perspectives of homeless people on their health and healthcare

Perspectives of homeless people on their health and health needs

priorities

Isolde Daiski

Accepted for publication 16 December 2006

Isolde Daiski BScN EdD RN

Assistant Professor

School of Nursing, York University,

Toronto, Ontario, Canada

Correspondence to I. Daiski:

e-mail: [email protected]

DAISKI I . (2007)DAISKI I . (2007) Perspectives of homeless people on their health and health needs

priorities. Journal of Advanced Nursing 58(3), 273281

doi: 10.1111/j.1365-2648.2007.04234.x

AbstractTitle. Perspectives of homeless people on their health and health needs priorities

Aim. This paper is a report of a study of the perspectives of homeless individuals on

their health and healthcare needs.

Background. Many studies show the high incidence and severity of diseases, phys-

ical and mental, amongst the homeless populations. However, the views of homeless

people themselves are usually omitted. In order to provide appropriate care,

healthcare professionals need to be aware of these perspectives.

Method. A descriptive, exploratory design, using semi-structured interviews and

observational field notes, was chosen for this qualitative study. A convenience

sample of 24 participants experiencing homelessness was recruited in one Canadian

city in 2005.

Findings. Participants described their health and healthcare needs in a holistic sense.

They reported concerns about physical illnesses, mental health, addictions and

stress. Shelter life promoted spread of diseases and lacked privacy. Violence was

rampant in shelters and on the streets, leading to constant fear. There was emotional

distress over social exclusion and depersonalization. Participants wanted to work

and to be housed, yet felt trapped in a dehumanizing system.

Conclusion. The recommendations are (a) elimination or mitigation of most health

problems of the homeless through safe, affordable housing; (b) reintegration into the

community through job counselling, treatment of addictions and employment.

Negative societal attitudes towards these clients need to change. Healthcare pro-

fessionals, particularly community nurses, have opportunities to collaborate

respectfully with these clients and work for changes in public policies, such as

national housing and addiction treatment policies, and for streamlined, humanized

services to smooth the processes of social reintegration.

Keywords: community care, health promotion, inequalities in health, nurse roles,

NursePatient Relationships, qualitative interviews

Introduction

Homelessness is a worldwide problem. In the developed

world it is due to widening income disparities (Prince 1998,

Shapcott 2003). In developing countries, in addition to

poverty, urbanization and natural disasters also contribute to

greater homelessness. When nurses and other healthcare

workers care for clients, including those who are homeless,

they need to know their clients specific needs in order to

provide holistic and effective care. Although the study

ORIGINAL RESEARCHJAN

2007 The Author. Journal compilation 2007 Blackwell Publishing Ltd 273

reported here was limited to experiences of homeless people

in an urban environment, many of its findings and the

proposed approaches are relevant to those working with

homeless people anywhere.

Background

Shelter is one of the basic pre-requisites of health (Ottawa

Charter for Health Promotion 1986). Lack of housing

contributes in major ways to ill health, including mental

illnesses, and shortened lives. More than half of those living

on the streets have one or more major chronic health

conditions, including affective disorders and substance abuse

(Hwang et al. 2003, Lafuente 2003, Yanos et al. 2004,

Frankish et al. 2005). When homeless people seek help, they

are typically sicker, their rates of hospitalization are much

higher, they require more intensive treatments and their

mortality rates are greater compared with people who are

housed (Hwang 2000, 2001, Layton 2000, Lafuente 2003,

Cheung & Hwang 2004, Levy & OConnell 2004, OConnell

2004, Frankish et al. 2005). Therefore, finding ways to meet

the health needs of the homeless more effectively is extremely

important.

There are numerous data on the incidence of various

diseases and poor health status amongst the homeless.

However, a little is known about the perceptions of health

and healthcare needs of these people themselves, as their

views about their health are usually omitted (Acosta & Toro

2000). In order to add their views to the discourse a

community-based approach was used, starting from the

bottom up with the wants and needs of those affected, as

they are seen as the experts on their lives (Raeburn &

Rootman 1998, Acosta & Toro 2000).

The study

Aim

The aim of the study was to explore the views of homeless

people on their health and healthcare needs. The specific

research questions were: What are the effects of homelessness

on health from homeless peoples perspectives? Which

strategies will improve their health most effectively?

Design

A qualitative descriptive, exploratory design was used.

Individual semi-structured interviews with participants and

observational field notes provided the data, which were

collected in 2005 in one city in Canada.

Participants

The convenience sample of 24 participants consisted of nine

women and 15 men. Participants were recruited and inter-

viewed in city parks, on streets and at a womens drop-in

centre. The author and a student assistant approached people

who carried shopping bags containing their belongings or

were hanging out in front of shelters. The womens drop-in

centre was added, as many women on the street seemed

reluctant to speak to strangers or admit to being homeless.

Many of those approached refused to participate or were

considered housed and therefore did not qualify. Homeless-

ness, for this study, was defined as lacking a permanent place

of ones own. Twenty of the participants represented those

usually referred to as the absolute homeless, and were living

on the streets, in parks, under bridges, in abandoned

buildings or in shelters (Frankish et al. 2005, p. 524). The

oldest participant, an 81-year old man, lived in semi-

permanent housing, a small room in a shelter with shared

bathroom and no cooking facilities. Three of the women were

couch surfing with friends, which some consider as at risk

for being homeless (Frankish et al. 2005, p. 524).

Data collection

Interviews with semi-structured questions were chosen to

collect the data, as this method allows for elaboration on

desired points without losing focus (Mishler 1986). They

ranged in duration from 20 to 60 minutes. Three pilot

interviews were conducted by the author alone, with no

resulting changes in questions. The remaining 21 interviews

were jointly carried out by one of two student assistants and

the author. The same topics were covered with all partici-

pants. Prompts were used as necessary to gain comprehensive

data. Some questions dealt with demographics, such as sex,

age and length of homelessness. The interview questions

were: What do you see as the impact of homelessness on

your health? and What would it take for you to get off the

street into housing and stay successfully housed? Other

questions were asked about participants strengths, fears and

doubts, hopes and plans for the future and what they would

need to realize these. The student asked the questions, while

the author usually injected additional prompts. Observa-

tional field notes were written after the interviews, which

took place in city parks, on street corners and at the womens

drop-in centre.

To capture the views of participants accurately, with the

interviewees permission all but two of the sessions were

audio-taped and later transcribed. Notes were written

during the two non-recorded sessions. Meanings were

I. Daiski

274 2007 The Author. Journal compilation 2007 Blackwell Publishing Ltd

clarified with participants during and at the end of the

interviews as a form of respondent validation. Although

there were three interviewers, the questions were broad and

open-ended, inviting participants to tell their stories in their

own words. For participants to feel comfortable and freely

share their thoughts, the interviewers followed the flow of

the conversations. Prompts were then used as needed to

cover all points.

Ethical considerations

Approval of the study was obtained through York Univer-

sitys Office of Research Administration. Before signing

consent forms, participants were informed in writing of the

guarantee of anonymity and their rights to withdraw at any

time. Because of their poverty a small honorarium was paid

to them, including to those few who withdrew before

answering any or all questions. Participants were told about

the reward at the end of the interview to avoid influencing

their decisions to participate. Many thanked us for the

opportunity to talk and for being listened to.

Data analysis

The data were transcribed and analyzed using thematic

content analysis to identify patterns in the data (Lincoln &

Guba 1985).

Findings

Demographics

The participants, nine women and 15 men, ranged in age

from 19 to 81 years. Their educational levels varied from

6 years of schooling to some university education, although

none held a completed degree. The majority had not finished

high school. Just less than half were white Canadian-born

(11), five were of Caribbean background, two from Eastern

Europe, one from Argentina, one had immigrated as a child

from Italy, and one was borne in Sri Lanka. Three others

identified themselves as members of First Nations, either full-

blood or mixed. We asked about duration of homelessness

but, as the ages varied greatly, the comparisons did not

provide useful data. Generally, duration of homelessness

ranged from a few days to, as one 64 year old stated, All my

life from when I was eight. The majority had been homeless

for several years or had cycled in and out of homelessness one

or more times. All had been previously employed, at least

once, in various jobs such as factory or clerical work, or as

nursing aids or skilled tradespeople.

Perceptions of physical health

As discussed extensively in the literature cited earlier,

physical health problems were mostly chronic and rein-

forced through poverty and the homeless lifestyle, which

lacks consistent healthcare. Medical conditions, such as

seizure disorders, chronic respiratory diseases and musculo-

skeletal problems, as well as the difficulties of obtaining

dental care, were mentioned frequently. One person had

been treated for tuberculosis contracted in overcrowded

shelters. Older participants mostly tended to consider their

physical health problems as age-related, as the following

statement shows:

From the time I was eight, I got into problems with drugs. I have pain all

over, also arthritis, especially in my back. I am just getting older, I

notice my eyesight deteriorating. My health has deteriorated a lot. I

have had pneumonia four times and was hospitalized each time. I was

told by the doctors that the next time I will die (man, 63, lives in a park).

Some of the younger people, however, also showed similar

effects on their bodies prematurely:

I have not maintained proper management of my body. It is showing

signs right nowsome days I wake up, I cant move because my legsare so stiff. (man, 31, lives in a park)

I get sick a lot more down hereA lot of the kids have bronchitis and

stuff like that. Especially us living under the bridge, with all the toxins.

Everyone is coughing, the dogs are coughing too. And in the summer

there is the smog and they say, Everyone stay inside today, ha ha.(woman, 19, lives under a bridge with other kids and their dogs)

For some, homelessness was caused by injury. A 75-year-old

woman who was couch surfing with friends had to retire

early from her job in the Canadian arctic, due to foot surgery.

Another older woman who chose not to disclose her age

stated:

Three years ago I fell down stairs, many fractures. I am getting

therapies right now, I was unable to work since.

Having immigrated to Canada 14 years ago, she feared that

she would not qualify for a pension when she was older.

For others, homelessness was further aggravated by phys-

ical injuries. A 19-year-old homeless woman, after an

accident and surgery, had been placed in a shelter with no

rehabilitation services provided. She limped severely. Others

had chronic disabilities. This man noted:

I am an epileptic and cannot work any more full-time. The last

5 years I have had seizuresI could have brain damage from all my

past. (man, 50, lives on street)

JAN: ORIGINAL RESEARCH Health needs of homeless persons


Obtaining food is another challenge for the homeless. In

general, however, it was deemed to be accessible in the

central downtown area, with its many soup kitchens:

I go to drop-ins. I get the food I need, it is not like I am starving.

(woman, 40, couch surfing)

Many participants, however, were concerned about the

quality of the food, described as starchy and greasy.

Supporting a living

Apart from the physical health problems, obtaining an

adequate income was of great concern. Many of the jobs

participants had held in the past were described as dangerous,

exhausting, poorly paid, and with high potential for injuries.

The minimum wage at approximately Canadian $7 per hour

(1$ Canadian $, 0.87 US 0.44 and 0.66 Euros), wasnot enough to pay the rent in a rooming house, which

amounted to at least $400 per month. Therefore, some opted

for other ways of making a living:

I have worked in jobs like (electronic small appliances factory)

many are physically dangerous, unsafe conditionsonce I almost lostmy face due to a dangling piece of metal. The physical labour left me

too exhausted to look for better job opportunities. Panhandling

(begging on the street) makes me $15/hour. Minimum wage should

be at least $15 per hour, so people can live not in a subhuman way.

As long as you can panhandle, you dont have any emergencies.

(woman, 41, lives on the street)

Several participants stated that, when looking for work, a

shelter address did not inspire confidence in prospective

employers. Shelter life also made it difficult to find and hold

down a job:

I am not looking for work I need housing first. There are people

snoringand stinky feet. I cannot get up at 5 a.m. without a decent

sleep. And half the time you dont get your messages. (man, 30, lives

in a shelter)

Many of the participants had formerly earned good wages

and now considered themselves exploited by employment

agencies:

If they said to me, Theres going to be a helicopter to take you to a

logging camp out west, Id go to it. Now they go by a piece of paper

instead of trying you out for a day Oh you lost this job here

they nitpick. And then they take some kid with three months

experience at Burger King. Ive done all kinds of things welding,

rigs, heavy construction, jack hammers - I love to work. They want to

pay you some chump wage like 9 (dollars) an hour no! I want 16

(dollars) at least. And Labor Ready (a temporary employment

agency) takes money off your wage and you work your ass off.

(man, 47, lives in a park)

Those applying for welfare payments also experienced

difficulties, including dealing with a number of different case

workers and very complicated paperwork:

I found getting welfare hard. My worker wanted (to know about) my

first- borne. And leaving the shelter was really hard for me, because

there was so much paperwork. Then I just go, Forget it and I go

back to the shelter, or prostituting. And I dont have to sign this, get

this, get thatEven if I get them what they want, they always want

something elseI always feel like I am getting money from theirpocket. (man, 32, lives in a shelter).

All those of working age stated that they would much prefer a

job rather than welfare payments, which, at just over $500

per month was not enough to live on:

Too bad they dont have a job programme where the government

checks out your skills and you get a jobWelfare is too easy. I feel

guilty for getting it and end up drinking it. (man, 47, lives in a park)

Lack of privacy and restrictive rules

Lack of privacy and restrictive rules in shelters had an impact

on participants feelings of dignity and self-worth:

The shelter opens the door at 5 a.m. Then people hang around all

day sitting in the park here. You dont feel good about yourself.

There are no places to goInside there are small rooms, one TV,

sometimes 60 or 70 people. Too crowded, lying on the floor,

watching TV for five hoursmany people feel sickI share a room

with seven people, I cannot relax. No privacy. (man, 45, lives in a

shelter)

Im 32 years old and I dont want to get used to being tucked in at

10pm at night. (man, 32, now lives in a park)

One participant likened shelters to the previous abusive

relationship she had run away from:

I have always been abused, now the government is abusing me. I ran

away from an abusive marriage to a government that told me it

would help meso I ran into its arms, only to get the same verbal ormore abusebecause I was not expecting it, it hurts moreThey

deny you a bed, a towel and shampoothen they put us in withothers who are criminals. (woman, 41, lives on the street)

However, shelter life had some advantages, as one grateful

woman suggested:

I like to live with only women. And there is friendship, too. I like to

be with other people that is why I came to the city. [T]hey

I. Daiski


[employees in the shelter] also look after you and help you out with

things such as clothing. (woman, 41, lives in a shelter)

Living in fear and feeling unsafe

Not surprisingly participants all described some typical fears

with regard to lack of safety and security:

I have a lot of fears, a lot of doubts, about being homeless. Where am

I going to lay my head, when I am not at a friends? Where am I going

to go? (woman, 37, couch surfing)

I am afraid of becoming a full-fledged alcoholic and dying of cirrhosis

of the liver, like my grandfather. And really, I am afraid to self-

destruct. (man, 32, lives in a park)

All participants expressed a fear of violence, and shelters

were generally viewed as the most dangerous accommoda-

tion. One participant reported that he had been robbed and

his personal identification documents had been stolen three

times in shelters. Many others told of experiences of robbery

and assault, and fighting was common:

I used to use shelters not any more. Got into a fight and left. I cant

be in an environment where I dont feel safe. I feel a lot safer on the

street. (man, 31, lives in a park)

However, the streets too were described as dangerous,

causing stress:

People think we are lazy because they see us sleeping in the park all

day. There is a reason for that we have to protect ourselves at night

we cant go to sleep. (man, 63, lives in a park)

Physically, I feel nauseous from stressSleeping in the park is veryscary. I doze off, wake up, doze off especially as a womanI want

to be careful of the guys. I am angry a lot, especially with my rights

not properly treated. I can fight, but I dont want to fight. (woman,

30, lives in a park)

Frequently, the very people employed to serve and protect

were seen as the sources of danger:

I have stayed on the streets of (city) and its not fun. The (police) give

you a hard time. (woman, 19, lives under a bridge)

The most harassment I have gotten is from police and securitytheyharass you, and treat you like crap for no reason at all. (woman, 41,

lives on the street)

Another great fear was of dying in the streets:

My biggest fear: I am afraid to die in the street, friendless, with no-

one to care, like a piece of garbage they pick up off the ground. (man,

63, lives in a park)

I dont want to die alone, homeless, in the gutter in a slow, sad way.

(man, 47, lives in a park)

Mental health and addictions

All participants reported experiencing emotional distress,

often associated with mental health problems, addictions and

crime:

The homeless life is not easy. The first three months after you are

homeless, your mental health is changingno money, family, food, itchanges peopleyou drink, do dope, and beg. (man, 37, lives in

woods)

I am worried I will get hurt, or some of my stuff gets stolen or my

health will deteriorate emotionally and mentallyand I will get

depressed and suicidal. (woman, 30, lives in park)

Several participants admitted to their addictions to drugs and

alcohol:

I got an alcohol problem. When I start drinking to escape my reality,

pain and loneliness, it washes it away. I feel happy. But then I come

down the next day all depressed and start the cycle all over again.

(man, 32, lives in park)

However, when people on the street are ready to give

up substance abuse, treatments are frequently not avail-

able:

Right now they [government] want to close 40% of the detox.

bedsthere is not going to be much left. Its not going to make people

who need detox. go away. There is nothing for women. Most of it is

for people who are older or very young. Mostly I have tried to deal

with it myself. It is hard on the street to get away from what you are

using. Every second person uses it. (woman, 19, lives under a bridge)

Exclusion and invisibility

Several participants ascribed their loneliness to the many

barriers and social exclusion they continuously faced:

Everyday I see the same people, they see me. They never offer to buy

you a coffee or something or even ask if you are okayThey never

say, Hi. (man, 37, lives in a shelter)

A social life was very difficult:

I love to cook, Id love to have a woman come over to my house. But

when youre with a woman, or in society, youre embarrassed to even

say [you are homeless]. You have to make up some bullshit Im

staying with a friend oh, we dont have a phone yet Its so

complicated. (man, 32, lives in park)



Many participants reported feeling a failure, which was

reinforced through being ignored by others:

I feel sad, I feel disappointed in myself, I want to do a lot better.

(woman, 32, lives in a shelter)

It [being ignored] affects your mind, affects you physically and

emotionally, mentally. We all need human touch and to talk to

somebody. And [if] you walk around by yourself all day and people

pretend they dont notice you (man, 32, lives in a shelter)

Feelings of exclusion and rejection can lead to depression and

perhaps crime:

It is hard for everybody, to be told No over and over again (when

panhandling). People pass you by so many times. With each No

your heart, your body breaks down. A true panhandler tries to keep

themselves psyched up so they dont get discouraged. With each No

they sink down a little more. Then you see them crawl into a hole and

then they shoplift and stuff. (woman, 41, lives on the street)

Discussion

Study limitations

One of the limitations of this study was the small and diverse

sample of volunteers. People in other settings or other parts

of the world might experience homelessness differently from

those in an urban setting. Furthermore, no families partici-

pated, as they are housed in specialized shelters or motels and

therefore were not recruited.

Perceptions of health

Despite the diversity among participants in age, ethnicity,

education and gender, common themes emerged from the

data. Their physical illnesses were similar to those identi-

fied in other studies investigating the health status of

homeless populations (Harris et al. 1994, Hwang et al.

1999, Hwang 2000, 2001, Hwang et al. 2003, Bryant

2004, OConnell 2004, Sunnak 2004, Frankish et al. 2005,

Shapcott 2005, Raphael 2006). They consisted of arthritis,

seizure disorders, breathing problems, tuberculosis and

cardio-vascular diseases. Life on the street takes a heavy

toll. As previously noted by Frankish et al. (2005),

conditions commonly associated with advanced age

appeared in young people decades earlier than expected.

Physical illnesses, injuries and disabilities were often caused

and further aggravated by homelessness a relationship

also established by Hartman (2000) while disrespectful

treatment by healthcare professionals has been found

responsible for seeking care late and only for serious

illness in other work (Daiski 2005).

Other diseases prevalent in this group, such as diabetes,

hepatitis and HIV/AIDS (Hwang et al. 1999, 2003, Lafuente

2003, Frankish et al. 2005), were not encountered, either

because of the small sample size or, in case of the latter two,

due to the stigma attached, preventing the sharing of such

information. Furthermore, participants themselves might

have been unaware of some health conditions, as few had

regular check-ups (Lafuente 2003, Daiski 2005).

Many participants admitted to addictions and alcohol

abuse. They mentioned feeling guilty about receiving

welfare benefits and drinking it, a phenomenon also

described by Bishop-Stall (2005). Several were afraid of the

consequences of addictions, such as dying of cirrhosis of the

liver. They discussed the unavailability of treatments for

those ready to deal with their substance abuse, while further

cuts in numbers of treatment beds was taking place at the

time of the study. Frankish et al. (2005) had found alcohol

abuse to be as high as 60% amongst homeless single men and

also reported a lack of treatment facilities. Several of our

participants shared their biggest fears as dying in the streets

friendless and alone, similarly described by Lafuente (2003)

and Rokach (2005).

While physical health was of concern, participants also

lived in constant fear of violence. Shelters, in particular, were

identified as lacking security measures, and there was a high

incidence of fights and thefts. The streets too were dangerous.

Having to constantly look over ones shoulder was described

as extremely stressful. Fearfulness led to inability to rest and

sleep, which have also been previously documented (Lafuente

2003, Yanos et al. 2004, Frankish et al. 2005). Shelters, in

addition to lacking security, were perceived as dehumanizing.

Most were overcrowded and had many restrictions, such as

early curfews and early waking. During the day there was no

place to stay and nothing to do, and so people just hung out

in the park. As shelters generally provided little counselling,

with only one woman reporting that she had obtained support

and friendship in her shelter, they seemed mostly inefficient in

helping people get off the streets. In frustration, some

participants turned to begging and prostitution.

All participants talked about experiencing emotional dis-

tress, which is associated with mental health problems,

addictions and crime (Kushel et al. 2005, Rokach 2005).

They worried about the effects of homelessness on their

mental health. They described the greatest hardship as feeling

invisible and excluded by the rest of society, leading to low

self-esteem and feeling like a failure. Disaffiliation of the

homeless from the community at large was also discussed by

I. Daiski


Miller and Keys (2001), Lafuente (2003), Yanos et al. (2004),

Hart Romeo (2005), Rokach (2005) and Zufferey and Kerr

(2004). Noddings (2002) attributed low self-esteem to

societys view of housing as an extension of oneself (p. 445).

All participants of working age expressed hope about, one

day, being housed and employed. In addition to begging and

doing things I should not be doing, many worked in

temporary jobs, performing dangerous work for low pay.

Additionally, a large portion of their wages went to employ-

ment agencies such as Labor Ready. Participants identified

that they needed to be fairly paid, and that neither the

minimum wage nor welfare were enough to live on and pay

rent. Most of all, they wanted to be treated like a human

being. Welfare and employment agencies were perceived

difficult to negotiate, due to excessive paperwork, lack of

continuity in services and disrespectful treatment. Overall,

these participants appeared trapped by their poverty, sur-

rounded by barriers that made it practically impossible to

escape it. However, the general discourse continues to treat

homelessness as a chosen lifestyle, blaming homeless people

themselves for their situation (Klodawsky et al. 2002).

In this study, participants seemed to have a good under-

standing of factors contributing to homelessness and what

they needed to escape it. They talked about health compre-

hensively, similarly to the World Health Organizations

(WHO) (1948) definition of health as a state of complete

physical, mental and social well-being and not merely the

absence of disease or infirmity. Recently health was pro-

claimed to be a human right and actions and commitments

were added to the constitution to address the determinants of

health, worldwide (WHO 2005). In line with this definition,

the following strategies emerged from the study. for improv-

ing the health of homeless people and reintegrating them into

society.

The first step seems to be changing attitudes, including

those of healthcare workers, towards the homeless. Health-

care professionals need to advocate for policies that promote

social equity. We need to listen to homeless people to

understand their experiences and collaborate with them in

order to individualize supportive measures and provide

respectful care tailored to their needs (Acosta & Toro

2000, Miller & Keys 2001, Registered Nurses Association

of Ontario 2002, Zufferey & Kerr 2004, Anderson & Funnell

2005). Individuals should be seen as experts on their own

lives. Instead of doing for, caregivers, in partnership with

clients, need to establish connections with them and help

them regain their self-esteem (Jezewski 1995, Bunkers 1998,

2004, Josephson 2000, Zerwekh 2000, Yanos et al. 2004,

Daiski 2005).

The second health strategy, as suggested by Lafuente

(2003), is to provide stable, safe housing. Housing facilitates

receiving regular healthcare, including treatments for addic-

tions. It prevents health problems resulting from exposure to

the elements and contracting communicable diseases in over-

crowded shelters (Golden 1999, Layton 2000, Trevena et al.

2001, Shapcott 2005). Housing allows for homecare and

rehabilitation after discharge from hospital, thereby prevent-

ing or mitigating long-term disabilities (Yanos et al. 2004,

Fichter & Quadflieg 2006). Being able to lock the door

reduces fears, prevents violence, and gives people back their

dignity (Noddings 2002, Lafuente 2003). Shapcott (2003,

2005) proposed that housing be subsidized to make it

affordable to all, and a fair stable income has been identified

as a prerequisite for permanent housing (Zlotnick et al.

1999).

Thirdly, shelters should not be used as long-term solutions

to get people off the streets, but as necessary short-term

accommodation. They should be humanized, relaxing some

of the restrictive rules that impinge on human dignity, such as

early curfews. They need to better ensure the safety of their

residents, and their main focus should be on helping homeless

people to negotiate the system to obtain housing, training,

employment and healthcare, and not merely providing

accommodation (Miller & Keys 2001).

Conclusion

The findings of this study are relevant to healthcare profes-

sionals everywhere who encounter homeless people in their

What is already known about this topic

Homelessness is associated with higher incidence ofdisease, both physical and mental.

Treatments are begun at a later stage, mostly throughemergency departments, increasing healthcare costs.

Homelessness is frequently considered to be a chosenlife-style.

What this paper adds

Homeless people live in fear and perceive social exclu-sion and low self-esteem as the greatest threats to their

health.

Homeless people desire to work, to be housed and to berespected.

Homeless people need continuity in services, employ-ment, housing and treatments for addiction to improve

their health.



work. Community nurses, in particular, are ideally positioned

to be concerned with holistic health and the needs of

homeless people. Although the harshness of climates might

render homelessness in some areas even harder than others,

the stigma and insecurity connected with it are universal. The

factors leading to homelessness, such as poverty and lack of

employment, are also universal. Although some homelessness

is caused by natural disasters, such as landslides and

earthquakes, for such victims help is generally provided from

national and international sources. However, those whose

homelessness results from poverty are treated with contempt.

Current attitudes towards the homeless perpetuate existing

social disparities and the resulting health problems, as well as

drive up costs for healthcare. Nurses should return to the

roots of nursing as practised by Nightingale, who was a social

reformer; this has implications for nursing curricula, which

should include care of marginalized populations. The goal

should be reintegrating homeless people into communities.

Social services providing counselling and adequate treatment

centres for addictions would also save on healthcare costs

and social spending in the long run. Future research could

include community-based action research, in collaboration

with homeless people, to streamline services and to develop

equitable social policies that are truly helpful in getting

people off the streets.

Acknowledgements

This study was supported by a small research grant from the

Social Sciences and Humanities Research Council of Canada

(SSHRC). Special thanks to the two research assistants

Lorraine Munro and Brandi Tapp.

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