Who are the homeless?

Public Health (1994), 108, 11-19

(~) The Society of Public Health, 1994

W h o are the Homeless? N. J. Shanks, PhD MRCGP 1, S. L. George, MBBS 2, L. Westlake, BSc 3 and D. AI-Kalai 4

7Head of Accident and Emergency and Senior General Practitioner; 2Lecturer in Epidemiology; 3Statistician; 4Medical Officer; 1"4Departmentof Primary Care, King Khalid National Guard Hospital, Jeddah, Saudi Arabia; 2"3Department of Community Medicine, Sheffield Medical School, UK

To describe the demographic, social and medical morbidity and usage of health services of the population of single homeless individuals in Sheffield, a census was carried out over a 12-hour period at sites which homeless people frequent, as identified by those who work with the homeless. These sites included Salvation Army hostels, reception centres, probation day centres, voluntary organisation hostels, and cheap bed and breakfast accommodation. Data were collected by means of a self-administered questionnaire. A total of 340 single homeless individuals were studied, constituting 80-90% of the single homeless population of Sheffield, as estimated by field workers. The population was younger than those of earlier studies and contained a higher proportion of females (14%). One-fifth of the population had been homeless for less than six months, and 60% had been at their present lodging for less than six months. The population has a higher proportion of both ex-prisoners (49%) and ex-inmates of psychiatric hospitals (36%). Over a quarter admit to a history of alcoholism, and 9% to a history of drug abuse; 65% of the population are registered locally with a GP, and 53% of the population see their GP. Those who are more likely to use an Accident and Emergency Department are less socially integrated and more likely to be alcoholic. This study of the single homeless highlights a need for social change to reduce poverty, provide cheap available housing and provide support for disadvantaged groups.

Introduction O n e of the most elusive social statistics is the exact n u m b e r of homeless persons in G r e a t Britain today. A reliable estimate of the n u m b e r is difficult to m a k e as one has to rely on those who come forward for help and can be counted. In a recent H o u s e of C o m m o n s debate it was estimated that there were 100,000 homeless in the United Kingdom. 1 H o w e v e r , in 1987 local authorities in E n g l a n d and Wales accepted some 120,000 households (350,000 people) as being homeless. This figure excluded most young, single homeless people, estimated by Shelter to be 150,000. 2 W h o are the homeless of today? In 1956 The 7~rnes newspaper described them as ' m e n who have had a row with their wives, youths who have drifted from casual e m p l o y m e n t , newly arrived labourers from Ireland, old lags, alcoholics, criminals on the run, mental defectives'. M o r e recently social service units and central g o v e r n m e n t departments have conducted three large-scale surveys, delving into the relationships of homelessness by seeking out certain d e m o g r a p h i c characteristics such as: age, sex, e m p l o y m e n t , medical and social morbidity. 3-s Homelessness is increasing. The reduction in public expenditure on housing, the Correspondence to: Dr N. J. Shanks, Head of Accident and Emergency and Senior General Practitioner, Department of Accident and Emergency and General Practice, King Khalid National Guard Hospital, PO Box 9515, Jeddah 21423, Kingdom of Saudi Arabia.

12

N . J . Shanks et al.

closure of large hospitals for the mentally ill and the increase in the number of single-parent families6 have increased the demand for the dwindling supply of rental accommodation. In the recent Salvation Army survey, 532 people were discovered sleeping rough in a small area of Central London. 7 There are more than 22,000 hostel bedspaces in London alone and another 37,000 elsewhere in England. Returns to the Department of Social Security suggest that there are 76,000 single claimants in board and lodgings. The number of families placed in temporary accommodation by local authorities soared from 23,000 in 1986 to 40,000 in 1989. 8 The Salvation Army 7 describes a new concept--that of 'hearthlessness', exemplifying this term by stating that 'those in hotels for example are more hearthless than those in squats, but may be less hearthless than those in hostels'. The most 'hearthless' of all are the single homeless. There is no consensus about what constitutes homelessness in the United Kingdom. However, in practice the term applies to those with a range of unsatisfactory long-term housing ranging from sleeping on the streets, through to night shelters and hostels to bed and breakfast accommodation. This homeless population is not homogeneous or static: people sleeping rough move from the streets into hostels or bed and breakfast accommodation and back again--a revolving door. In this paper we describe a census of the homeless in Sheffield. Method

The value of large-scale surveys3-5 in the study of the homeless is strictly limited. A random sample of the homeless population is difficult to obtain, because there is no defined sampling frame, and it is apparent that any interviewer who does not establish a good relationship with this group is unlikely to achieve consistent results. 9 The shortcomings of this approach have been highlighted previously. 1° Clearly, a census of a homeless population is preferable to an attempt at a random sample. A census of all single homeless people in Sheffield was conducted over a 12-hour period on a single day. This was set between 8 a.m. and 8 p.m. on 12 December 1988, an ordinary mid-week day, at the times when the hostels open/close their doors. The weather was mild~ The population was more likely to be stable during the winter months and those who travelled, particularly for casual summer employment, were likely to have returned to Sheffield for the winter. Some of the more healthy may have been working or sleeping rough. Others may have been detained in police cells or hospitals. However, the numbers in prison or hospital or working, compared with those included in the census, are likely to have been small. (The police originally agreed to take part in the survey, but shortly before its commencement declined as they were concerned that the confidential relationship between themselves and the public might be jeopardised.) Information from local authority and voluntary organisation sources leads us to believe that in excess of 90% of Sheffield's single homeless were included in the census° Sheffield Local Authority employs a Principal Homelessness Officer leading a team of workers, and an Environmental Health Officer with specific responsibility for the homeless. The Probation Service, in addition, houses a homelessness team and has a day centre specifically for the homeless. Information from these individuals, and from others working in the field, led to the identification of specific sites which homeless people frequent. These included Salvation Army hostels, reception centres, probation day centres, voluntary organisation hostels, makeshift self-built shelters (where people sleep rough) and cheap bed and breakfast accommodation. Only those personnel who work with the homeless conducted the survey, and these were tutored as to how to

13

W h o are the H o m e l e s s ?

administer the questionnaire. There was no compulsion or reward for completion of the questionnaire. All the forms were collected centrally. Duplicated, inappropriately completed or defaced forms were discarded. The remaining forms were computer coded for analysis using the Statistical Package for the Social Sciences (SPSSX). 11 This paper reports on the demographic data recorded and on that pertaining to social and employment history, and contact with welfare agencies and medical services. Analysis of the data, in the form of contingency tables, used chi-square tests or Fisher's exact test where the expected frequency in any cell of a two-by-two table fell to less than five. Results

Nine people refused to complete the questionnaire. A total of 379 questionnaires were collected for the census. However, 39 of these were either duplicated, defaced or had less than two-thirds of the questions (66) completed and were excluded, leaving 340 questionnaires for analysis. Twenty-eight of the population were illiterate and had to be helped to complete the questionnaire. As some 10% of the population are estimated to be illiterate or semi-literate, 12 it seems a reasonable assumption that the figure would be expected to be considerably higher in homeless populations and that they would also be people more likely to refuse to participate or to deface self-completion questionnaires. This population of single homeless had an average age of 42.6 years (Table I) and 25% were less than 30 years old. In comparison with a 1966 study in which there were only 10% under 30,13 and a 1981 study of the homeless in which the average age was 48.7 years 14 our population appeared younger (Table II). Forty-eight (14%) were female. Table III shows that females were more likely than males to be registered with a GP, to have self-reported psychiatric problems and to have been previously admitted to a psychiatric hospital. However, they were less likely to have been in prison or to have a self-reported history of alcoholism. Three hundred and twenty (96%) were white. Thirty-eight (11%) were Scottish, and 2 0 (6%) Irish, but the majority 260 (78%) were born in England. A total of 74 (22%) were Catholic, a proportion which is markedly above the 5% of the Sheffield

Table I Age (years) Under 25 25-34 35-44 45-54 55-64 65 or over Missing Total Mean Median

Age and sex structures of census population Male 43 51 56 67 29 31 15 292 42.5 42

(15.5) (18.4) (20.2) (24.2) (10.5) (11.2)

Female 10 7 8 11 5 5 2 48 40.0 42

(21.7) (15.2) (17.4) (23.9) (10.9) (10.9)

Total 53 58 64 78 34 36 17 340 42.5 42

(16.4) (18.0) (19.8) (24.1) (10.5) (11.1)

Note: Figures in parentheses are percentages of totals, excluding missing values.

14

N . J . S h a n k s et al.

Table II

Age distribution of populations studied in four studies of homeless persons Percentage of population

Age in years Under 30 30-39 40-49 50-59 60 or over

1966a

1966b

1981c

1988d

10 11 20 24 35 100

4 5 15 26 50 100

7 20 26 29 18 100

25 18 28 13 17 100

aNational Assistance Board3; bLodge Patch, I. C.13; CShanks, N. j.14; dStudy population. Note: Standard OPCS age categories (as in Table I) not used due to age classifications in previous studies considered. Table III

Analysis of study participants by sex against other demographic, social and medical variables

Group

Registered with GP Not registered with GP Self-reported history of alcoholism No history of alcoholism Been in prison Not been in prison Previously admitted to psychiatric hospital No previous psychiatric admission Self-reported psychiatric problems No psychiatric problems

Male

Female

;(2 for difference between group (df = 1)

173 102 83 190 152 103

38 8 4 40 8 33

6.79

< 0.01

8.64

< 0.01

22.86

< 0.01

97 176 77 189

25 21 27 15

5.1

< 0,05

18.7

P value

< 0.0001

population who are such, 15 but in general agreement with previous studies of the homeless. 16 This cannot be explained by the p r o p o r t i o n of Irish in the population. Only 14 (4%) respondents r e p o r t e d being married, with 75 (22%) being either separated or divorced and 151 (44%) n e v e r having married. This is part of an overall picture of social and emotional deprivation, as 206 (6%) r e p o r t e d having no contact with any m e m b e r of their family, and 16 (5%) r e p o r t e d that at least one other family m e m b e r was homeless. Nearly half of the population (165) had been in prison, and 65 (40%) of those were discharged within the five years preceding the study. T h e association of homelessness and history of imprisonment is well k n o w n . 3,4'13,14,16 T h e reliability of the reasons given for being homeless is in doubt, as response was to an o p e n - e n d e d question which produced answers which were sometimes difficult to interpret. H o w e v e r , 27 (8%) of the population m e n t i o n e d eviction as the reason for homelessness. Twelve (4%) described themselves as 'travellers', and one could speculate that these formed the 'men of the road' of bygone days. In addition the possible characteristics of non-responders (48: refusers plus p o o r completion of

15

W h o are the Homeless?

questions) and others not captured in the census may make up a core of 'men of the road'. It is likely that these traditional colourful characters are disappearing in real terms as well as being overshadowed by increases in other types of homelessness. One-fifth had been homeless for less than six months, although the median length of time homeless was four years. The census revealed that 205 (60%) had been at their present lodging place for less than six months, and 71 (21%) for less than one month. This contrasts with the Homeless Single Persons' study (1966) 3 in which only 38% of the sample had lived at their index lodging house for less than six months. Only 20 (6%) of the population did any paid work in the seven days preceding the study, whilst 161 (47%) were in receipt of social security benefit. Only one of the illiterate people had 'signed on', indicating that the literate were 15 times more likely to be in receipt of social security benefit than illiterate people (P < 0.0005). Study participants were asked if they had ever suffered from a variety of conditions, including 'alcoholism' and 'drug abuse'. Whilst we realise that this is a subjective self-assessment by participants it is nevertheless the best that can be achieved without expert history taking, physical examination, and access to medical records. Table IV shows that over one-third reported a history of psychiatric illness, and over one-quarter reported problems of alcoholism. Questions on the use of medical services revealed that 220 (65%) were registered with a GP in Sheffield, and, more importantly, 179 (53%) claimed to see their GP. Table V shows that those registered with a GP were more likely to be female, to have some family contact and to have some serious medical condition, such as epilepsy or psychiatric problems. 13 Individuals reporting either alcoholism or drug abuse were less likely to be registered with a GP. A total of 65 (19%) individuals had either attended or been admitted to a general hospital in the previous month, the largest single reason for attendance being use of Accident and Emergency (A&E) services. In addition, 120 (35%) of the population reported a previous admission to a psychiatric hospital, but 34 of these did not claim to have a psychiatric history. Table VI shows self-reported use of either a GP, A & E services or both. A total of 197 (58%) individuals had used one or both services. Although the majority of individuals make use of the GP, those reporting either alcohol or drug problems were more likely to utilise A&E services. Discussion

The homeless of today are younger. Our population is on average six years younger than that of a 1981 studyJ 4 There are several possible explanations for this over and above any explanation due to demographic changes. First, the breakdown of the Table IV

Self-reported medical history of census population

Medical Problems

Epilepsy Tuberculosis Alcoholism Drug abuse Psychiatric illness Other

Yes

13 (3.9) (3.4) (27.6) (9.4) (34.1) (22.3)

11 92 31 110 73

No

Missing

319 (96.1) (96.6) (72.4) (90.6) (65.9) (77.7)

15 7 10 17 13

314 241 299 213 254

8

Note: Figures in parentheses are percentages of total data obtained on each variable, excluding those missing.

16 Table V

N. J. Shanks" et al.

Analysis of participants who were registered with a general practitioner by other demographic and social variables

Group

Number (%) registered with a GP

Total

X2 for difference between groups (dr = 1)

P value

173 (63) 38 (83) 11 (92) 206 (65) 89 (83) 118 (56) 47 (52) 170 (71) 15 (50) 201 (68) 99 (80) 120 (59) 80 (50) 138 (82) 94 (73)

275 46 12 316 107 211 90 238 30 297 124 203 160 169 129

6.79

< 0.01

3.62

< 0.05

22.21

< 0.01

10.76

< 0.01

3.79

< 0.05

14.95

< 0.01

36.84

< 0.01

4.62

< 0.03

124 (61)

202

26 (84)

31

5.71

< 0.02

171 (62) 171 (96) 43 (52)

275 179 82

70.73

< 0.01

Male Female Epileptic Not epileptic Psychiatric illness No psychiatric illness Alcoholic Not alcoholic Drug abuse No drug abuse Family contact No family contact Signs on as unemployed Does not sign on Psychiatric hospital admission No psychiatric hospital admission Attends psychiatric outpatients Does not attend psychiatric outpatients Sees GP Does not see GP

family unit, c o m m o n today, was not so 30 years ago; second, m o r e elderly p e o p l e are entering old p e o p l e s ' h o m e s or other f o r m s of specialised housing for the elderly; third, there has b e e n an increase in u n e m p l o y m e n t , especially a m o n g unskilled persons, and a c o n s e q u e n t n e e d to travel to find e m p l o y m e n t . It is of interest to n o t e a similar age trend in A m e r i c a . 17,18

Table VI

Analysis of use of GP and attendance at A&E department, against other demographic, social and medical variables

Respondents Had been to prison Epileptics Self-reported psychiatric problems Suffering from tuberculosis Self-reported alcohol problems Self-reported drug problems Chronic medical conditions All respondents

GP only

69 (72.6) 10 (100) 66 (82.5) 4 (66,7) 35 (64.8) 14 (73.7) 45 (81.8) 153 (77.7)

A & E only

11 (11.6) 0 (--) 4 (5,0) 1 (16,7) 9 (16,7) 4 (21.0) 4 (7.3) 18 (9.1)

Note: Figures in parentheses are percentages in each category for each variable.

Both GP and A & E

15 (15.8) 0 (--) 10 (12.5) 1 (16.7) 10 (18,5) 1 (5.3) 6 (10,9) 26 (13.2)

W h o are the Homeless?

17

The proportion of female homeless also appears to be increasing. The Homeless Single Persons' Study3 reported 7% of the hostel population to be female. More recently Shanks 14 reported a much lower figure of 3%. The large apparent increase observed in our study is difficult to explain. 19 It may represent a breakdown of social ties or point to the fact that many young girls are now leaving home early with high hopes and aspirations only to end up homeless. It may be that the female homeless have always existed b u t are only now becoming visible in such numbers. Homeless women are less disaffiliated than homeless men, but are more frequently disturbed and psychiatrically ill. Marshall and Reed 2° reported that 64% of the homeless women they interviewed had a clinical diagnosis of schizophrenia. One explanation for this high incidence of psychiatric illness is that it may require higher levels of disturbance for women to sever links with home than for men; therefore, women becoming homeless are more likely to be ill. The proportion of our study population who admit to a history of alcoholism (27%) seems high in comparison with the general population, but is low in comparison with the American homeless, who have 68% prevalence of alcoholism. TM Moreover, Bogue 21 has clearly disproved the assumption that everyone on Skid Row is an alcoholic. Importantly recent evidence suggests that severely dependent drinkers can be detoxified as effectively in a hostel for the homeless as in a hospital. Furthermore such a setting is cheaper, just as safe and preferred by the homeless. 22 Drug problems have never been considered to be a problem among the British homeless, and our finding of a significant number of self-reported drug abusers is an issue to monitor carefully, as drug abuse in America is now one of the major causes of homelessness. 18 The high prevalence (49%) of previous convictions is in keeping with previous studies. 3,13,14 The majority harboured a negative experience of prison and had not received any help or rehabilitation on discharge. This highlights a missed opportunity for therapeutic aftercare. In agreement with other studies of the homeless23-26 a high prevalence of chronic medical morbidity prevails, including tuberculosis and epilepsy: In contrast with other studies, however, a high proportion of our population was registered with a general practitioner; and the majority of those so registered saw their general practitioner. Only 39% of London's homeless are registered with a GP, whom most of them do not consult57 The reasons underlying these differences are complex and not fully researched, although there may be some geographical bias. The high number of homeless in Sheffield registered with general practitioners may be partly explained by the sympathetic policy of health and social workers who endeavour to obtain registration in practices known to be sympathetic to the needs of the homeless in the city. This study demonstrates that it is the more socially stable, evidenced by their degree of family contact, who are more likely to be registered with a GP. Those registered with a GP are also less likely to have a history of alcoholism, but more likely to suffer from epilepsy, have a history of psychiatric hospital admission or have a self-assessed psychiatric history. It is perhaps no surprise that those who need frequent follow up, regular medication and more contact with social and medical services have increased rates of GP registration. It is useful to consider why those who are not in contact with their families, who abuse drugs, or are alcoholic, are less likely to register with a general practitioner. Such people find waiting rooms and appointment systems difficult to adhere to. Some do not use day centres or hostels and clearly would not benefit from efforts to improve their health based on doctors' attendance solely in such centres. It is this group of socially isolated patients who have most to gain from outreach programmes such as Mobile Surgeries. 27 Close liaison between the shelter staff, care agencies and

18

N . J . Shanks et aL

medical staff is the most likely way of providing effective social and medical care to the homeless. 28 An examination of the use of hospital services reveals that it is the less socially integrated who are more likely to use an A&E department. These, although they form the minority, give a false impression of large numbers because of their drunken, disorderly behaviour and readily recognised appearance. 29 There is a very high prevalence of self-reported mental illness among this Sheffield contingent. Previous studies 13,14,24,30-32 have demonstrated a high degree of social and psychiatric morbidity among the homeless. The demand on services is such that nearly two-thirds of the mentally ill, three-quarters of the alcoholics and half of the physically handicapped homeless claim to receive no medical treatment. 6 The high proportion of women claiming to have been admitted to psychiatric hospital or to have a history of psychiatric illness is especially worthy of comment, and contrasts with low self-reporting of alcohol abuse by women compared with homeless males, and with the small proportion of women, compared with men, who have a prison history. Present society has a limited tolerance of mentally abnormal behaviour. There is increasing evidence of removal of mentally ill persons, in need of treatment, to prison instead of hospital. 33 It is possible that the police will deal more sympathetically with a women who is behaving strangely and might initiate a hospital admission in circumstances in which a male is likely to be charged and remanded in prison. On the other hand, homeless women tend to cooperate poorly with treatment and are significantly more likely to discharge themselves from hospital than menP 5 and it might be that the male counterparts of these individuals remain in hospital care. Since 1954 the number of long-stay patients in psychiatric institutions in England and Wales has halved. There has been a failure among health authorities to create community services for patients discharged from long-term mental hospitals. 34 Yet, despite statutory obligations towards the vulnerable homeless (Health and Public Services Act 1968), few have been accommodated by local authorities. 35 The closure of mental hospitals in the 1980s has led to the unchallenged assumption that this was directly responsible for the high incidence of mental illness amongst the homeless. Although a reasonable hypothesis, there is little supporting evidence. Surprisingly little attention has been paid to the effects of the recent closure of many state-funded reception centres, shelters and hostels which may be the real cause of increased homelessness. The recent increase in the numbers of those homeless has been caused by a combination of a scarcity of social housing following council house sales, changes to social security regulations which restrict payments to young people and a gross shortage of 'half-way houses' from which people can migrate into homes of their own. References

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Who are the Homeless?

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