B901 Public Health : Homelessness in Developing Countries
Main body:
Discuss health problems associated with homelessness as identified by various authors, researches and articles.
Discuss health service issues associated with homelessness which includes: Health /services inequalities and government health policies Health policies initiatives.
Answer:
Introduction:
Definitions:
Homelessness is the state of the person in which he/she lives without permanent house. These persons can’t offered to have normal, protected, sheltered and enough housing for the shelter. Different definitions of homelessness are quoted in different countries and within a country, also there are different definitions in the different jurisdictions. Different types of homeless conditions include whole night stay in the temporary shelters, shelter at other places due to domestic violence and long term stay in the vehicle and tent. According to the definition quoted by United Nations, homelessness is defined as homeless person lives without shelter who lacks access to the basic requirements for life, health and human and social development. Basic requirements for the life of person comprises of protected house, safeguard form the adverse weather, personal security, hygienic conditions, drinkable water, literacy, employment and health services. Definition by the United Nations linked homelessness with the humanitarian principles. Lack of home can affect overall basic needs of the person and personal as well social development can be brought to a standstill. Definition by the United Nations is directly related to the emotions of the person and which can lead to the complete detoriation of the quality of life (Naidoo and Wills, 2008).
Homeless Committee of the City of Montrea, quoted definition of homelessness as ‘A person without confirmed address, stable, protected and hygienic house for the next 2 months with very less source of income, socially isolated and lack of access to social services, susceptible for the psychological problems, prone to addictions like alcohol and drugs and not associated with any of the social group. This definition considered complexity of the functional problems of the human being. This definition can be diffentiated form the definition of the United Nations in terms of susceptibility to the addiction development. This definition correlated homeless person with the social groups, however correlation of the homeless person with social groups is not there in the definition of United Nations. It is difficult to quote exact definition of the homelessness because homelessness condition is not stable, it is dynamic, not time bound, and can be permanent or temporary. Homelessness is not a particular characteristic of the person, however it is a circumstances or conditions due to lack of home. Certain criteria in terms of days and weeks should be fixed for consideration as the homeless person (Graham and Suzanne, 2005).
Types of homelessness:
Homelessness can be classified into three categories like chronically homeless, cyclically homeless, and temporarily homeless. Chronically homeless people comprise of the individuals who lives on the edge of the society and these individuals are often associated with psychological issues including drug and alcohol abuse. Cyclically homelessness occurs in the individuals due to certain changes in their life like joblessness, moving out of the house, prison term and stay in the hospital for long treatment. Women with family violence, runway youths and persons freed from the prison try to occupy safehouses. Temporarily homeless group includes people without home for short duration. These people may lose their home due to disaster like fir, flood or war. These people may lose their home due to alteration in the condition like loss of job or separation from the family members. However, most of the researchers didn’t consider this group as homeless group (Sabine, 2000).
Causes of homelessness:
Causes of homelessness include poverty mainly due to unemployment and underemployment, deficient in inexpensive house, deficient in access to healthcare services, war situations, migration to the place or country with deficiency in the affordable housing, psychological disorders like autism spectrum disorders and schizophrenia, living with disability, traumatic brain injury, social exclusion due to sexual orientation and gender identity, alcohol and drug abuse, domestic violence, separation of young people from the parents, freed from the prison and re-entry in the society, forced eviction by Government authorities, gentrification and mortgage foreclosures (Dromi, 2012).
UK statistics:
Approximately 250,000 people are identified as homeless in UK. 14,420 and 75,740 people are statutorily homeless and on temporary accommodation in the year 2016 respectively. UK authorities took action to prevent homelessness in 50,970 people in 2016. Prevalence of homelessness is varied in different parts of UK. Approximately 1 in 63, 69, 119, 204, 266, 164 and 170 people are homeless in Luton, Brighton, Brimingham, Coventry, Manchester, Slough and Reading respectively. 86 % of the homeless people are with mental disorder in UK and this population is 44 % as compared to the general population. 41 and 27 % homeless people in UK are associated with drug and alcohol abuse respectively (Hannah, 2016).
In this essay, physical and mental health issues associated with the homeless people is going to be discussed along with the barriers for provision of healthcare services to these people. Also, recommendations are made to address the issues of homeless people for providing permanent home and healthcare services.
Main body:
Physical illness:
Health issues associated with homeless people are almost similar to the normal people, however their prevalence is more in homeless people. Traumatic health problems like contusions, lacerations, sprains, bruises, and superficial burns are more prevalent in homeless people. Prevalence of traumatic disorders is more in homeless people is more because these people are sufferers of violence like rape, stabbing and attempted robbery. Musculoskeletal disorders that affect joints, ligaments and tendons are more common in homeless people. Hunger and nutrition are the most prominent issues associated with homeless people and these issues lead to the development of weakness and fatigue in these children. Mortality and unintentional injuries are more common in homeless people. These unintentional injuries can occur due to falls and hit by the vehicle as most of these people stay on the road (Kim et al., 2010).
Homeless people are generally living in the risky environmental conditions. These conditions are also responsible for the traumatic disorders. One of the examples of risky environment is use of open fire for getting rid of the cold can lead to the burns in these people. Insect bites and infestations can lead to the occurrence of pustular skin lesions in homeless people. Most of the homeless people are in sitting or sleeping position for the longer duration. This lead to the development of lower extremities stasis due to varicose veins and consequent poor circulation. This results in the edema, cellulitis and ulceration of the skin. There is also occurrence of venous valve incompetence and chronic phlebitis in homeless people. Dermatitis, lice and scabies occurrence is also evident in homeless people due to lack of bath and consequent infestation. This lead to the occurrence of red, warm, tender skin lesions in homeless people (Arnaud et al., 2016). Needle-stick infections are also prevalent in homeless people mainly due to drug abuse. Homeless people generally live on the streets, crowded places, in groups, open environment and without proper nutrition. These all factors lead to reduced resistance to infection and occurrence of respiratory tract and lungs infection (O'Sullivan, 2008; Romaszko et al., 2017).
Tuberculosis which is mainly cause by the Mycobacterium tuberculosis is most prevalent among homeless people. Tuberculosis is mainly caused due to personals contacts and comparatively it is more prevalent in homeless people as compared to the people with proper homes. Occurrence of chronic disease like hypertension, diabetes, and chronic obstructive pulmonary disease is more in homeless people as compared to the people with home. Older age and alcohol consumption of the homeless people are main reasons responsible for the prevalence of hypertension. Moreover, for these chronic diseases long duration medication is required. However, these homeless people can’t offer to take medications for longer duration and management of these chronic diseases is difficult in these people. Superficial fungal infections and calluses, corns, and bunion of the foot are most common in homeless people due to lack of shoes or inappropriate shoes. Prevalence of inadequate oral hygiene, cavities, and gingival disease are observed in these people (Coles and Freeman, 2016).
Hypothermia and hyperthermia can also occur in homeless people due to exposure to adverse environmental conditions. Chronic physical disorders are more prevalent in homeless children as compared to the children in the society. These homeless children are more prone to the development of anemia, malnutrition, and refractory asthma as compared to the other children. It is evident that more than 50 % homeless children are not accessible to immunization, hence there is more occurrence of illness like diphtheria, tetanus, measles, and polio. There is also possibility of iron deficiency in homeless children. These children develop various complications like developmental, emotional, and learning problems. Incidence of substance abuse, sexually transmitted diseases, and pregnancy are more in homeless youths and adolescents as compared to the domiciled counterparts (O'Connell et al., 2004).
Mental illness:
Homeless people are more susceptible to the development of mental and emotional problems. Prevalence of mental and psychological problems in homeless people is between 25 – 50 %. Disability for proper functioning and lack of social involvement are the main reasons for the development of mental and psychological disorders in the homeless people. Personality disorders can occur in homeless people due to inability to meet basic requirements of daily normal life and demand of the society. Mental illness like schizophrenia and the affective disorders (bipolar and major depressive disorders) do not develop due to homelessness. However, these conditions can be exaggerated in homeless people. Disability and the social isolation are the important factors responsible for the exaggeration of these mental disorders. Homeless people develop maladaptive behavior which hampers individuals capability to relate to others and bring limitation on the individual’s potential. Anxiety, phobic disorder and mild depression can lead to homelessness. These psychological disorders can also develop due to stress of homelessness (Bachrach, 1984; Narendorf et al., 2017).
Anxiety and depression can lead to the development of loss of appetite and sleeplessness which consequently results in the addictions like alcohol and drugs (Polcin, 2016). Chronic alcohol consumption can lead to the development of long duration hypertension, small cerebral hemorrhage and uncontrolled epilepsy. These conditions can lead to the development of dementia in homeless persons. Brief Symptom Inventory, the General Health Questionnaire, or the Center for Epidemiological Studies Depression Scale are the screening techniques can be useful for the assessment of mental and psychological disorders in homeless people. It is evident that these techniques are sensitive in identifying persons with psychiatric disorders in homeless population. Percentages of homeless people identified with these techniques are more as compared to the other population. In a study, it was estimated that 40 % of the homeless people developed major mental health illness and this number increased upto 78 % with addition of disorders like drug and alcohol abuse, personality disorders, and organic disorders. In another study, it was estimated that 39 % people developed mental illness like mania, depression, and schizophrenia, however this number increased upto 90 % with addition of drug and alcohol abuse and personality disorders (Cox et al., 2012).
It was estimated that schizophrenia, major affective disorders, dementia, antisocial personality disorder and alcohol or drugs abuse can be developed in 11.5, 20, 3, 17 and 30 % of total population of homeless people respectively. There is no substantial data available for the mental illness of homeless women. However, few studies indicated that women are more susceptible to the development of psychiatric disorders as compared to the men. Prevalence of schizophrenia is more and drug abuse is less in homeless women as compared to the homeless men. Children of these homeless women are prone to development of emotional and intellectual impairment. Clinicians working for the homeless people also reported more prevalence of alcoholism as compared to the other psychiatric disorders. Prevalence of psychiatric disorder is more in white homeless people as compared to the black homeless people (Hodgson et al., 2015).
Policies and Initiatives:
UK authorities like Homelss UK in collaboration with local authorities working together to gather information about homeless people and to advise, prevent and support in improvement in their health. UK Governement is providing specialized healthcare servise to UK homeless people through CareQuality Commission. In 2016, UK Government announced £40 million for homeless people. Out of the £20 million is to tackle homelessness, £10 million to support people at risk of homelessness and £10 to homeless people with complex problems with long term requirement. Tasks in these initiatives include identification of at-risk homeless people, planning intervention prior to eviction, and helping people prior to 28 days after eviction. This initiative also includes provision of accommodation, employment and education, mental health and addiction counseling (Wilson and Barton, 2017).
Health service issues associated with homelessness:
It is evident that only few of the private hospitals provide healthcare services to the poor and homeless people. Homeless people can’t avail healthcare benefits offered by Government. These homeless people have very less knowledge about the Government policies, subsidies and insurance schemes. Hence, homeless people can’t utilize financial benefits from the Government and these homeless people can’t offer to pay on their own for their treatment. Even though these homeless people know about these policies, it would be difficult for them to avail these facilities because most of the homeless people are not eligible for availing it. These homeless people can’t generate required documents to avail these facilities. Morevoer, these homeless people can’t give permanent address to receive information about the appointment to doctor, clinical laboratory or any other medical test (Baggott, 2011).
Bureaucratic obstacles are also one of the important factors which act as barrier for healthcare services to homeless people. It is difficult for homeless people to maintain and follow rules and regulations of Bureaucrats. It would be difficult for homeless people to meet appointment timings due to lack of watch and inability to avail public transportation system. Most of the healthcare organizations try to avoid homeless people due to prior negative experience. Healthcare providers are unwilling to provide healthcare services to these people due to physically unattractive, unwashed, and lack clean clothes (Poremski et al., 2016; Phillips et al., 2015). Most of the homeless people are passively resistant to the healthcare services. Hence, healthcare providers need to put extra efforts for homeless people. Neither healthcare providers not homeless people are motivated for healthcare services to homeless people. Most of the homeless people are old people and veterans. Due to old age and disability, these people can’t access healthcare services because of difficulty in mobility (van den Berk-Clark and McGuire, 2013).
Financial scarcity is the predominant factor responsible for less access to healthcare facilities for homeless people. Homeless people can’t offer to pay huge amount for medical tests, procedures and medications. Moreover, most of the diseases of homeless people are chronic diseases and treatment required for such diseases is long term. These homeless people can’t maintain such a long treatment schedule. There is lack of community based treatment facilities for homeless people (Weber et al., 2013).
Clinical problems are also responsible for providing healthcare facilities to homeless people. Few homeless people don’t believe in medications and these people try to refuse medications. Few of the homeless people are adversely affected due to psychotropic and other medications and they are not willing to consume medications. Few of the homeless people are lacking insight of reality of their medical condition due to illiteracy about health and these people don’t think of necessity of treatment. Homeless people are also not ready to believe that they can avail medical services. Homeless people are lacking support from family and friends for availing medical services. In case of mental illness of homeless people, provision of medical services is more difficult. These people are not willing to accept slow but sincere efforts of healthcare provider to improve their condition and they express negative emotions towards healthcare provider. Separate medical facilities should be provided for homeless mentally ill people because these people can become violent. However, such separate facilities do not exist. Mentally ill patients can be offensive, embarrassing, or frightening to others. Most of the homeless people are alcohol and drug abused. These people should be detoxified for alcohol and drug before providing medical treatment. However, it would be very difficult to detoxify and rehabilitate these people (Bralock et al.,2011).
Conclusion and Recommendations:
Improvement in the condition of the homeless people can be achieved by providing them with stable residence, income, employment and deinstitutionalization. Provision of housing is not only the social determinant for homeless people but also important for maintaining normal health. In homeless people most of the health issues occur due to lack of permanent residence. There should be stable income source for homeless people so that either they can buy affordable home or rent a house. Stable income source is also helpful in treating diseases in these people. Few of the homeless people who are mentally and physically disabled due to alcohol and drug abuse, housing is not enough for their rehabilitation (Hinds et al., 2016; Fleisch and Nash, 2017).
These people need social support and counseling to get rid of these addictions. It would be helpful for them to maintain themselves in the society. There should be broad initiative for the provision of healthcare services to the homeless people. Government should establish policies for life and fire safety, sanitation and disease prevention. Government should work in collaboration with service providing agencies for homeless people. There should be integration of public and private sectors for providing healthcare services to homeless people. There should be long term plan for healthcare services and it should be provided on the voluntary basis. There should be evaluation of the existing healthcare services for homeless people and bring improvement in it. Ambulatory medical services should be provided for the homeless people. Ambulatory medical services can be provided to homeless people through skilled and trained personals who can link patients with clinics, work on free-standing clinics and hospital outpatient departments. These healthcare providers should be trained in homeless patient communication, engagement and follow-up. There should be special provision for supply of dietary requirements and medications to these people (Salize et ., 2013). For the prevention of alcohol and drug abuse, there should be implementation of targeted outreach services, supportive living environments, treatment and rehabilitation services and specialized case management (Warren, 2016).
References:
Arnaud, A., Chosidow, O., Détrez, M.A., Bitar, D., et al. (2016). Prevalences of scabies and pediculosis corporis among homeless people in the Paris region: results from two randomized cross-sectional surveys (HYTPEAC study). British Journal of Dermatology, 174(1), pp. 104-12.
Bachrach, L. L. (1984). The homeless mentally ill and mental health services: An analytical review of the literature. pp. 11-53 in The Homeless Mentally Ill, H. R. Lamb, editor. , ed. Washington, D.C.: American Psychiatric Association.
Baggott, R. (2011). Public Health Policy and Politics. Basingstoke, Palgrave.
Bralock, A.R., Farr, N,B., Kay, J., Lee, M.J., et al. (2011). Issues in community-based care among homeless minorities. National Black Nurses Association, 22(1), pp. 57-67.
Coles, E., and Freeman, R. (2016). Exploring the oral health experiences of homeless people: a deconstruction-reconstruction formulation. Community Dentistry and Oral Epidemiology, 44(1), pp. 53-63.
Cox, W. T.L., Abramson, L.Y., Devine, P. G., Hollon, S. D. (2012). Stereotypes, Prejudice, and Depression: The Integrated Perspective. Perspectives on Psychological Science, 7(5), pp. 427–449.
Dromi, S. M. (2012). Penny for Your Thoughts: Beggars and the Exercise of Morality in Daily Life. Sociological Forum. 27(4), pp. 847–871.
Fleisch, S.B., and Nash, R. (2017). Medical Care of the Homeless: An American and International Issue. Primary Care, 44(1), 57-65.
Graham, T., and Suzanne, S. (2005). Definitions of Homelessness in Developing Countries. Habitat International. 29(2), pp. 337–52.
Hannah, R. (2016). More than 250,000 are homeless in England – Shelter. (BBC News From the section Education & Family). BBC News. Education and social affairs reporter. Retrieved 5 December 2016.
Hinds, A.M., Bechtel, B., Distasio, J., Roos, L.L., and Lix, L.M. (2016). Health and social predictors of applications to public housing: a population-based analysis. Journal of Epidemiology and Community Health, 25, pii: jech-2015-206845. doi: 10.1136/jech-2015-206845.
Hodgson, K.J., Shelton, K.H., and van den Bree, M.B. (2015). Psychopathology among young homeless people: longitudinal mental health outcomes for different subgroups. British Journal of Clinical Psychology, 54(3), pp. 307-25.
Kim, M.M., Ford, J.D., Howard, D.L., and Bradford, D.W. (2010). Assessing trauma, substance abuse, and mental health in a sample of homeless men. Health & Social Work, 35(1), pp. 39-48.
O'Connell, J.J., Roncarati, J.S., Reilly, E.C., Kane, C.A., Morrison, S.K., et al. (2004). Old and sleeping rough: elderly homeless persons on the streets of Boston. Care Management Journal, 5(2), pp. 101-6.
O'Sullivan, K. (2008). Primary care access for homeless people. Combat Poverty Agency
Naidoo, J., and Wills, J. (2008). Health Studies: An Introduction. 2nd ed. Basingstoke, Palgrave Macmillan.
Narendorf, S.C., Cross, M.B., Santa Maria, D., Swank, P.R., and Bordnick, P.S. (2017). Relations between mental health diagnoses, mental health treatment, and substance use in homeless youth. Drug and Alcohol Dependence, 1, pp. 175:1-8.
Phillips, M., Richardson, L., Wood, E., Nguyen, P., Kerr, T., and DeBeck, K. (2015). High-Intensity Drug Use and Health Service Access Among Street-Involved Youth in a Canadian Setting. Substance Use & Misuse, 50(14), pp. 1805-13.
Polcin, D.L. (2016). Co-occurring Substance Abuse and Mental Health Problems among Homeless Persons: Suggestions for Research and Practice. Journal of Social Distress and the Homeless, 25(1), pp. 1-10
Poremski, D., Woodhall-Melnik, J., Lemieux, A.J., and Stergiopoulos, V. (2016). Persisting Barriers to Employment for Recently Housed Adults with Mental Illness Who Were Homeless.
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Romaszko, J., Kuchta, R., Opalach, C., Bertrand-Buci?ska, A., et al. (2017). Socioeconomic Characteristics, Health Risk Factors and Alcohol Consumption among the Homeless in North-Eastern Part of Poland. Central European Journal of Public Health, 25(1), pp. 29-34.
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Salize, H.J., Werner, A., and Jacke, C.O. (2013). Service provision for mentally disordered homeless people. Current Opinion in Psychiatry, 26(4), pp. 355-61.
van den Berk-Clark, C., and McGuire, J. (2013). Elderly homeless veterans in Los Angeles: chronicity and precipitants of homelessness. American Journal of Public Health, 103(2), pp. S232-8.
Warren O. (2016). Intoxicated, Homeless, And In Need Of A Place To Land. Health Affairs (Millwood), 35(11), pp. 2138-2141.
Weber, M., Thompson, L., Schmiege, S.J., Peifer, K., and Farrell, E. (2013). Perception of access to health care by homeless individuals seeking services at a day shelter. Archives of Psychiatric Nursing, 27(4), pp. 179-84.
Wilson, W., and Barton, C. (2017). Statutory Homelessness in England. Retrieved from file:///C:/Users/lg/Downloads/SN01164.pdf on 12.05.2017.
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