness among veterans than in the general population. These findings suggest an important role for health systems in addressing complex social determinants of health. While some conditions unique to the VHA facilitated the change in homelessness, lessons learned here are applicable to other health systems.

Homelessness is a persistent problem in the US despite long-standing federal, state, and community efforts to address this need. While much of the focus on people who are unhoused centers around addiction, mental illnesses, physical disabilities, and chronic diseases that may be associated with individual homelessness, 1 structural factors—the lack of affordable housing, livable wages, or access to services—play an equally important role. 2

In 2010, the US Interagency Council on Homelessness, representing 19 federal agencies, released Opening Doors: Federal Strategic Plan to Prevent and End Homelessness. 3 One of the hallmarks of their plan was the adoption of a systems approach, including the adoption of “housing first” as a policy as opposed to a preferred program model. Housing first emphasizes low-barrier, rapid, and streamlined access to permanent supportive housing. This contrasts with the historic approach of requiring unhoused people to meet threshold criteria (eg, sobriety, employment) prior to housing being made available. Supportive services, including substance use services, mental health care, and job training, among others, are then provided and more easily accessed once participants are housed. Other elements of the federal plan called for increased collaboration to leverage and integrate resources of mainstream systems for housing, employment, education, health care, and income supports as well as using data to measure and improve system and program performance. 3

The US Department of Veterans Affairs (VA), as one of the participating federal agencies, actively implemented this plan with the goal of eliminating veteran homelessness by 2015. 4 The Ending Veteran Homelessness initiative built on and expanded VA homeless programming to reflect a continuum of wrap-around services that supported placement and retention in permanent supportive housing. These included outreach and engagement services; homelessness prevention; emergency and transitional housing; the US Housing and Urban Development–Veterans Administration Supportive Housing program (HUD-VASH), which links HUD-provided Section 8 housing vouchers with VA-supported case management services and expanded and tailored physical, mental, and substance use disorders care; and access to additional social determinants of health interventions (food and income security, justice programming) ( Figure 1 ). Key strategies of the Ending Veteran Homelessness initiative were the adoption of housing first as an agency policy and emphasizing partnerships with other federal agencies, state and local governments, and community agencies as operational partners.

In this report, we present data from a mixed-methods analysis to better understand the VA’s relative success in addressing the social determinants of housing security and reducing veteran homelessness. While the impact of the substantial financial support of this effort cannot be overstated, the specific role of policy changes, programming, community engagement, and the mobilization of an integrated health system to address social determinants of health needs are discussed.

We conducted a cohort study using a mixed-methods analysis looking at 16 years of data (3 baseline years and 13 programmatic years) tracking housing placement, community grants, and PIT data that we contextualized to interview responses from VA leadership involved in implementing the Ending Veteran Homelessness initiative. We followed the Strengthening the Reporting of Observational Studies in Epidemiology ( STROBE ) reporting guideline when applicable for the annual PIT count assessments and veteran HUD-VASH housing placements during the course of the study period and the Consolidated Criteria for Reporting Qualitative Research ( COREQ ) guideline for qualitative research in presenting interview data. The data were collected for operational purposes and deemed as an operational evaluation under VA Handbook 1200.51. 5 Use of deidentified PIT count and HUD-VASH data did not require informed consent; interviewees were informed of the intent of the project and provided written consent.

The cohort for this study represents operational data collected as part of the Ending Veteran Homelessness initiative. The longitudinal operational data of veterans experiencing homelessness comes from several sources, including HUD’s PIT annual incident count of general population and veteran-specific homelessness and VA operational data collected as part of this initiative. The initiative was conceived and preparatory steps were developed (including expanding existing programs and launching new programs) beginning in 2009. The baseline years are from January 1, 2007, to December 31, 2009, and action years are from January 1, 2010, to December 31, 2022.

The PIT is an annual head count of persons who are unsheltered or living in an emergency shelter or in transitional housing on a given night in January of each year, so that year’s data are predominantly affected by the previous year’s program activities. The count is conducted by volunteers within each community and is sponsored by HUD, with deidentified data with limited demographic features reported for each continuum of care community in the US. A continuum of care is defined by HUD as “a regional or local planning body that coordinates housing and services funding for homeless families and individuals.” 6 In the 2022 data, there were 388 continuum of care communities that reported data. The PIT count has been debated intensely, but it provides the best available national data on homelessness. Data on annualized national homelessness and veteran-specific homelessness counts are presented. It is not possible to track specific individuals across multiple PIT counts due to limits in the data collection and reporting process.

We focused on 2 programs: one representative of a permanent housing approach (HUD-VASH) and the other a prevention intervention (Supportive Services for Veterans and Families [SSVF]). Both also represented a significant portion of the overall budgetary outlay for this initiative. From publicly available sources, specifically the federal budget, congressional testimony, and program office data, we present annualized data on the number of HUD-VASH vouchers and SSVF community grants awarded. We also present the overall number of veterans engaged in VA programming who were housed each year. In context, there are currently 2.07 million people living in Section 8 project housing and 5.23 million people using a Housing Choice voucher. 7 However, the waitlist for those programs historically exceeds supply.

We conducted 8 semistructured interviews with Veterans Health Administration (VHA) Homeless Program Office leaders who were key figures during the implementation of the Ending Veteran Homelessness initiative. There were no nonparticipants. The interviews were methodologically oriented to a grounded theory of the underpinnings of the Ending Homeless Veteran initiative based on formative discussions with key leaders who were in place at the time of the initiative’s inception. These themes were further examined through purposive sampling of section and program leads responsible for operationalizing the initiative. The interviews focused on 3 thematic areas: (1) strategic changes, including new structures and programs needed within the VHA for this initiative; (2) policy changes that occurred; and (3) obstacles and challenges when implementing these policies along with mitigating steps. Interviews were conducted over email exchanges and telephone interviews with one of us (T.P.O.) who did not have any current supervisory relationship with any of the respondents.

In our analysis, we correlated the PIT data for the general population and veterans with programmatic data to describe differential effects of the Ending Veterans Homelessness initiative in the veteran cohort. We mapped those findings to HUD-VASH and SSVF program data and qualitative findings to support relational inferences of the noted trends. While direct causality could not be ascertained, there was value in our analytic approach to support our construct and conclusions.

To determine the 95% CIs for the annual PIT counts, we used the formula from the normal approximation, which allows for the use of population proportions to find an approximate distribution when the sample does not have the true population distribution. This approach was used to address data collection limitations inherent to the PIT. Standard errors were calculated using the sqrt[(P × [1 – P])]/n formula for proportions, while 95% CIs were calculated with X ± gnorm(0.975) × SE. Statistical significance ( P  < .05) among proportions of population subgroups in the general population and unhoused veterans in the 2022 and 2015 PIT counts was determined using 2-sample testing (Stata software, version 8 [StataCorp LLC]).

Limited demographic data on deidentified individuals were captured at each annual PIT count. In 2022, 33 129 veterans were identified; 88.7% were men; 10.4%, women; and 0.9% transgender, not singularly male or female, or gender questioning. In terms of race, 3.1% were American Indian or Alaska Native; 1.2%, Asian; 30.9%, Black; 1.3%, Native Hawaiian or Other Pacific Islander; 58.4%, White; and 5.1%, multiracial. A total of 12.2% were of Hispanic ethnicity. Compared with the general population of unhoused persons identified in 2022, more veterans were men (88.7% vs 60.6%; P  < .001) and White (58.4% vs 50.0%; P  < .001), and comparable proportions were unsheltered (40.9% vs 40.1%; P  = .004). The 2022 veteran demographic data were consistent with the veteran PIT data collected in 2015 except that fewer veterans were unsheltered in 2015 (34.0% vs 40.9%; P  < .001) (eTable in Supplement 1 ).

Figure 2 shows the PIT count for veterans from 2007 to 2022. The PIT count for veterans increased substantially from 60 998 in 2007 to 74 087 in 2010 before steadily dropping to 33 129 in 2022, a 55.3% decline from the 2010 peak. There was also a decline in the proportion of unhoused veterans compared with the overall population of unhoused persons in the PIT count, from 11.6% in 2010 to 5.6% in 2022. From 2016 to 2022, there was an increase in the PIT count in the general population, from 549 928 in 2016 to 582 462 in 2022, with most of that increase occurring between 2018 and 2020. In contrast, aside from a small increase from 2016 to 2017, there was a steady decline in veteran homelessness during that time, from 39 471 in 2016 to 33 129 in 2022. Because the data are deidentified, it was not possible to ascertain how many veterans were recounted in subsequent PIT counts or lost to follow-up.

Table 1 shows the growth of the HUD-VASH program, measured by the cumulative number of Section 8 vouchers allocated by HUD to unhoused veterans. The program grew at a substantial rate initially before stabilizing between 2% and 5% between 2016 and 2020. These vouchers are awarded through local public housing authorities, with the most socioeconomically disadvantaged communities receiving proportionately more. Also shown in Table 1 is the number of community grants awarded each year by the SSVF program. From its inception in 2011 to 2022, the number of community agencies working with the SSVF program tripled from 85 to 261. In 2022, the program served 102 306 veterans and their families.

Table 1 also includes the number of veterans placed in permanent housing each year. The number peaked in 2016 with 69 178 placed, coinciding with the largest number of SSVF community grants awarded in 2015 and 2016 and the largest increase in new HUD-VASH vouchers made available. In 2022, 40 401 veterans were placed in permanent housing, reversing a declining trend from that peak. These numbers do not include veterans who were prevented from becoming homeless or family members of unhoused veterans or of veterans at risk for homelessness who also benefited from these programs. Overall, 280 023 veterans were engaged in VHA homeless programs in 2022 and, cumulatively, an estimated 995 404 veterans and their families were either placed in permanent housing or prevented from becoming homeless between 2010 and 2022 (personal communication from the VHA Homeless Program Office; February 7, 2023).

A consistent theme among respondents was the synergy between adopting the housing first policy and the role of engaged partnerships in this initiative. This was shown in comments that housing first was not intended to be housing only and that the availability of wrap-around services provided by VHA medical centers needed to be actively incorporated into the community housing model. Another theme was the importance of real-time, actionable data (and data systems) that both increased accountability and the ability to pivot toward more effective strategies. Also noted in our semistructured interviews was the adoption of housing first and a focus on partnerships initially met with resistance from both community agencies and VA staff. There was community skepticism and concern about program requirements, data tracking, and accountability that came with these partnerships. The scope and context of the partnership was also not always clearly defined, leading to some confusion. Similarly, respondents noted that VA frontline staff voiced concerns about safety with the change in workspace and focus. Specific policies, requirements, and safeguards were needed to help alleviate this issue. Key comments from these interviews include the following 3 themes: (1) changes in strategy and philosophy toward homelessness and the role of VHA; (2) the effect of adopting a housing first policy, including areas and context when resistance was met; and (3) the role of operational partnerships and engagement with community agencies ( Table 2 ).

The PIT count is the current standard for quantifying community, population-specific, and national homelessness. While there are well-described limits to its interpretation, 8 the PIT count provides an opportunity to assess and benchmark temporal changes among subgroups of people experiencing homelessness, in this case veterans, with the overall homeless population. These data showed a substantially greater decline in homelessness among veterans compared with the general population from 2010, when the Ending Veteran Homelessness program was being launched, through 2022, when it was brought to scale, ultimately reflecting a 55.3% decline in homelessness among veterans compared with an 8.6% decline in the general population.

The reason for this difference is likely multifactorial. The guidance and leadership of the US Interagency Council on Homelessness; the leadership commitment and accountability to outcomes by the Secretary of the VA that extended to program offices, regional networks, and medical center directors; the financial investment and support by the US Congress spanning 3 administrations; and the partnerships with other branches of government and community agencies were all likely impactful. These factors are consistent with previous work to better understand how factors outside clinical care affect population health and social determinants of health. 9 The cross-sector alignment theory of change that resulted from that work, reported by Landers et al 10 and Lanford et al, 11 describes how health care, public health, and social services align and captures many of the elements noted in the Ending Veteran Homelessness initiative.

The interviews with project leaders underscored the importance of adopting housing first as a systemwide policy for housing placement. The housing first policy substantially changed who was being considered for housing placements, how permanent housing was considered an intervention, and how harm reduction and supportive services were incorporated. Equally important to the policy adoption was the VA’s investment in programs and services that allowed the model to work. The VA invested substantial resources in the development and expansion of case management support services, substance use disorder treatment, mental health services, and general medical care programming to veterans to provide the wrap-around care and supports needed once housed. Research examining fidelity to the housing first model identified this level of posthousing programming as a core domain element 12 , 13 associated with longer periods of housing stability, reductions in inpatient and emergency department use, and increases in outpatient services. 14 , 15 More broadly, the housing first policy reflected an implementation strategy of top-down policy changes coupled with grassroots investment in community-VHA partnerships. The combination was critical to ensuring the appropriate use of limited resources and community and health systems–level engagement of service providers.

The VHA also has certain advantages in building and implementing an initiative such as Ending Veteran Homelessness that other health systems may not experience. First, the moral imperative of meeting the needs of men and women who find themselves unhoused after they have served in the US military and whose homelessness is often a direct result of that military service 16 represents a shared national priority. This has led to strong congressional oversight, monitoring, and support for this effort, which has been critical. Second, the VHA is the nation’s largest integrated health care system with a management infrastructure to support advanced population health care programming (including housing support services and community partnerships to provide housing), enhanced capabilities for tracking and monitoring, and a reimbursement model similar to capitation that is less reliant on episode-of-care charges and billing. Last, the VHA, as an integrated health care system, is well situated to support a housing first model with the supportive clinical, case management, and social services needed to make it work. This dynamic is not always present in private sector health systems, which as noted in the literature, 17 , 18 can greatly challenge their ability to effectively intervene in a social determinant of health. However, these factors should not be construed to suggest that implementation of an initiative addressing homelessness is only possible in a federally funded, integrated health system. Academic health centers and community health systems have also successfully worked in this area. The framework of policy-driven processes that informs on-the-ground engagement and coordination of services is applicable broadly. It is also important to note the significant public health and societal impact of efforts to address homelessness that extends beyond the narrower scope of providing health services to the unhoused population that often defines the role of a health system.

There are several limitations and caveats to acknowledge when interpreting these findings. This was a retrospective analysis over an extended period looking at key variables likely influencing the relative accomplishments of the Ending Veteran Homelessness initiative. There may have been other factors, either internal or external to the VA, that might have been associated with the outcomes that were not identified or assessed. As noted previously, the PIT count has several well-described limitations that make determining missing data or loss to follow-up in a longitudinal assessment difficult. A formal correlation analysis of the different components of this initiative was beyond the scope of this study and the data available and should be considered in future research. As noted, the significant fiscal commitment to this effort, the strong congressional and Cabinet-level support, and the unique capacities of the VA to execute this project played important roles separate from any specific policy or program. Last, the qualitative data were limited to key leadership within the VHA Homeless Program Office when this initiative was launched. Their account of the project could have been impacted by recall bias; additional perspectives from other agencies, community groups, or veterans themselves were not collected.

In this cohort study using a mixed-methods analysis of the federal Ending Veteran Homelessness initiative, after program implementation, there was a substantially greater decrease in homelessness among veterans than in the general population. This change occurred during a shift to housing first as agency policy to create low-barrier housing availability. The data demonstrated the role of a health system in addressing a complex social determinant of health. Along with leadership commitment and resources, working to a model of care, adopting key policies, developing partnerships, and making key investments in programming and supports were critical. While some of these advantages are unique to the VHA, there are other aspects and lessons learned that can be adopted by other health systems.

Accepted for Publication: November 30, 2023.

Published: January 29, 2024. doi:10.1001/jamanetworkopen.2023.53778

Open Access: This is an open access article distributed under the terms of the CC-BY License . © 2024 O’Toole TP et al. JAMA Network Open .

Corresponding Author: Thomas P. O’Toole, MD, Harwood Research Center, Providence Veterans Affairs System Center for Innovation in Long Term Services and Support, 385 Niagara St, Providence, RI 02907 ( [email protected] ).

Author Contributions: Drs O’Toole and Rudolph had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: O’Toole, Pape, Kane, Diaz, Dunn.

Acquisition, analysis, or interpretation of data: O’Toole, Kane, Dunn, Rudolph, Elnahal.

Drafting of the manuscript: O’Toole, Kane, Rudolph.

Critical review of the manuscript for important intellectual content: All authors.

Statistical analysis: O’Toole, Dunn, Rudolph.

Obtained funding: Kane.

Administrative, technical, or material support: Pape, Diaz, Dunn, Rudolph, Elnahal.

Supervision: O’Toole, Elnahal.

Conflict of Interest Disclosures: Dr Rudolph reported receiving grant funding from the Department of Veterans Affairs during the conduct of the study and receiving grant funding from Brown University, Brown Physicians Inc, and Lifespan Health System outside the submitted work. No other disclosures were reported.

Data Sharing Statement: See Supplement 2 .

Additional Contributions: Keith Harris, PhD, VHA Homeless Program; John Kuhn, MSW, MBA, Greater Los Angeles Veterans Affairs Medical Center (VAMC); Anthony Love, MA, VHA Homeless Program; and Jesse Vazzano, MSW, Salt Lake City VAMC, contributed study advice, guidance, and data collection. Christopher Halladay, MSC, provided statistical assistance and advice.

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Connecting unstably housed veterans living in rural areas to health care: Perspectives from Health Care Navigators

Affiliations.

• 1 Department of Health Behavior, School of Public Health, University of Alabama at Birmingham, Birmingham, Alabama, USA.
• 2 Birmingham, AL Veterans Affairs Health Care System, Birmingham, Alabama, USA.
• 3 School of Social Policy & Practice, University of Pennsylvania, Philadelphia, Pennsylvania, USA.
• 4 Corporal Michael J. Crescenz Department of Veterans Affairs Medical Center, Philadelphia, Pennsylvania, USA.
• 5 South Central Mental Illness, Research, Education and Clinical Center, New Orleans, Louisiana, USA.
• 6 Southeast Louisiana Veterans Heath Care System, New Orleans, Louisiana, USA.
• 7 Section of Community and Population Medicine, Department of Medicine, Louisiana State University School of Medicine, New Orleans, Louisiana, USA.
• 8 VA Greater Los Angeles Healthcare System, Los Angeles, California, USA.
• 9 Health Systems Research Center for the Study of Healthcare Innovation, Implementation, and Policy, Los Angeles, California, USA.
• 10 Department of Psychiatry and Biobehavioral Sciences, Los Angeles David Geffen School of Medicine, University of California, Los Angeles, California, USA.
• 11 Center for Healthcare Organization & Implementation Research (CHOIR), VA Bedford Healthcare System, Bedford, Massachusetts, USA.
• 12 Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Bedford, Massachusetts, USA.
• 13 Boston Health Care for the Homeless Program, Bedford, Massachusetts, USA.
• PMID: 38726620
• DOI: 10.1111/1475-6773.14316

Objective: To understand existing care practices and policies, and potential enhancements, to improve the effectiveness of the US Department of Veterans Affairs (VA) Supportive Services for Veteran Families (SSVF) Health Care Navigators (HCN) in linking Veterans experiencing housing instability in rural areas with health care services.

Data sources and study setting: We used primary data collected during semistructured interviews with HCNs (n = 21) serving rural areas across the United States during Spring 2022.

Study design: We applied the Consolidated Framework for Implementation Research (CFIR) 2009 and the Social Ecological Model (SEM) to the collection and analysis of qualitative data to understand how HCNs administer services within SSVF and the larger community.

Data collection/extraction methods: We used rapid qualitative methods to summarize and analyze data. Templated matrix summaries identified facilitators and barriers to linking Veterans with health care services and policy and practice implications.

Principal findings: Using CFIR 2009, we identified contextual factors affecting successful implementation of HCN services within SSVF; we offer a crosswalk between CFIR 2009 and the version updated in 2022. Framing facilitators and barriers within the SEM provided insight into whether implementation strategies should be addressed at a community, interpersonal, or intrapersonal level within the SEM. Facilitators included sufficient knowledge, training, and mentorship opportunities for HCNs and their capacity to collaborate within their organization and with other community-based organizations. Barriers included lack of local technology and housing resources, inadequate understanding of Veterans' service eligibilities and pathways to access those services, and deficient collaboration with the VA.

Conclusions: Understanding facilitators and barriers experienced by HCN when linking unstably housed Veterans in rural areas with health care services can inform future strategies, including policy changes such as increased training to support HCNs' understanding of eligibility, benefits, and entitlements as well as improving communication and collaboration between VA and community partners.

Keywords: Health Care Navigator; homelessness; housing instability; implementation science; rural; veterans.

Published 2024. This article is a U.S. Government work and is in the public domain in the USA.

Grants and funding

• U.S. Department of Veterans Affairs, Office of Rural Health

Why Veterans Remain at Greater Risk of Homelessness

One way to stand up for former service personnel is to advocate for more affordable housing, says BU researcher

Thomas Byrne, a BU School of Social Work associate professor, calls homelessness a “really temporary phenomenon”—and says giving assistance to solve a short-term housing crisis usually leads to long-term stability. Photo by debbiehelbing/iStock

Andrew Thurston

The signs dot highway bridges and town halls, celebrating the return of armed services personnel from dangerous overseas missions. “Welcome Home,” they proudly, joyously, declare. But for many veterans—carrying the visible and invisible scars of battle, more vulnerable to suicide , physical and mental illness , and substance use disorders —the message rings hollow: they might not even have a stable home to return to. Ex-service members have long been at greater risk of homelessness than the general population.

Thomas Byrne , a Boston University School of Social Work associate professor, is an expert on homelessness, and among the researchers studying why veterans are more likely to land in shelters—and how to better help them. He says that a lack of affordable housing can make it especially tough for former service members to find a stable home, and that those who want to help them should advocate for more economical options.

Byrne has studied housing insecurity in rural areas , the effectiveness of Department of Veterans Affairs (VA) housing programs , and the community and structural drivers of homelessness , such as income inequality and housing affordability . His latest project is a major assessment of Supportive Services for Veteran Families , a program that provides grants to community organizations helping those at high risk of homelessness. One focus of the research is an initiative giving veterans flexible temporary financial assistance that they can use on anything from security deposits to utility bills.

“We’ve found it’s associated with better housing and health outcomes,” says Byrne, who is also an investigator at the VA’s National Center on Homelessness among Veterans and with the Center for Healthcare Organization & Implementation Research at the VA Bedford Healthcare System . “We’re also nearly there on a study that’s comparing participation in this program to a group of veterans who don’t get it, so we can as rigorously as possible estimate its impact.”

Byrne first became involved with the VA as a graduate researcher—but the work has taken on additional meaning in recent years.

“I have members of my immediate family who are on active duty,” says Byrne, “including one of my sisters and brother-in-law. I serendipitously became involved with the VA, but it also has a personal salience for me.”

The Brink spoke with Byrne about why veterans might be at greater risk of homelessness, the stigma faced by those dealing with housing insecurity, and what we can all do to help.

with Thomas Byrne

The brink: how big of an issue is homelessness among veterans i’ve read that while veterans have historically been at greater risk of homelessness, the situation is improving..

Byrne: The research , including some studies that I’ve been a part of , does show that veterans do face an elevated risk of homelessness relative to the general population. Folks may think that veterans face an elevated risk due to stressors they might experience while they’re on active duty, combat experiences. When you look specifically within members of the military, combat exposure and PTSD are associated with higher risk of homelessness. And when we are talking about the most recent generations who served in Iraq and Afghanistan, there is some evidence that the dynamics of their homelessness is different, in that they appear to become homeless more quickly after exiting the military as compared to older veterans. But, broadly speaking, it’s not entirely clear why veterans, as a group, have a higher risk than the civilian population. One possibility is that it has to do with the fact that military veterans are not necessarily representative of the general US population. There’s some evidence that you see the elevated risk of homelessness for veterans first show up when the military switched to an all-volunteer force. What you get is not necessarily a broad-based sample of the population entering the military. You have folks who have socioeconomic characteristics, and maybe life experiences, that may have put them at an elevated risk of homelessness even prior to their military service. And so they remain at an elevated risk once they discharge. I think that’s certainly a plausible theory.

The Brink: Veterans experiencing homelessness are mostly male, but are there other things, apart from service, that they have in common?

Byrne: Military veterans are a heterogeneous group with respect to premilitary, military, and post-military risk factors. There’s been some research that’s tried to look explicitly at those three things. A lot of the risk factors for homelessness in the general population—adverse life experiences, lack of economic resources— also apply to members of the military . For premilitary risk factors, adverse childhood experiences can contribute; during military service, traumatic experiences—whether it’s combat exposure, military sexual trauma; and then post-military factors—job loss, financial difficulties, dissolution of relationships. One of my colleagues did a study looking at risk factors among military veterans who served in the post-9/11 era, and one of the strongest was military pay grade, which is a proxy for socioeconomic status.

The Brink: How do you define homelessness, because different groups categorize it in different ways?

Byrne: When we’re talking about homelessness in the United States, there is a definition that is shared by the Department of Veterans Affairs and by the Department of Housing and Urban Development. And it is basically people who are living in emergency shelters or transitional housing, residential programs specifically meant for people experiencing homelessness, or people who are unsheltered—literally living on the streets or in places not meant for human habitation. When we’re talking about the number of veterans experiencing homelessness, it doesn’t count people who might be doubled up, or couch surfing, who might be in housing arrangements that are less than ideal or unstable in some way. For some context, on a given night, there are around 37,000 veterans experiencing homelessness across the United States, and that’s a number that’s decreased by about 50 percent since 2009. Homelessness is a dynamic phenomenon: most folks who are homeless only experience homelessness for a fairly short period of time, and so there’s a lot of turnover in the population. The big reductions in homelessness among veterans over the past 10 to 12 years has a lot to do with the investments that the Department of Veterans Affairs has made in housing programs.

The Brink: There’s still a lot of stigma around homelessness. Can you humanize it for us?

Byrne: In some ways, the stigma of homelessness is an extension of the stigma that surrounds poverty in this country more broadly. Some of that is just deeply rooted in what we—broadly speaking, as an American society—value in individualism and self-reliance. We see poverty and homelessness as moral failings of individuals, when in reality there’s a lot of evidence, including work that I’ve done , that links homelessness in the aggregate most strongly to housing market conditions, the lack of affordable housing. It’s often the product of structural factors that mean we’re going to have some amount of homelessness, and then individual vulnerabilities that place people at a higher risk. There’s a lot of stigma, but there ought not be. For most veterans and people who are experiencing homelessness, it’s a really temporary phenomenon. It’s not something that people fall into and never escape from—it’s a housing crisis that people experience. More often than not, if people get some assistance to resolve that housing crisis, they’re likely to remain stably housed thereafter. I think there’s less stigma when we’re talking about military veterans specifically, because of the social status that they hold in society. They’re a group of folks whom we as a society and our political leaders have decided merits special attention, and that’s come in the form of big investments in housing programs specifically for veterans experiencing homelessness. There’s been a lot of success from those efforts. I think that goes to show what can happen when you destigmatize the issue of homelessness and focus on solutions that work to address the problem.

The Brink: According to Pine Street Inn , “56 percent of all homeless veterans are African American or Hispanic.” It also seems the improvements you’ve talked about haven’t necessarily reached them evenly. What is causing those huge disparities?

Byrne: It’s part and parcel of the same structural forces that underpin lots of inequities in our society. When we’re talking specifically about housing, you can bring into the conversation things like redlining and discrimination in rental markets that may have historically made it more difficult for people of color to access housing and to build wealth, which might buffer them in the instance of an economic shock. What holds true in the broader population likely holds true for military veterans, as well.

The Brink: What’s one thing everyone reading this can do to help veterans and others experiencing homelessness?

Byrne: Ultimately, what’s at the root of homelessness, both among veterans and more broadly, are the issues of affordable housing and housing affordability. Wherever it’s within your power, advocate for the expansion of housing for folks who are experiencing homelessness or just everyone in general. Part of what motivates me to do this work is that I think having a safe, decent place to live is a really fundamental right, and prerequisite to having any kind of decent life. Everyone would want that for themselves and for their family members, so just think about it in those terms. If people want to get involved more specifically, there are certainly organizations that are working directly with veterans experiencing homelessness. There’s a number of them here, locally, in Boston and in Massachusetts that are doing really great work. There is also sometimes a gap where some funding sources can’t be used to pay for certain things that people might need to set up their apartment, for example, so there’s a real need for philanthropy to fill in and provide funds.

The Brink: Lastly, what message or advice would you have for veterans—or families of veterans—reading this who are concerned about their housing status?

Byrne: It’s not unusual for me to get emails directly from veterans who are experiencing homelessness. And there are two resources that I direct folks to. The first is the National Call Center for Homeless Veterans , a 24/7 hotline where trained staff work to connect veterans and others with VA and non-VA services. The phone number is 1-877-4AID-VET (1-877-424-3838). The second is Supportive Services for Veteran Families , a homelessness prevention and rapid rehousing program funded by the VA, but operated by community-based agencies. The VA’s website has a comprehensive list of providers throughout the country and their contact information.

This interview was edited for brevity and clarity.

Byrne’s veteran-specific work is supported by the Department of Veterans Affairs’ Health Services Research and Development Service, Quality Enhancement Research Initiative, and National Center on Homelessness among Veterans.

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Andrew Thurston is originally from England, but has grown to appreciate the serial comma and the Red Sox, while keeping his accent (mostly) and love of West Ham United. He joined BU in 2007, and is the editor of the University’s research news site, The Brink ; he was formerly director of alumni publications. Before joining BU, he edited consumer and business magazines, including for corporations, nonprofits, and the UK government. His work has won awards from the Council for Advancement and Support of Education, the In-House Agency Forum, Folio: , and the British Association of Communicators in Business. Andrew has a bachelor’s degree in English and related literature from the University of York. Profile

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Boston University moderates comments to facilitate an informed, substantive, civil conversation. Abusive, profane, self-promotional, misleading, incoherent or off-topic comments will be rejected. Moderators are staffed during regular business hours (EST) and can only accept comments written in English. Statistics or facts must include a citation or a link to the citation.

There are 3 comments on Why Veterans Remain at Greater Risk of Homelessness

I don’t believe any of our veterans should be homeless. It’s time our VA did the right thing for them.

I 100% agree! They need to make sure the people who sacrificed their bodies for x amount of time are taken care of.

I have the utmost respect for human life. Our veterans are believers in your safety. ITS A JOB not for many but resilience and determination they do it. I am currently waiting for a homeless service man now. I live in a travel trailer small but to help and feed one who protects my family and myself , it’s a honor to give back what they do for me. Thanks ps love is free….

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Homelessness and Public Health: A Focus on Strategies and Solutions

David a. sleet.

1 School of Public Health, San Diego State University, San Diego, CA 92182, USA; moc.liamg@teelsadivad

2 Veritas Management, Inc., Atlanta, GA 30324, USA

Louis Hugo Francescutti

3 School of Public Health, University of Alberta, Edmonton, AB T6G 1C9, Canada

4 Faculty of Medicine & Dentistry, University of Alberta, Edmonton, AB T6G 1C9, Canada

5 Royal Alexandra Hospital, Edmonton, AB T5H 3V9, Canada

On any given night, hundreds of thousands of people are homeless in the United States and Canada. Globally, the problem is many times worse, making homelessness a global public health and environmental problem. The facts [ 1 ] are staggering:

• On a single night in January 2020, 580,466 people (about 18 out of every 10,000 people) experienced homelessness across the United States—a 2.2% increase from 2019.
• While 61% percent of the homeless were staying in sheltered locations, the remainder—more than 226,000 people—were in unsheltered locations on the street, in abandoned buildings, or in other places not suitable for human habitation.
• Homelessness has increased in the last four consecutive years.
• The increase in unsheltered homelessness is driven largely by increases in California.
• In 2020, 171,575 people in families with children experienced homelessness on a single night.
• A total of 3598 homeless people were children under the age of 18 without an adult present.
• Veterans comprised 8% of all homeless adults (over 46,000 veterans struggle with homelessness).
• People of color are significantly over-represented among those experiencing homelessness.

A layman’s definition of homelessness is usually “a person that has no permanent home”. However, many scholars have divided the broad group of people characterized as homeless into three (or more) categories:

• - People without a place to reside;
• - People in persistent poverty, forced to move constantly, and who are homeless for even brief periods of time;
• - People who have lost their housing due to personal, social, or environmental circumstances.

While this definition refers specifically to homeless individuals, it is equally applicable to homeless families.

Homelessness is closely connected to declines in physical and mental health. Homeless persons experience high rates of health problems such as Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome (HIV/AIDS) and Hepatitis A infections, alcohol and drug addiction, mental illness, tuberculosis, and other serious conditions. The health problems facing homeless persons result from various factors, including a lack of housing, racism and discrimination, barriers to health care, a lack of access to adequate food and protection, limited resources for social services, and an inadequate public health infrastructure. Legal and policy interventions have often been used to attempt to address homelessness, although not always from a public health perspective.

In health care, for example, if someone experiencing homelessness comes to an emergency department for medical aid, once treated, the only alternative is to release the patient back onto the street. This creates an endless cycle of emergency department visits, increasing costs and expending resources in the health care system.

Recent work [ 2 ] has emphasized the important role of public health, the health care system, and health care providers in homelessness prevention. In this Special Issue of the International Journal of Environmental Research and Public Health (IJERPH), we have brought together researchers, practitioners, and community organizers to articulate the public health problem of homelessness and identify clear strategies to reduce homelessness and provide more adequate health care and housing for this population. We also explore solutions for important subpopulations, including adults, families with children, adolescents, women, transitional aged youth, and those suffering from mental illness, PTSD, alcohol dependency, mental illness, adverse childhood experiences, and chronic homelessness.

We address many of these issues in the context of public health and explore the public health implications and potential solutions to homelessness, focusing on contemporary and emerging research and innovative strategies, and highlighting best practices to address homelessness among key populations. The papers in this Special Issue attempt to answer several questions related to homelessness and public health, such as:

• What is the extent of homelessness and why do people become homeless?
• What are the public health and health services implications of homelessness?
• What role does housing play as a precursor to and potential solution for homelessness?
• What public health and health care interventions are being employed, and what effectiveness is being achieved?
• What long-term strategies can be developed to prevent homelessness?

The 13 research papers and one commentary in this Special Issue are summarized as follows:

• Conceptualizing an Interdisciplinary Collective Impact Approach to Examine and Intervene in the Chronic Cycle of Homelessness. This study by Abdel–Samad et al. [ 3 ] focuses on a novel, interdisciplinary academic–practice partnership model for addressing the problem of homelessness. Whereas singular disciplinary approaches may fall short in substantially reducing homelessness, this approach draws from a collective impact model that integrates discipline-specific approaches through mutually reinforcing activities and shared metrics. The paper describes what is necessary for capacity-building at the institution and community levels, the complementary strengths and contributions of each discipline in the model, and future implementation goals to address homelessness in the Southern California region using a cross-disciplinary approach.
• Mental Illness and Youth-Onset Homelessness: A Retrospective Study among Adults Experiencing Homelessness . Iwundu et al. [ 4 ] conducted a retrospective study and evaluated the association between the timing of homelessness onset (youth versus adult) and mental illness. The results indicated that mental illness (as a reason for current homelessness) and severe mental illness comorbidities were each associated with increased odds of youth-onset homelessness, providing a basis for agencies that serve at-risk youth in order to address mental health precursors to youth homelessness.
• Well-Being without a Roof: Examining Well-Being among Unhoused Individuals Using Mixed Methods and Propensity Score Matching. Ahuja et al. [ 5 ] found that the mean overall well-being score of unhoused participants was significantly lower than that of matched housed participants, with unhoused participants reporting lower mean scores for social connectedness, lifestyle and daily practices, stress and resilience, emotions, physical health, and finances. The unhoused participants had a statistically significantly higher mean score for spirituality and religiosity than their matched housed counterparts. The qualitative interviews highlighted spirituality and religion as a coping mechanism for the unhoused.
• Combatting Homelessness in Canada: Applying Lessons Learned from Six Tiny Villages to the Edmonton Bridge Healing Program. Authors Wong et al. [ 6 ] discuss the Bridge Healing Program in Edmonton, Alberta, a novel approach to combatting homelessness by using hospital emergency departments (ED) as a gateway to temporary housing. The program provides residents with immediate temporary housing before transitioning them to permanent homes. The paper discusses effective strategies that underlie the Tiny Villages concept by analyzing six case studies and applying the lessons learned to improving the Bridge Healing Program and reducing repeat ED visits and ED lengths of stay among homeless individuals.
• Change in Housing Status among Homeless and Formerly Homeless Individuals in Quebec, Canada: A Profile Study. Kaltsidis et al. [ 7 ] used a cluster analysis to develop a typology of the housing status change for 270 currently or formerly homeless individuals who were residing in shelters and temporary or permanent housing. The findings suggest that the maintenance or improvement in the housing status requires the availability of suitable types and frequencies of service use (enabling factors) that are well-adapted to the complexity of health problems (needs factors) among homeless individuals. Specific interventions, such as outreach programs and case management, are prioritized as necessary services, especially for individuals at a higher risk of returning to homelessness.
• Urban Stress Indirectly Influences Psychological Symptoms through Its Association with Distress Tolerance and Perceived Social Support among Adults Experiencing Homelessness. To investigate the simultaneous impact of intrapersonal characteristics (distress tolerance) and interpersonal characteristics (social support) and their association with homelessness, Hernandez et al. [ 8 ] recruited homeless adults from six homeless shelters in Oklahoma City who self-reported urban life stress, distress tolerance, social support, major depressive disorder, and PTSD symptoms. Based on the resulting associations, their findings stress the importance of implementing interventions aimed at increasing social support for homeless persons, something that may also increase skill development for distress tolerance and indirectly lead to a reduction in depression and PTSD.
• “I Felt Safe”: The Role of the Rapid Rehousing Program in Supporting the Security of Families Experiencing Homelessness in Salt Lake County, Utah. Garcia and Kim [ 9 ] describe their research into The Road Home (TRH) program, which provides services to homeless individuals and families. TRH is known for their emergency shelters and also administers the Rapid Rehousing Program (RRHP), designed to help homeless families transition back into stable housing. After collecting qualitative data from focus groups with participants and families, landlords, case managers, and service providers, they make recommendations for program improvements that can increase the residential security of families experiencing homelessness.
• “It’s Just a Band-Aid on Something No One Really Wants to See or Acknowledge”: A Photovoice Study with Transitional Aged Youth Experiencing Homelessness to Examine the Roots of San Diego’s 2016–2018 Hepatitis A Outbreak. In this study, Felner et al. [ 10 ] examined the experiences and needs of transitional aged youth (TAY) aged 18–24 experiencing homelessness who may have been uniquely affected by an unprecedented outbreak of hepatitis A virus (HAV). The findings documented a stigmatization of TAY, interventions that failed to address root causes of the outbreak, and interactions with housing- and social support-related resources that limited rather than supported economic and social mobility. The findings have implications for understanding how media and public discourse, public health interventions, and the availability and delivery of resources can contribute to and perpetuate stigma and health inequities faced by TAY experiencing homelessness.
• Predictors of Overnight and Emergency Treatment among Homeless Adults. Iwundu et al. [ 11 ] aimed to identify the sociodemographic predictors associated with overnight and emergency hospital treatment among a sample of homeless adults. Participants were recruited from a shelter in Dallas, Texas and were predominantly uninsured, low-income men and women from various social and ethnic groups. In logistic regression models, gender emerged as the only predictor of overnight treatment in a hospital and treatment in an emergency department. Women were more likely than men to be treated overnight and use emergency care. The authors concluded that interventions and policies targeted toward homeless women’s primary health care needs would reduce health care costs.
• Association of Problematic Alcohol Use and Food Insecurity among Homeless Men and Women. In a study on alcohol use and food insecurity among homeless men and women, Reitzel et al. [ 12 ] investigated the link between problematic alcohol use and food insecurity among homeless adults in Oklahoma. Problematic alcohol use was measured using the Alcohol Quantity and Frequency Questionnaire and the Patient Health Questionnaire. Food insecurity was measured with the USDA Food Security Scale-Short Form. The results indicated that heavy drinking and probable alcohol dependence/abuse were each associated with increased odds of food insecurity. The results question whether alcohol may take precedence over eating or food purchases among this population of homeless individuals.
• Exploring Tiny Homes as an Affordable Housing Strategy to Ameliorate Homelessness: A Case Study of the Dwellings in Tallahassee, FL. “Tiny Homes” is an emerging strategy to combat homelessness, and Jackson et al. [ 13 ] raise a number of questions about the intentions, efficacy, and policy feasibility of this strategy. The paper seeks to understand the strategies used by stakeholders to plan, design, and implement a “Tiny Homes” strategy, and to assess their effectiveness. Using a case study, they examined how the community was planned, the experiences of residents, and the constraints to success. Their findings highlighted how funding constraints and NIMBYism (Not in My Backyard-ism) stymied stakeholder efforts to achieve equity and affordability, resulting in the inability to achieve project aims to develop affordable housing that served homeless populations.
• Predictors of Emergency Department Use among Individuals with Current or Previous Experience of Homelessness. The study by Gabet et al. [ 14 ] assessed the contributions of predisposing, enabling, and needs factors in predicting emergency department (ED) use among 270 individuals with a current or previous experience of homelessness. Participants were recruited from types of housing in Montreal, Quebec (Canada) and were interviewed about their ED use at baseline and again 12 months later. The findings revealed two needs factors associated with ED use: having a substance use disorder and low perceived physical health. Two enabling factors—the use of ambulatory specialized services and stigma—were also related to ED use. ED use was not associated with the type of housing. The authors suggest that improvements are needed to manage substance use disorders and the physical health of homeless individuals in order to reduce ED use.
• Being at the Bottom Rung of the Ladder in an Unequal Society: A Qualitative Analysis of Stories of People without a Home. The Mabhala and Yohannes article [ 15 ] examines the stories of homeless people and their perceptions of their social status using interviews in three centers for homeless people in Cheshire, in the English Northwest. Education, employment, and health were three domains that provided a theoretical explanation for the reasons that led to their homelessness. Participants catalogued their adverse childhood experiences, which they believe limited their capacity to meaningfully engage with social institutions for social goods, such as education, social services, and institutions of employment. They conclude that, although not all people who are poorly educated, in poor health, and unemployed end up being homeless, a combination of these together with multiple adverse childhood experiences may weaken resilience and contribute to homelessness.
• Commentary: Investing in Public Health Infrastructure to Address the Complexities of Homelessness. In a final commentary, Allegrante and Sleet [ 16 ] introduce the notion that investments in public health infrastructure are needed to address the complexities of homelessness, including the continued threats posed by SARS-CoV-2 (COVID-19) and its variants. The lack of affordable housing, widespread unemployment, poverty, addiction and mental illness, which all contribute to the risk of homelessness, would be well-served by improving the fundamental public health infrastructure. They argue that homelessness is exacerbated by system-wide infrastructure failures at the municipal, state and federal governments and from the neglect to invest in public infrastructure, including a modern public health system.

In conclusion, shelter is a basic human need. Thus far, we have an inadequate understanding of all the medical and nonmedical, public health, and infrastructural influences that drive homelessness and why so many people are living without adequate shelter. Housing is one of the most critical factors in addressing homelessness and one of the best-researched social determinants of health. Several articles here focus on innovative approaches to providing temporary or permanent housing for those who need it, and it is well known that selected housing interventions can improve health and decrease health care costs. From that perspective, some professionals in the field contend that housing equates to health [ 17 ] and that improved housing options for homeless individuals and families would advance population-level health.

Many of the articles in this Special Issue [ 18 ] focus on specific aspects of life, quality of life, and co-morbidities related to behavioral and social variables influencing homelessness. Explored in detail are factors such as lack of housing, distress, wellness, emergency department use, mental health, drug and alcohol addiction, poverty, low educational attainment, inadequate health care and social services, adverse childhood experiences, ongoing infections, unemployment, and public health infrastructure. In addition to highlighting the impact these factors can have on the likelihood that someone would become homeless, many of the articles also provide recommendations for relevant policies, practices, and interventions that could help reduce homelessness and improve overall well-being.

The intersection of environmental, behavioral, and social factors, in addition to the lack of an adequate infrastructure, must also be considered when studying the determinants of homelessness and designing appropriate interventions. Our ultimate goal in producing this Special Issue of IJERPH is to encourage the development of better evidence to inform public health, social services, and medical care policies and practices that will result in better health for homeless populations.

Acknowledgments

We thank the authors and reviewers for their commitment to preparing and editing these manuscripts and for adding to the knowledge base of this important public health problem.

Conflicts of Interest

The authors declare no conflict of interest.

Publisher’s Note: MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affiliations.

• Open access
• Published: 22 August 2017

Social conditions of becoming homelessness: qualitative analysis of life stories of homeless peoples

• Mzwandile A. Mabhala   ORCID: orcid.org/0000-0003-1350-7065 1 , 3 ,
• Asmait Yohannes 2 &
• Mariska Griffith 1  

International Journal for Equity in Health volume  16 , Article number:  150 ( 2017 ) Cite this article

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It is increasingly acknowledged that homelessness is a more complex social and public health phenomenon than the absence of a place to live. This view signifies a paradigm shift, from the definition of homelessness in terms of the absence of permanent accommodation, with its focus on pathways out of homelessness through the acquisition and maintenance of permanent housing, to understanding the social context of homelessness and social interventions to prevent it.

However, despite evidence of the association between homelessness and social factors, there is very little research that examines the wider social context within which homelessness occurs from the perspective of homeless people themselves. This study aims to examine the stories of homeless people to gain understanding of the social conditions under which homelessness occurs, in order to propose a theoretical explanation for it.

Twenty-six semi-structured interviews were conducted with homeless people in three centres for homeless people in Cheshire North West of England.

The analysis revealed that becoming homeless is a process characterised by a progressive waning of resilience capacity to cope with life challenges created by series of adverse incidents in one’s life. The data show that final stage in the process of becoming homeless is complete collapse of relationships with those close to them. Most prominent pattern of behaviours participants often describe as main causes of breakdown of their relationships are:

engaging in maladaptive behavioural lifestyle including taking drugs and/or excessive alcohol drinking

Being in trouble with people in authorities.

Homeless people describe the immediate behavioural causes of homelessness, however, the analysis revealed the social and economic conditions within which homelessness occurred. The participants’ descriptions of the social conditions in which were raised and their references to maladaptive behaviours which led to them becoming homeless, led us to conclude that they believe that their social condition affected their life chances: that these conditions were responsible for their low quality of social connections, poor educational attainment, insecure employment and other reduced life opportunities available to them.

It is increasingly acknowledged that homelessness is a more complex social and public health phenomenon than the absence of a place to live. This view signifies a paradigm shift, from the definition of homelessness in terms of the absence of permanent accommodation [ 1 , 2 , 3 , 4 , 5 ], with its focus on pathways out of homelessness through the acquisition and maintenance of permanent housing [ 6 ], to understanding the social context of homelessness and social interventions to prevent it [ 6 ].

Several studies explain the link between social factors and homelessness [ 6 , 7 , 8 , 9 , 10 ]. The most common social explanations centre on seven distinct domains of deprivation: income; employment; health and disability; education, skills and training; crime; barriers to housing and social support services; and living environment [ 11 ]. Of all forms, income deprivation has been reported as having the highest risk factors associated with homelessness [ 7 , 12 , 13 , 14 ]: studies indicate that people from the most deprived backgrounds are disproportionately represented amongst the homeless [ 7 , 13 ]. This population group experiences clusters of multiple adverse health, economic and social conditions such as alcohol and drug misuse, lack of affordable housing and crime [ 10 , 12 , 15 ]. Studies consistently show an association between risk of homelessness and clusters of poverty, low levels of education, unemployment or poor employment, and lack of social and community support [ 7 , 10 , 13 , 16 ].

Studies in different countries throughout the world have found that while the visible form of homelessness becomes evident when people reach adulthood, a large proportion of homeless people have had extreme social disadvantage and traumatic experiences in childhood including poverty, shortage of social housing stocks, disrupted schooling, lack of social and psychological support, physical, sexual, and emotional abuse, neglect, dysfunctional family environments, and unstable family structures, all of which increase the likelihood of homelessness [ 10 , 13 , 14 ].

Furthermore, a large body of evidence suggests that people exposed to diverse social disadvantages at an early age are less likely to adapt successfully compared to people without such exposure [ 9 , 10 , 13 , 17 ], being more susceptible to adopting maladaptive coping behaviours such as theft, trading sex for money, and selling or using drugs and alcohol [ 7 , 9 , 18 , 19 ]. Studies show that these adverse childhood experiences tend to cluster together, and that the number of adverse experiences may be more predictive of negative adult outcomes than particular categories of events [ 17 , 20 ]. The evidence suggests that some clusters are more predictive of homelessness than others [ 7 , 12 ]: a cluster of childhood problems including mental health and behavioural disorders, poor school performance, a history of foster care, and disrupted family structure was most associated with adult criminal activities, adult substance use, unemployment and subsequent homelessness [ 12 , 17 , 21 ]. However, despite evidence of the association between homelessness and social factors, there is very little research that examines the wider social context within which homelessness occurs from the perspective of homeless people themselves.

This paper adopted Anderson and Christian’s [ 18 ] definition, which sees homelessness as a ‘function of gaining access to adequate, affordable housing, and any necessary social support needed to ensure the success of the tenancy’. Based on our synthesis of the evidence, this paper proposes that homelessness is a progressive process that begins at childhood and manifests itself at adulthood, one characterised by loss of the personal resources essential for successful adaptation. We adopted the definition of personal resources used by DeForge et al. ([ 7 ], p. 223), which is ‘those entities that either are centrally valued in their own right (e.g. self-esteem, close attachment, health and inner peace) or act as a means to obtain centrally valued ends (e.g. money, social support and credit)’. We propose that the new paradigm focusing on social explanations of homelessness has the potential to inform social interventions to reduce it.

In this study, we examine the stories of homeless people to gain understanding of the conditions under which homelessness occurs, in order to propose a theoretical explanation for it.

The design of this study was philosophically influenced by constructivist grounded theory (CGT). The aspect of CGT that made it appropriate for this study is its fundamental ontological belief in multiple realities constructed through the experience and understanding of different participants’ perspectives, and generated from their different demographic, social, cultural and political backgrounds [ 22 ]. The researchers’ resulting theoretical explanation constitutes their interpretation of the meanings that participants ascribe to their own situations and actions in their contexts [ 22 ].

The stages of data collection and analysis drew heavily on other variants of grounded theory, including those of Glaser [ 23 ] and Corbin and Strauss [ 24 ].

Setting and sampling strategy

The settings for this study were three centres for homeless people in two cities (Chester and Crewe) in Cheshire, UK. Two sampling strategies were used in this study: purposive and theoretical. The study started with purposive sampling and in-depth one-to-one semi-structured interviews with eight homeless people to generate themes for further exploration.

One of the main considerations for the recruitment strategy was to ensure that the process complies with the ethical principles of voluntary participation and equal opportunity to participate. To achieve this, an email was sent to all the known homeless centres in the Cheshire and Merseyside region, inviting them to participate. Three centres agreed to participate, all of them in Cheshire – two in Chester and one in Crewe.

Chester is the most affluent city in Cheshire and Merseyside, and therefore might not be expected to be considered for a homelessness project. The reasons for including it were: first, it was a natural choice, since the organisations that funded the project and the one that led the research project were based in Chester; second, despite its affluence, there is visible evidence of homelessness in the streets of Chester; and third, it has several local authority and charity-funded facilities for homeless people.

The principal investigator spent 1 day a week for 2 months in three participating centres, during that time oral presentation of study was given to all users of the centre and invited all the participants to participate and written participants information sheet was provided to those who wished to participate. During that time the principal investigator learned that the majority of homeless people that we were working with in Chester were not local. They told us that they came to Chester because there was no provision for homeless people in their former towns.

To help potential participants make a self-assessment of their suitability to participate without unfairly depriving others of the opportunity, participants information sheet outline criteria that potential participants had to meet: consistent with Economic and Social Research Council’s Research Ethics Guidebook [ 25 ], at the time of consenting to and commencing the interview, the participant must appear to be under no influence of alcohol or drugs, have a capacity to consent as stipulated in England and Wales Mental Capacity Act 2005 [ 26 ], be able to speak English, and be free from physical pain or discomfort.

As categories emerged from the data analysis, theoretical sampling was used to refine undeveloped categories in accordance with Strauss and Corbin’s [ 27 ] recommendations. In total 26 semi-structured interviews were carried out. Theoretical sampling involved review of memos or raw data, looking for data that might have been overlooked [ 27 , 28 ], and returning to key participants asking them to give more information on categories that seemed central to the emerging theory [ 27 , 28 ].

The sample comprised of 22 male and 4 female, the youndgest participant was 18 the eldest was 74 years, the mean age was 38.6 years. Table 1 illustrates participant’s education history, childhood living arrangements, brief participants family and social history, emotional and physical health, the onset of and trigger for homelessness.

Ethical approval

Ethical approval was obtained from the Research Ethics Committee of the University of Chester. The centre managers granted access once ethical approval had been obtained, and after their review of the study design and other research material, and of the participant information sheet which included a letter of invitation highlighting that participation was voluntary.

Data analysis

In this study data collection and analysis occurred simultaneously. Analysis drew on Glaser’s [ 23 ] grounded theory processes of open coding, use of the constant comparative method, and the iterative process of data collection and data analysis to develop theoretical explanation of homelessness.

The process began by reading the text line-by-line identifying and open coding the significant incidents in the data that required further investigation. The findings from the initial stage of analysis are published in Mabhala [ 29 ]. The the second stage the data were organised into three themes that were considered significant in becoming homeless (see Fig. 1 ):

Engaging in maladaptive behaviour

Being in trouble with the authorities.

Being in abusive environments.

Social explanation of becoming homeless. Legend: Fig. 1 illustrates the process of becoming homeless

The key questions that we asked as we continued to interrogate the data were: What category does this incident indicate? What is actually happening in the data? What is the main concern being faced by the participants? Interrogation of the data revealed that participants were describing the process of becoming homeless.

The comparative analysis involved three processes described by Glaser ([ 23 ], p. 58–60): each incident in the data was compared with incidents from both the same participant and other participants, looking for similarities and differences. Significant incidents were coded or given labels that represented what they stood for, and similarly coded or labeled when they were judged to be about the same topic, theme or concept.

After a period of interrogation of the data, it was decided that the two categories - destabilising behaviour, and waning ofcapacity for resilience were sufficiently conceptual to be used as theoretical categories around which subcategories could be grouped (Fig. 1 ).

Once the major categories had been developed, the next step consisted of a combination of theoretical comparison and theoretical sampling. The emerging categories were theoretically compared with the existing literature. Once this was achieved, the next step was filling in and refining the poorly defined categories. The process continued until theoretical sufficiency was achieved.

Figure 1 illustrates the process of becoming homeless. The analysis revealed that becoming homeless is a process characterised by a progressive waning of resilience created by a series of adverse incidents in one’s life. Amongst the frequently cited incidents were being in an abusive environment and losing a significant person in one’s life. However, being in an abusive environment emerged from this and previously published studies as a major theme; therefore, we decided to analyse it in more detail.

The data further show that the final stage in the process of becoming homeless is a complete collapse of relationships with those with whom they live. The most prominent behaviours described by the participants as being a main cause of breakdown are:

Engaging in maladaptive behaviour: substance misuse, alcoholism, self-harm and disruptive behaviours

Being in trouble with the authorities: theft, burglary, arson, criminal offenses and convictions

The interrogation of data in relation to the conditions within which these behaviours occurred revealed that participants believed that their social contexts influenced their life chance, their engagement with social institution such as education and social services and in turn their ability to acquire and maintain home. Our experiences have also shown that homeless people readily express the view that behavioural lifestyle factors such as substance misuse and engaging in criminal activities are the causes of becoming homeless. However, when we spent time talking about their lives within the context of their status as homeless people, we began to uncover incidents in their lives that appeared to have weakened their capacity to constructively engage in relationships, engage with social institutions to make use of social goods [ 29 , 30 , 31 ] and maturely deal with societal demands.

Being in abusive environments

Several participants explicitly stated that their childhood experiences and damage that occurred to them as children had major influences on their ability to negotiate their way through the education system, gain and sustain employment, make appropriate choices of social networks, and form and maintain healthy relationships as adults.

It appears that childhood experiences remain resonant in the minds of homeless participants, who perceive that these have had bearing on their homelessness. Their influence is best articulated in the extracts below. When participants were asked to tell their stories of what led to them becoming homeless, some of their opening lines were:

What basically happened, is that I had a childhood of so much persistent, consistent abuse from my mother and what was my stepfather. Literally consistent, we went around with my mother one Sunday where a friend had asked us to stay for dinner and mother took the invitation up because it saved her from getting off her ass basically and do anything. I came away from that dinner genuinely believing that the children in that house weren’t loved and cared for, because they were not being hit, there was no shouting, no door slamming. [Marco]

It appears that Marco internalised the incidents of abuse, characterised by shouting, door slamming and beating as normal behaviour. He goes on to intimate how the internalised abusive behaviour affected his interaction with his employers.

‘…but consistently being put down, consistently being told I was thick, I started taking jobs and having employers effing and blinding at me. One employer actually used a “c” word ending in “t” at me quite frequently and I thought it was acceptable, which obviously now I know it’s not. So I am taking on one job after another that, how can I put it? That no one else would do basically. I was so desperate to work and earn my own money. [Marco]

Similarly, David makes a connection between his childhood experience and his homelessness. When he was asked to tell his life story leading to becoming homeless, his opening line was:

I think it [homelessness] started off when I was a child. I was neglected by my mum. I was physically and mentally abused by my mum. I got put into foster care, when I left foster care I was put in the hostel, from there I turn into alcoholic. Then I was homeless all the time because I got kicked out of the hostels, because you are not allowed to drink in the hostel. [David]

David and Marco’s experiences are similar to those of many participants. The youngest participant in this study, Clarke, had fresh memories of his abusive environment under his stepdad:

I wouldn't want to go back home if I had a choice to, because before I got kicked out me stepdad was like hitting me. I wouldn't want to go back to put up with that again. [I didn't tell anyone] because I was scared of telling someone and that someone telling me stepdad that I've told other people. ‘[Be] cause he might have just started doing again because I told people. It might have gotten him into trouble. [Clarke]

In some cases, participants expressed the beliefs that their abusive experience not only deprived them life opportunities but also opportunities to have families of their own. As Tom and Marie explain:

We were getting done for child neglect because one of our child has a disorder that means she bruise very easily. They all our four kids into care, social workers said because we had a bad childhood ourselves because I was abused by my father as well, they felt that we will fail our children because we were failed by our parents. We weren’t given any chance [Tom and Marie]

Norma, described the removal of her child to care and her maladaptive behaviour of excessive alcohol use in the same context as her experience of sexual abuse by her father.

I had two little boys with me and got took off from me and put into care. I got sexually abused by my father when I was six. So we were put into care. He abused me when I was five and raped me when I was six. Then we went into care all of us I have four brothers and four sisters. My dad did eighteen months for sexually abusing me and my sister. I thought it was normal as well I thought that is what dads do [Norma]

The analysis of participants in this study appears to suggest that social condition one is raised influence the choice of social connections and life partner. Some participants who have had experience of abuse as children had partner who had similar experience as children Tom and Marie, Lee, David and his partners all had partners who experienced child abuse as children.

Tom and Marie is a couple we interviewed together. They met in hostel for homeless people they have got four children. All four children have been removed from them and placed into care. They sleep rough along the canal. They explained:

We have been together for seven years we had a house and children social services removed children from us, we fell within bedroom tax. …we received an eviction order …on the 26th and the eviction date was the 27th while we were in family court fighting for our children. …because of my mental health …they were refusing to help us.

Our children have been adopted now. The adoption was done without our permission we didn’t agree to it because we wanted our children home because we felt we were unfairly treated and I [Marie] was left out in all this and they pin it all on you [Tom] didn’t they yeah, my [Tom] history that I was in care didn’t help.

Tom went on to talk about the condition under which he was raised:

I was abandoned by my mother when I was 12 I was then put into care; I was placed with my dad when I was 13 who physically abused me then sent back to care. [Tom].

David’s story provides another example of how social condition one is raised influence the choice of social connections and life partner. David has two children from two different women, both women grew up in care. Lisa one of David’s child mother is a second generation of children in care, her mother was raised in care too.

I drink to deal with problems. As I say I’ve got two kids with my girlfriend Kyleigh, but I got another lad with Lisa, he was taken off me by social services and put on for adoption ten years ago and that really what started it; to deal with that. Basically, because I was young, and I had been in care and the way I had been treated by my mum. Basically laid on me in the same score as my mum and because his mum [Lisa] was in care as well. So they treated us like that, which was just wrong. [David]

In this study, most participants identified alcohol or drugs and crime as the cause of relationships breakdown. However, the language they used indicates that these were secondary reasons rather than primary reasons for their homelessness. The typical question that MA and MG asked the interview participants was “tell us how did you become homeless”? Typically, participants cited different maladaptive behaviours to explain how they became homeless.

Alvin’s story is typical of:

Basically I started off as a bricklayer, … when the recession hit, there was an abundance of bricklayers so the prices went down in the bricklaying so basically with me having two young children and the only breadwinner in the family... so I had to kinda look for factory work and so I managed to get a job… somewhere else…. It was shift work like four 12 hour days, four 12 hour nights and six [days] off and stuff like that, you know, real hard shifts. My shift was starting Friday night and I’ll do Friday night, Saturday night to Monday night and then I was off Tuesday, Wednesday and Thursday, but I’d treat that like me weekend you know because I’ve worked all weekend. Then… so I’d have a drink then and stuff like that, you know. 7 o’ clock on a Monday morning not really the time to be drinking, but I used to treat it like me weekend. So we argued, me and my ex-missus [wife], a little bit and in the end we split up so moved back to me mum's, but kept on with me job, I was at me mum’s for possibly about five years and but gradually the drinking got worse and worse, really bad. I was diagnosed with depression and anxiety. … I used to drink to get rid of the anxiety and also to numb the pain of the breakup of me marriage really, you know it wasn’t good, you know. One thing led to another and I just couldn’t stop me alcohol. I mean I’ve done drugs you know, I was into the rave scene and I’ve never done hard drugs like heroin or... I smoke cannabis and I use cocaine, and I used to go for a pint with me mates and that. It all came to a head about November/December time, you know it was like I either stop drinking or I had to move out of me mum's. I lost me job in the January through being over the limit in work from the night before uum so one thing led to another and I just had to leave. [Alvin]

Similarly, Gary identified alcohol as the main cause of his relationship breakdown. However, when one listens to the full story alcohol appears to be a manifestation of other issues, including financial insecurities and insecure attachment etc.

It [the process of becoming homeless] mainly started with the breakdown of the relationship with me partner. I was with her for 15 years and we always had somewhere to live but we didn't have kids till about 13 years into the relationship. The last two years when the kids come along, I had an injury to me ankle which stopped me from working. I was at home all day everyday. …I was drinking because I was bored. I started drinking a lot ‘cause I couldn't move bout the house. It was a really bad injury I had to me ankle. Um, and one day me and me partner were having this argument and I turned round and saw my little boy just stood there stiff as a board just staring, looking at us. And from that day on I just said to me partner that I'll move out, ‘cause I didn't want me little boy to be seeing this all the time. [Gary]

In both cases Gary and Alvin indicate that changes in their employment status created conditions that promoted alcohol dependency, though both explained that they drank alcohol before the changes in their employment status occurred and the breakdown of relationships. Both intimated that that their job commitment limited the amount of time available to drink alcohol. As Gary explained, it is the frequency and amount of alcohol drinking that changed as a result of change in their employment status:

I used to have a bit of a drink, but it wasn’t a problem because I used to get up in the morning and go out to work and enjoy a couple of beers every evening after a day’s work. Um, but then when I wasn't working I was drinking, and it just snowballed out, you know snowball effect, having four cans every evening and then it went from there. I was drinking more ‘cause I was depressed. I was very active before and then I became like non-active, not being able to do anything and in a lot of pain as well. [Gary]

Furthermore, although the participants claim that drinking alcohol was not a problem until their employment circumstances changed, one gets a sense that alcohol was partly responsible for creating conditions that resulted in the loss of their jobs. In Gary’s case, for example, alcohol increased his vulnerability to the assault and injuries that cost him his job:

I got assaulted, kicked down a flight of stairs. I landed on me back on the bottom of the stairs, but me heel hit the stairs as it was still going up if you know what I mean. Smashed me heel, fractured me heel… So, by the time I got to the hospital and they x-rayed it they wasn't even able to operate ‘cause it was in that many pieces, they weren't even able to pin it if you know what I mean. [Gary]

Alvin, of the other hand, explained that:

I lost my job in the January through being over the limit in work from the night before, uum so one thing led to another and I just had to leave. [Alvin]

In all cases participants appear to construct marriage breakdown as an exacerbating factor for their alcohol dependence. Danny, for example, constructed marriage breakdown as a condition that created his alcohol dependence and alcohol dependence as a cause of breakdown of his relationship with his parents. He explains:

I left school when I was 16. Straight away I got married, had children. I have three children and marriage was fine. Umm, I was married for 17 years. As the marriage broke up I turned to alcohol and it really, really got out of control. I moved in with my parents... It was unfair for them to put up with me; you know um in which I became... I ended up on the streets, this was about when I was 30, 31, something like that and ever since it's just been a real struggle to get some permanent accommodation. [Danny]

Danny goes on to explain:

Yes [I drank alcohol before marriage broke down but] not very heavily, just like a sociable drink after work. I'd call into like the local pub and have a few pints and it was controlled. My drinking habit was controlled then. I did go back to my parents after my marriage break up, yes. I was drinking quite heavily then. I suppose it was a form of release, you know, in terms of the alcohol which I wish I'd never had now. When I did start drinking heavy at me parents’ house, I was getting in trouble with the police being drunk and disorderly. That was unfair on them. [Danny]

The data in this study indicate that homelessness occurs when the relationships collapse, irrespective of the nature of the relationship. There were several cases where lifestyle behaviour led to a relationship collapse between child and parents or legal guardians.

In the next excerpt, Emily outlines the incidents: smoking weed, doing crack and heroin, and drinking alcohol. She also uses the words ‘because’, ‘when’ and ‘obviously’, which provide clues about the precipitating condition for her behaviours “spending long time with people who take drugs”.

I've got ADHD like, so obviously my mum kicked me out when I was 17 and then like I went to **Beswick** and stuff like that. My mum in the end just let me do what I wanted to do, ‘cause she couldn't cope anymore. …I mean I tried to run away from home before that, but she'd always like come after me in like her nightie and pyjamas and all that. But in the end she just washed her hands of me . [Emily]

Emily presented a complex factors that made it difficult for her mother to live with her. These included her mother struggle with raising four kids as a single parent, Emily’s mental health (ADHD], alcohol and drug use. She goes on to explain that:

Ummm, well the reason I got kicked out of my hostel was ‘cause of me drinking, so I'd get notice to quit every month, then I’d have a meeting with the main boss and then they'd overturn it and this went on every month for about six months. Also, it was me behaviour as well, but obviously drink makes you do stuff you don't normally do and all that shit. I lived here for six months, got kicked out because I jumped out the window and broke me foot. I was on the streets for six months and then they gave me a second chance and I've been here a year now. So that's it basically. [Emily]

There were several stories of being evicted from accommodation due to excessive use of alcohol. One of those is David:

I got put into foster care. When I left foster care I was put in the hostel, from there I turn into alcoholic. Then I was homeless all the time because I got kicked out of the hostels, because you are not allowed to drink in the hostel. It’s been going on now for about… I was thirty-one on Wednesday, so it’s been going on for about thirteen years, homeless on and off. Otherwise if not having shoplifted for food and then go to jail, and when I don’t drink I have lot of seizures and I end up in the hospital. Every time I end up on the street. I trained as a chef, I have not qualified yet, because of alcohol addiction, it didn’t go very well. I did couple of jobs in restaurants and diners, I got caught taking a drink. [David]

Contrary to the other incidents where alcohol was a factor that led to homelessness, Barry’s description of his story appears to suggest that the reason he had to leave his parents’ home was his parents’ perception that his sexuality brought shame to the family:

When I came out they I’m gay, my mum and dad said you can’t live here anymore. I lived in a wonderful place called Nordic... but fortunately, mum and dad ran a pub called […] [and] one of the next door neighbours lived in a mansion. His name was [….] [and] when I came out, he came out as in he said “I'm a gay guy”, but he took me into Liverpool and housed me because I had nowhere to live. My mum and dad said you can't live here anymore. And unfortunately, we get to the present day. I got attacked. I got mugged... only walked away with a £5 note, it’s all they could get off me. They nearly kicked me to death so I was in hospital for three weeks. By the time I came out, I got evicted from my flat. I was made homeless. [Barry]

We used the phrase “engaging in maladaptive behaviour” to conceptualise the behaviours that led to the loss of accommodation because our analysis appear to suggest that these behaviours were strategies to cope with the conditions they found themselves in. For example, all participants in this category explained that they drank alcohol to cope with multiple health (mental health) and social challenges.

In the UK adulthood homelessness is more visible than childhood homelessness. However, most participants in this research reveal that the process of becoming homeless begins at their childhood, but becomes visible after the legal age of consent (16). Participants described long history of trouble with people in authority including parents, legal guardians and teachers. However, at the age of 16 they gain legal powers to leave children homes, foster homes, parental homes and schools, and move outside some of the childhood legal protections. Their act of defiance becomes subject to interdiction by the criminal justice system. This is reflected in number of convictions for criminal offenses some of the participants in this study had.

Participants Ruddle, David, Lee, Emily, Pat, Marco, Henry and many other participants in this study (see Table 1 ) clearly traced the beginning of their troubles with authority back at school. They all expressed the belief that had their schooling experience been more supportive, their lives would have been different. Lee explains that being in trouble with the authorities began while he was at school:

‘The school I came from a rough school, it was a main school, it consisted of A, B, C, D and The school I came from [was] a rough school, it was a main school, it consisted of A, B, C, D and E. I was in the lowest set, I was in E because of my English and maths. I was not interested, I was more interested in going outside with big lads smoking weed, bunking school. I used to bunk school inside school. I used to bunk where all cameras can catch me. They caught me and reported me back to my parents. My mum had a phone call from school asking where your son is. My mum grounded me. While my mum grounded me I had a drain pipe outside my house, I climbed down the drain pipe outside my bedroom window. I used to climb back inside. [Lee]

Lee’s stories constructed his poor education experiences as a prime mover towards the process of becoming homeless. It could be noted in Table 1 that most participants who described poor education experiences came from institutions such as foster care, children home and special school for maladjusted children. These participants made a clear connection between their experiences of poor education characterised by defiance of authorities and poor life outcomes as manifested through homelessness.

Patrick made a distinct link between his school experience and his homelessness, for example, when asked to tell his story leading up to becoming homeless, Patrick’s response was:

I did not go to school because I kept on bunking. When I was fifteen I left school because I was caught robbing. The police took me home and my mum told me you’re not going back to school again, you are now off for good. Because if you go back to school you keep on thieving, she said I keep away from them lads. I said fair enough. When I was seventeen I got run over by a car. [Patrick]

Henry traces the beginning of his troubles with authorities back at school:

[My schooling experience]… was good, I got good, well average grades, until I got myself into [a] few fights mainly for self-defence. In primary schools, I had a pretty... I had a good report card. In the start of high school, it was good and then when the fights started that gave me sort of like a... bad reputation. I remember my principal one time made me cry. Actually made me cry, but eh... I don't know how, but I remember sitting there in the office and I was crying. My sister also stuck up for me when she found out what had happened, she was on my side; but I can’t remember exactly what happened at that time. [Henry]

Emily’s story provides some clues about the series of incidents - including, delay in diagnosing her health condition, being labelled as a naughty child at school, being regularly suspended from school and consequently poor educational attainment.

Obviously, I wasn't diagnosed with ADHD till I was like 13, so like in school they used to say that's just a naughty child. … So it was like always getting suspended, excluded and all that sort of stuff. And in the end [I] went to college and the same happened there. [Emily]

The excerpt above provides intimations of what she considers to be the underlying cause of her behaviour towards the authorities. Emily suggests that had the authorities taken appropriate intervention to address her condition, her life outcomes would have been different.

Although the next participant did not construct school as being a prime mover of their trouble with authorities, their serious encounters with the criminal justice system occurred shortly after leaving school:

Well I did a bit of time at a very early age, I was only 16… I did some remand there, but then when I went to court ‘cause I'd done enough remand, I got let out and went to YMCA in Runcorn. Well, that was when I was a kid. When I was a bit older, ‘cause it was the years 2000 that I was in jail, I was just trying to get by really. I wasn’t with Karen at the time. I was living in Crewe and at the time I was taking a lot of amphetamines and was selling amphetamines as well, and I got caught and got a custodial sentence for it. But I've never been back to jail since. I came out in the year 2000 so it's like 16 years I've kept meself away from jail and I don't have any intentions of going back. [Gary]

The move from school and children social care system to criminal justice was a common pathways for many participants in this study. Some including Lee, Crewe, David, Patrick spent multiple prison sentences (see Table 1 ). Although Crewe did not make connection between his schooling experiences and his trouble with law, it could be noted that his serious encounter with criminal justice system started shortly after leaving foster care and schooling systems. As he explains:

I was put into prison at age of 17 for arson that was a cry for help to get away from the family, I came out after nine months. I have been in prison four times in my life, its not very nice, when I came out I made a promise to myself that I’m never going to go back to prison again. [Crewe]

Lee recalls his education experience. He explained:

I left school when I was fifteen… then I went off the rails. I got kidnapped for three and half months. When I came back I was just more interested in crime. When I left school I was supposed to go to college, but I went with travellers. I was just more interested in getting arrested every weekend, until my mum say right I have enough of you. I was only seventeen. I went through the hostels when I was seventeen. [Lee]

None describe the educational experience with a similar profundity to Marco:

On few occasions I came out on the corridors I would be getting battered on to my hands and knees and teachers walk pass me. There was quite often blood on the floor from my nose, would be punched on my face and be thrown on the floor. …. It was hard school, pernicious. I would go as far as saying I never felt welcome in that school, I felt like a fish out of the water, being persistently bullied did my head in. Eventually I started striking back, when I started striking back suddenly I was a bad one. My mother decided to put me in … school for maladjusted boys, everyone who been there including myself have spent time in prison. [Marco]

The trouble with authorities that was observes in participants stories in this category appear to be part of the wider adverse social challenges that the participants in this study were facing. Crewe’s description of arson as a cry for help appears to be an appropriate summation of all participants in this category.

The participants’ description of the social conditions in which were raised and their references to maladaptive behaviours which led to them becoming homeless, led us to conclude that they believe that their social condition affected their life chances: that these conditions were responsible for their low quality of social connections, poor educational attainment, insecure employment and other reduced life opportunities available to them.

The key feature that distinguish this study from comparable previous studies is that it openly acknowledges that data collection and analysis were influenced by the principles of social justice [ 28 , 30 , 31 ]. The resulting theoretical explanation therefore constitutes our interpretation of the meanings that participants ascribe to their own situations and actions in their contexts. In this study, defining homelessness within the wider socioeconomic context seemed to fit the data, and offered one interpretation of the process of becoming homeless.

While the participants’ experiences leading to becoming homeless may sound trite. What is pertinent in this study is understanding the conditions within which their behaviours occurred. The data were examined through the lens of social justice and socio-economic inequalities: we analysed the social context within which these behaviours occurred. We listened to accounts of their schooling experiences, how they were raised and their social network. The intention was not to propose a cause-and-effect association, but to suggest that interventions to mitigate homelessness should consider the social conditions within which it occurred.

Participants in this study identified substance misuse and alcohol dependency as a main cause of their homelessness. These findings are consistent with several epidemiological studies that reported a prevalence of substance misuse amongst the homeless people [ 32 , 33 , 34 , 35 , 36 ]. However, most these studies are epidemiological; and by nature epidemiological studies are the ‘gold standard’ in determining causes and effects, but do not always examine the context within which the cause and effect occur. One qualitative study that explored homelessness was a Canadian study by Watson, Crawley and Cane [ 37 ]. Participants in the Watson, et al. described ‘lack of quality social interactions and pain of addition. However, Watson et al. focus on the experiences of being homeless, rather than the life experiences leading to becoming homeless. To our knowledge the current study is one of very few that specifically examine the conditions within which homelessness occurs, looking beyond the behavioural factors. Based on the synthesis of data from previous studies, it makes sense that many interventions to mitigate homelessness focus more on tackling behavioural causes of homelessness rather than fundamental determinants of it [ 38 ]. From the public health intervention’ point of view, however, understanding the conditions within which homelessness occurs is essential, as it will encourage policymakers and providers of the services for homelessness people to devote equal attention to tackling the fundamental determinants of homelessness as is granted in dealing behavioural causes.

Participants in this study reported that they have been defiant toward people in positions of authority. For most of them this trouble began when they were at school, and came to the attention of the criminal justice system as soon as they left school at the age of 16. These findings are similar to these in the survey conducted by Williams, Poyser, and Hopkins [ 39 ] which was commissioned by the UK Ministry of Justice. This survey found that 15 % of prisoners in the sample reported being homeless before custody [ 39 ]; while three and a half percent of the general population reported having ever been homeless [ 39 ]. As the current study reveals there are three possible explanations for the increased population of homeless young people in the criminal justice system: first, at the age of 16 they gain legal powers to leave their foster homes, parents homes, and schools and move beyond some of the childhood legal protections; second, prior to the age of 16 their defiant behaviours were controlled and contained by schools and parents/legal guardians; and third, after the age of 16 their acts of defiant behaviour become subject to interdiction by the criminal justice system.

The conditions in which they were born and raised were described by some participants in this study as ‘chaotic’, abusive’, ‘neglect’, ‘pernicious’ ‘familial instability’, ‘foster care’, ‘care home’, etc. Taking these conditions, and the fact that all but one participants in this left school at or before the age of 16 signifies the importance of living conditions in educational achievement. It has been reported in previous studies that children growing up in such conditions struggle to adjust in school and present with behavioural problems, and thus, poor academic performance [ 40 ]. It has also been reported that despite these families often being known to social services, criminal justice systems and education providers, the interventions in place do little to prevent homelessness [ 40 ].

Analysis of the conditions within which participants’ homelessness occurred reveals the adverse social conditions within which they were born and raised. The conditions they described included being in an abusive environment, poor education, poor employment or unemployment, poor social connections and low social cohesion. These conditions are consistent with high index of poverty [ 37 , 41 , 42 ]. And several other studies found similar associations between poverty and homelessness [ 42 ]. For example, the study by Watson, Crowley et al. [ 37 ] found that there were extreme levels of poverty and social exclusion amongst homeless people. Contrary to previous studies that appear to construct homelessness as a major form of social exclusion, the analysis of participants’ stories in this current study revealed that the conditions they were raised under limited their capacity to engage in meaningful social interactions, thus creating social exclusion.

Homeless people describe the immediate behavioural causes of homelessness; however, this analysis revealed the social and economic conditions within which homelessness occurred. The participants’ descriptions of the social conditions in which were raised and their references to maladaptive behaviours which led to them becoming homeless, led us to conclude that they believe that their social condition affected their life chances: that these conditions were responsible for their low quality of social connections, poor educational attainment, insecure employment and other reduced life opportunities available to them.

Limitations

The conclusions drawn relate only to the social and economic context of the participants in this study, and therefore may not be generalised to the wider population; nor can they be immediately applied in a different context. It has to be acknowledged that the method of recruitment of the 26 participants generates a bias in favour of those willing to talk. The methodology used in this study (constructivist grounded theory) advocates mutual construction of knowledge, which means that the researchers’ understanding and interpretations may have had some influence on the research process as the researchers are an integral part of the data collection and analysis

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Acknowledgements

The authors wish to thank all participants in this study; without their contribution it would not have been possible to undertake the research. The authors acknowledge the contribution of Professor Paul Kingston and Professor Basma Ellahi at the proposal stage of this project. A very special thanks to Robert Whitehall, John and all the staff at the centres for homeless people for their help in creating a conducive environment for this study to take place; and to Roger Whiteley for editorial support. A very special gratitude goes to the reviewers of this paper, who will have expended considerable effort on our behalf. 

This research was funded by quality-related research (QR) funding allocation for the University of Chester.

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The datasets generated during and/or analysed during the current study are not publicly available due to ethical restriction and privacy of participant data but are available from the corresponding author on reasonable request.

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Contributions

MM wrote the entire manuscript, designed the study, collected data, analysed and interpreted data, and presented the findings. AY contributed to transcribing data and manuscript editing. MG contributed to data collection, and transcribed the majority of data. All authors read and approved the final manuscript.

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Correspondence to Mzwandile A. Mabhala .

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Ethical approval to conduct the study was provided by the Faculty of Health and Social Care Research Ethics Subcommittee of the University of Chester.

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Mabhala, M.A., Yohannes, A. & Griffith, M. Social conditions of becoming homelessness: qualitative analysis of life stories of homeless peoples. Int J Equity Health 16 , 150 (2017). https://doi.org/10.1186/s12939-017-0646-3

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Received : 24 March 2017

Accepted : 10 August 2017

Published : 22 August 2017

DOI : https://doi.org/10.1186/s12939-017-0646-3

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