research papers on homelessness

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• 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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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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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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Homelessness and the Persistence of Deprivation: Income, Employment, and Safety Net Participation

Homelessness is arguably the most extreme hardship associated with poverty in the United States, yet people experiencing homelessness are excluded from official poverty statistics and much of the extreme poverty literature. This paper provides the most detailed and accurate portrait to date of the level and persistence of material disadvantage faced by this population, including the first national estimates of income, employment, and safety net participation based on administrative data. Starting from the first large and nationally representative sample of adults recorded as sheltered and unsheltered homeless taken from the 2010 Census, we link restricted-use longitudinal tax records and administrative data on the Supplemental Nutrition Assistance Program (SNAP), Medicare, Medicaid, Disability Insurance (DI), Supplemental Security Income (SSI), veterans’ benefits, housing assistance, and mortality. Nearly half of these adults had formal employment in the year they were observed as homeless, and nearly all either worked or were reached by at least one safety net program. Nevertheless, their incomes remained low for the decade surrounding an observed period of homelessness, suggesting that homelessness tends to arise in the context of long-term, severe deprivation rather than large and sudden losses of income. People appear to experience homelessness because they are very poor despite being connected to the labor market and safety net, with low permanent incomes leaving them vulnerable to the loss of housing when met with even modest disruptions to life circumstances.

The Census Bureau has reviewed this data product for unauthorized disclosure of confidential information and has approved the disclosure avoidance practices applies to this release, authorization number CBDRB-FY2022-CES005-015. We thank the U.S. Census Bureau for their support, as well as John Abowd, Mark Asiala, George Carter, James Christy, Dennis Culhane, Kevin Deardorff, Conor Dougherty, Ingrid Gould Ellen, Anne Fletcher, Katie Genadek, Tatiana Homonoff, Kristin Kerns, William Koerber, Margot Kushel, Larry Locklear, Tim Marshall, Brian McKenzie, Brendan O’Flaherty, James Pugh, Trudi Renwick, Annette Riorday, Nan Roman, William Snow, Eddie Thomas, Matthew Turner, and John Voorheis for providing feedback and answering questions. We also thank participants in seminars at Yale University (Labor/Public Economics Workshop), the University of Chicago (Demography Workshop), APPAM, NTA, NBER Labor Studies, IRS/Census (Income Measurement Workshop), and the Institute for Research on Poverty. Ilina Logani and Mandana Vakil provided excellent research assistance. We appreciate the financial support of the Alfred P. Sloan Foundation, the Russell Sage Foundation, the Charles Koch Foundation, the Menard Family Foundation, and the American Enterprise Institute. Wyse thanks the National Institute on Aging for their support. The views expressed herein are those of the authors and do not necessarily reflect the views of the National Bureau of Economic Research.

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A qualitative systematic review on the experiences of homelessness among older adults

• Phuntsho Om 1 , 2 ,
• Lisa Whitehead 1 , 3 ,
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Adults who experience homelessness for an extended period of time also experience accelerated ageing and other negative impacts on their general health and wellbeing. Homelessness amongst older adults is on the rise, yet there are few systematic reviews investigating their experiences. Thus, this review classifies and synthesises qualitative research findings of studies published between 1990 to 2020 that have examined the needs and challenges of homeless older adults to elucidate their journey of homelessness. Seven papers met the requirements for inclusion. Three main themes were identified in the review: - (1) Pathways to homelessness, (2) Impact of homelessness, and (3) Outcomes and resolutions. This review collates current evidence on what is known about the experience of homelessness among older adults. In this study, homeless older adults identified a wide range of challenges associated with the experience of homelessness.

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The population globally is ageing. Although, ageing is truly a triumph of development, this demographic change presents both advantages and challenges. The concept of successful ageing is to “add life to years” rather than adding days to life and is about maximizing wellbeing and happiness for the older adult [ 1 ]. The risk of developing physical and mental health issues among older adults along with associated costs are linked to a higher demand for health and social care [ 2 ].

Theories on ageing have been developed with the goal of understanding the ageing process and how best to support “healthy ageing at home” and “ageing-in-place” [ 3 ] however these do not consider older adults who do not live in a supportive environment or adults who are homeless. The home setting can be a place associated with poor subjective well-being and some older adults may feel compelled to leave the home setting as a result [ 4 ].

There is no consistent definition of homelessness, rather it has been confined to socio-historical, geographical, and cultural contexts from which the term is drawn [ 5 ]. Homelessness can be defined by a range of categories: absolute and or hidden with homelessness defined as sleeping in parked cars or parks, in emergency shelters, or in temporary shelters (couch surfing) with no or minimal health and safety requirement standards, and risk to personal safety [ 6 , 7 , 8 ]. This includes people residing in sub-standard housing such, as single-room occupancy hotels, or cheap boarding houses, as well as low-cost tiny, lodgings with minimal amenities [ 9 , 10 ].

There is an increasing rise in homelessness among older adults and older homeless adults have been identified as the “new homeless”, a “forgotten group” and a “hidden group” [ 9 , 11 , 12 ].

The reasons for homelessness amongst older adults are diverse. These can include: the impact of natural disasters; the availability of affordable housing, including rising rental costs, a decline in social welfare and support programs; financial insecurity; a lack of social amenities; and increasing rates of mental health issues, combined with various addictions, including gambling [ 2 , 9 , 11 , 12 , 13 , 14 , 15 , 16 ]. In addition to this, family relationship breakdowns, or the death of loved ones, can cut people’s social connections, resulting in older adults experiencing homelessness for the first time. This displacement of older more vulnerable adults can lead to deprivation including the basic need for a place they can relate to as home, subsequently leaving them homeless [ 3 , 7 , 15 , 17 ].

Molinari, Brown and Frahm et al. (2013) found homelessness was unanimously perceived as a humiliating experience by homeless older adults [ 13 ]. According to a survey conducted by the United States Department of Housing and Urban Development, over 15% of 634,000 homeless individuals were 50 years or older, where the number of homeless people aged over 65 has been projected to double by 2050 [ 13 ]. The same survey reported that in the United States alone, adults as young as 50 years of age were facing challenges of homelessness, effectively accelerating ageing processes. Further to this, homeless older adults face a greater threat of age-related disease burden, where they are more likely to experience: functional, auditory, visual, and neurological impairments, frailty, emotional distress, and urinary incontinence, at higher rates than in the general community [ 18 ].

Similarly, van Dongen et al. have reported within a longitudinal cohort study, that older homeless adults, unlike their younger counterparts, reported a higher incidence of cardiovascular disease and visual problems, as well as reporting limited social support from family and friends or acquaintances, and limited medical or hospital care use in the past [ 19 ].

However, there is limited published research identifying the distinct needs of homeless older adults. This is a critical gap in the literature, where a deeper understanding of the experiences of older adults who have been or are currently homeless is required.

The main aim of this qualitative systematic review is to synthesise the evidence on the experience of homelessness of older adults.

Using Joanna Briggs Institute (JBI) guidelines, a meta-synthesis of global qualitative evidence was undertaken. Studies with titles and abstracts that met the analysis goals were retrieved and chosen, based on inclusion and exclusion criteria. These studies were further appraised to evaluate methodological validity by analysing evidence relevant to viability, appropriateness, meaningfulness, and effectiveness [ 20 ]. Qualitative and mixed-method studies with ample qualitative data in their results sections to allow secondary data analysis met the inclusion criteria. The sample comprised of older adults aged between 45 and 80 years that had experienced homelessness for at least one period. The search was restricted to studies that were published in English and available in full-text form, where studies with participants below 45 years, older adults in housing facilities, and aged care residents were excluded.

Search methods

This analysis followed the Joanna Briggs Institute (JBI) method for systematic reviews [ 20 ]. A qualitative assessment and review instrument (JBI-QARI 10 item tool) [ 20 ] was used to facilitate the meta-synthesis. Results from the studies were extracted, categorised, and synthesised. Searches were conducted in PsycINFO, Web of Science, Google Scholar, Medline, PubMed, and CINAHL using appropriate search terms. Additionally, important citations were searched from reference lists of relevant articles. Searches were limited to published studies from 1990 to 2020 (see Fig.  1 ).

PRISMA flowchart

Quality appraisal

Two reviewers independently assessed 21 articles for methodological quality in their design, conduct and analysis using the JBI-QARI 10 item tool [ 20 ]. Any discrepancies were discussed within the team. Out of the 21 articles, seven were included in the synthesis. Each selected study was re-read several times, discussed within the review team and data were abstracted for interpretation.

Data abstraction

Findings relating to both current and past experiences of homelessness among older adults were extracted from the seven selected studies. A total of 56 findings were extracted. Each finding was reviewed and further compared and manually coded to identify themes. Table  1 lists the author and year, sample size, design, setting, and participant characteristics of the selected studies.

Analysis of the seven reviewed articles was carried out using the qualitative evidence synthesis method [ 20 ] developed by JBI (2014). Qualitative findings from each study were first read and reread, followed by an identification of common themes. Recurring themes across studies were then grouped together in a meta-synthesis of the findings. This process comprised critical appraisal, data extraction, analysis, and a meta synthesis involving organisation and categorisation through decoding and encoding of the extracted data to produce a final summation of the findings. The qualitative evidence summation and synthesis were deliberated, cross-checked, and then reviewed by all the authors.

Of the seven studies identified for review (see Table 1 above), four studies directly explored pathways to homelessness amongst older adults. Individual study sample sizes ranged from 14 in Reynolds, et al. (2016) [ 21 ] to 60 in Viwatpanich (2015) [ 24 ]. Three studies applied in-depth face to face interviews, with three studies using semi-structured interviews, and one study conducting focus groups to collect data. The studies were conducted in three countries: Canada, USA, and Thailand.

Data synthesis commenced using open descriptive coding to search and identify concepts and finding relationship between them. Next using an interpretive process, the meaning units were categorised within each domain using labels close to the original language of the participants. The categorization of the data for each case was then followed by a cross-case analysis that examined the similarities and differences. Following categorisation, themes were conceptualised for each category. An overarching theme was identified: ‘the journey of homelessness’. Within this context, three core themes were identified: 1) Pathways to homelessness; 2) impact of homelessness; and 3) outcomes and resolutions, where each of these 3 themes had relevant sub-themes. (see Fig.  2 ).

The Journey of Homelessness Model

The conceptual model depicted in Fig. 2 represents the overarching theme of the ‘journey to homelessness,” and key concepts and relationships between variables from the synthesis of the literature. Unlike other conceptual models that involve causal and directional relationships, this model is both directional and non-hierarchical. The model illustrates the pathways to homelessness, the associated impacts of homelessness and the outcomes of homelessness. The following section explores the three themes and sub-themes in more detail.

Theme 1. Pathways to homelessness

The causes of homelessness were shown to be multifaceted, where pathways to homelessness revolved around a combination of individual, social, and structural factors. The reviewed data suggested that becoming homeless involved two distinct pathways: one that was gradual and one that was rapid.

Sub-theme 1.1: gradual pathway to homelessness

Findings from six studies contributed to this subtheme. This sub-theme captured the factors contributing to gradual pathways into homelessness amongst older people. These factors were identified as accelerated ageing, poverty, rising housing costs, failing and uncommitted social security systems, a lack of social programs and services, social distress, rural-urban migration, substance abuse and addiction, as well as estrangement from family or lack of living relatives [ 13 , 14 , 21 , 22 , 23 , 24 , 25 , 26 ].

The following quotations from these studies illustrate both estrangement from family and the impact of a lack of support from social services:

Many conflicts we had at that time, we never talked … never talked in normal way … nothing clear between us, emotion never came clear...they did not want to talk to me, not even to look at my face … I could not stand it, I surrendered. Beating and scolding by descendants is not in our tradition, no respect, if they did not want me to stay with them, I moved out [ 24 ] .

I submitted applications for low-income housing, I’ve been on the waiting list, seven years is a long time, especially at my age [ 22 ] .

Personal vulnerability to difficult familial relationships, neglected needs and unstable housing were the most cited causes of homelessness amongst these older adults [ 3 , 9 , 14 , 25 ].

Two studies [ 15 , 21 ] described a pathway to homelessness as related to alcoholism and drug abuse, as highlighted in the following quotation:

I got into crack cocaine, I got into hooking, I got into anything you could think of I guess . . . So it was my addictions that brought me down, and unhealthy relationships [ 25 ] .

Feeling ‘homeless at home’ [ 27 ] due to loneliness was noted by some older adults as their reason for ‘living on the streets’. For example, homeless older adults that experienced social rejection and conflicts with housing management, neighbours, and roommates, noted this to ultimately lead them to homelessness. For example, one participant stated, “I have lived alone and never really felt at home, because to me home is a place that includes other people, your family” [ 23 ].

Sub-theme 1.2: rapid pathway to homelessness

Some older adults described the process of homelessness as ‘rapid’. A rapid pathway to homelessness was associated with abrupt life changes such as losing a loved one, divorce, and the impact of these losses on their lives. The two quotes below highlight rapid pathway process:

Losing them, let’s just say it evaporates over time. It’s the fact that I wake up like I am here that I can’t accept … homeless … in the street. I sold everything, every single thing! I never thought I’d end up like this. It’s like starting from zero [ 23 ].

I had a wife, then she died, I did not know where to go, what to do, I turned homeless [ 24 ] .

Older adults that faced a series of losses and a rapid deprivation of social support systems noted the experience of disrupted circumstances. Accordingly, they noted their fear of losing their independence and ‘sense of self’ resulted in their resistance to any help that was offered, in turn contributing to their homelessness.

Theme 2. Impact of homelessness

Findings from five studies contributed to this subtheme. Homelessness and ageing were presented to form a ‘double jeopardy’ where homelessness aggravated the challenges of old age [ 15 , 21 , 22 , 23 , 24 ].

This theme included the subthemes of: unmet needs, coping strategies, and the realities of housing availability.

Sub-theme 2.1: unmet needs

‘Unmet needs’ amongst older homeless adults were categorised as involving physical, emotional and social needs leading to despair and destitution. As this quote below highlights:

I’m supposed to get a pneumoscopy, but where am I, where do I stay? How can they get a hold of me? I don’t have money to get around [ 15 ] .

Sub-theme 2.1.1: lack of physical wellbeing

Findings from six studies [ 14 , 15 , 18 , 21 , 22 , 24 ] contributed to this subtheme. Physical decline and physical disability were described as exacerbated by the experience of being homeless. Participants described a relationship between age and frailty, fatigue, poor physical health, and impaired mobility while homeless, as these quotes demonstrate:

Ah! Walking all day, for me, it’s very hard on the body, ok. Sleeping outside on a park bench, that’s very, very hard on the body. The bones, the humidity. Just leaving in the morning and then not going to work. … You’re always faced with the outdoors, and always faced with walking, walking. It’s not easy walking from downtown [ 15 ] .

My health was very poor. I was very prone to pneumonia. I was taken out of the shelter in the ambulance and it was later determined that I had actually contracted tuberculosis [ 22 ] .

At that time, I got Psoriasis, I knew that it was disgusting … . It looked scary. I am much too old. It is so difficult to find a job … nobody needed me … so I decided to stay and sleep here [ 24 ] .

Homelessness in later life was shown to often be linked to a multitude of health problems. Most studies described older homeless people as living with physical health problems including chronic diseases such as hypertension, diabetes, bone and joint diseases, respiratory illness, and skin diseases [ 14 , 21 , 22 ]..

Sub-theme 2.1.2: lack of emotional wellbeing

Findings from five studies contributed to this subtheme. Accordingly, homelessness was described as contributing to poor emotional health related to social exclusion and isolation amongst older adults. Further, homelessness was associated with cognitive impairment, stigma, shame, stress and anxiety, as well as depression amongst homeless older adults [ 15 , 21 , 24 , 25 ]. Homelessness was described as a humiliating and degrading experience, as evident in these quotes:

At my age, I don’t see life ahead of me anymore. You see, I don’t know, I don’t see the end of the tunnel, … … It’s as if I wanted to erase myself [ 15 ] .

All I could think about was suicide. How did I end up here? When I think a lot to myself, what the hell am I doing? [ 23 ] .

Feelings such as shame, demoralisation, and loss of dignity were described and these impacted on emotional health.

Opportunities to improve emotional wellbeing were rarely described, however one example stood out as an exception and this was related to volunteering:

One thing I didn’t expect was when I helped people with whatever issues they were having on their bicycle, I really enjoyed that. It gave me a chance to teach someone [ 25 ] .

Examples such as these were rare, with social exclusion and the lack of opportunity to contribute and connect with others more commonly described.

Sub-theme 2.1.3: lack of social relationships

Findings from four studies contributed to this subtheme. Social relationships were described as central to creating a life that had meaning and familial interactions. Disconnection from loved ones was associated with feelings of unhappiness [ 13 , 15 , 27 ], while companionship was shown to improve wellbeing [ 25 ]. Social relationships were shown to decline, leading to the experience of social exclusion and isolation.

I am a walking dying woman. I walk until I can’t walk anymore, and then I sit. The busses pass me by. We are untouchables and I do not think anybody’s going to do anything about it [ 25 ] .

At my age, I don’t see life ahead of me anymore. Because everywhere I go: “Ah! He’s homeless.” It is as if I wanted to erase myself. I think that it’s more “society,” as such, that rejects homeless people [ 15 ] .

I think that living homeless, you exclude yourself, and a lot of other people exclude you. I was on the other side before becoming homeless. So, you know, the perception that people have, it plays a big part. … So that together makes it so that, if you don’t have family either, let’s say, you don’t have … close friends or a strong social network. Well, you experience all that, you live with loneliness and isolation [ 15 ] .

Sub-theme 2.2: impaired coping strategies

Findings from four studies contributed to this subtheme. Older homeless adults described a range of factors as impacting their ability to cope. These included moving to shelters, challenges to adapt to their unique requirements, limited housing options, limited income supports, social exclusion, isolation, and a lack of coordination and access to community health and support services [ 13 , 15 , 23 , 25 ].

As the quote below shows, there were expressions about the fear of homelessness and how long it will last:

Struggling to get your basic needs met, scrounging, just trying to get by as best I can, and feeling desperation, humiliation, despair, a shocking feeling, full of fear, and turmoil. What’s tomorrow gonna bring? Why am I in this situation? How do I get out of it? [ 13 ]

Coping with the harsh realities of homelessness in later life was described as being increasingly challenging for most older adults because older homeless individuals experience mental health disorders and acute or chronic physical illnesses.

Sub-theme 2.3: realities of housing availability

Findings from three studies [ 13 , 15 , 23 ] described the challenges experienced in accessing housing services and fulfilling requirements for safe, secure, and affordable housing. This theme captured impacts of poor coordination and communication between homeless veterans and housing intervention providers in regard to information for service availability, gaining access to homeless shelters and a lack of training and education by some housing providers especially with regard to homelessness.

He … got this rule book and threw it at me. Find a place! [ 13 ]

You know, I’m 60, I’m not 20 anymore. So that’s what makes you tired, you get stressed. So, after that, they give you pills as a solution. I told the doctor, sorry I didn’t come here for pills, I came for housing [ 23 ] .

I submitted applications for low-income housing, I’ve been on the waiting list, seven years is a long time, especially at my age [ 23 ] .

I want a space where I can be well. I wasn’t well when I was young. I’ve never been well anywhere. I need a simple place … where I can have peace, and quiet … but not be all alone [ 15 ] .

Older homeless adults described a need to create stability and escape homelessness through the provision of services, and in particular, housing. Older adults described how oscillating in and out of shelters prevented senses of safety, stability, or autonomy.

Theme 3. Outcomes and resolutions

In four studies [ 13 , 15 , 21 , 24 ] homeless older adults described how the outcomes and resolutions of homelessness involved overcoming both complex challenges and habituations. This theme encompassed the finding of directions and strengths to improve difficult situations and overcome challenges that occurred at the intersection of homelessness and ageing.

Three subthemes were identified within this theme: building resilience, strength, and hope; seeking spiritual meaning; and exiting the cycle of homelessness.

Sub-theme 3.1: exiting the cycle of homelessness

Some older adults moved out of the phase of homelessness and described facilitators and barriers to this transition whilst other described choosing to stay homeless until the end of their lives.

Sub-theme 3.1.1: factors facilitating the exit

Two studies [ 13 , 15 ] contributed to this sub-theme, where older adults described means of overcoming challenges and establishing priorities in order to exit homelessness in later life. The results suggested that the creation of autonomy, flexibility, and privacy helped people feel belonging and often this meant living in a place where they could continue to drink and/or occasionally use drugs, have access to a health system to manage health problems; and have access to food and shelter facilitated exits.

They listen to you and they help you with . . . your transition, your program. You sit down and you work the program out with them;” “If you have a question, you can walk in anytime and ask them what’s going on [ 13 ] .

In the next couple years, I hope to find myself an apartment for the few good years I have left, before the big pains of “aging” come [ 15 ] .

Fulfilling financial support, housing and health care services was identified facilitate older adults exiting homelessness.

Sub-theme 3.2: remaining homeless

Some older adults experienced homelessness at a younger age and described continuing to be homeless in older age, where they oscillated between living in shelters and on the streets.

I am used to being in this way, moved from place to place … me alone, without father and mother since childhood … it become normal and I feel happier, than to stay with others [ 24 ] .

It’s just a continual cycle. I just got sucked down into it, you know. It’s hard to describe because when I found myself there, I was just like, wow. How did I get here? [ 21 ]

Participants described the chronic nature of homelessness as involving a challenge of disentangling themselves from the cycle of homelessness. A lack of tailored intervention programs to respond to homelessness in later life also prevented older adults from exiting homelessness.

Sub-theme 3.2.1: perceived barriers to exiting homelessness

In two studies [ 21 , 24 ], older adults described experiences of vulnerabilities and challenges to exiting homelessness. Shelters were described as constraining and not being able to adapt to the unique needs of older adults. Where limited housing options were seen as available, income supports were described as limited, with a lack of coordinated and, accessible community health and social support services, impacting on participants’ ability to ‘feel in place’.

My health pretty much stayed the same as when I was homeless. The conditions I have aren't gonna improve [ 22 ] .

It’s harder to keep a place, especially when you keep falling back in the same circle and you’re in the same crowd. I am finding out today, you keep falling back in the same circle, the same circle is not gonna change [ 21 ] .

One participant described the difficulty of obtaining employment as a barrier to exiting homelessness:

You know being 50 years old, it’s going to be really difficult to be able to reintegrate into the workforce [ 21 ] .

Housing facilities and transition to housing shelters were shown to present challenges for homeless older adults. A lack of privacy, autonomy, rigid rules, and challenging interpersonal relationships within housing and shelter programs were identified as leading older adults to feel homeless at home.

Sub-theme 3.3: building resilience and strength

This sub-theme captured the life lessons, resilience, strength, and hope of older homeless adults, described as having formed through experiences and skills developed whilst living on the streets. This theme also suggests how individuals cope with difficult symptoms related to social support and, addiction, relying on positive things learned while living with other homeless people on the streets. Some older adults chose to stay homeless accepting homelessness as their fate.

In the next couple years, I hope to find myself an apartment for the few good years I have left, before the big pains of “aging” come. I really want a normal life, get up in the morning, go to work, think about vacation. Hang out with other people … I don’t have a girlfriend but would like to start a life with someone else [ 15 ] .

What does ageing mean to you, getting older on the streets? A: Experience. Q: Ok. A: Wisdom. Q: Getting older on the streets, that’s how you see it, it’s the wisdom that you have gained. A: Yeah, that’s where I learned to be wise. Because there are several people who told me I am wise [ 15 ] .

I think because of karma … I accept it as punishment from bad deeds in my former life, but only in this life okay! Next life I am looking forward for a normal life, like others [ 24 ] .

Most studies [ 3 , 8 , 13 , 17 ] cited that wisdom, experience, and optimism were necessary in order to help older adults exit homelessness. Optimism instilled future hope and self-worth back into the self-esteem of homeless older adults.

Sub-theme 3.3.1: seeking spiritual meaning

In two studies [ 24 , 25 ], older adults described finding meaning in life through adopting and accepting religious faith with a belief to achieve higher self-actualisation.

I want to be closer to Dhamma (Buddhist teaching), I want to be a monk till I die [ 24 ] .

Meditate, just being by myself. Living the night, just being alone and listening to my music, that makes [my pain] feel better. I like jazz but I just listen to my music, just go away to myself. That makes me feel - I like being alone. I love being alone [ 25 ] .

When I feel [anger over my situation] I go to the water and I pray hard. I just start praising God until I can feel the spirit come over me to comfort me. I pray until He comes and allows his spirit to wrap his arm around me; I feel a lot better. A psychiatrist can’t tell me what’s wrong with me. For someone to try to help would mean a lot. I do not have nobody but to trust God. He’s my only psychiatrist [ 25 ] .

Homeless older adults recognised and confirmed that psychosocial and existential symptoms caused as much distress as physical symptoms triggering negative changes in personality, energy, and motivation. Some homeless older adults viewed their age as a source of strength, wisdom, and experience in learning to manage their symptoms, describing themselves as survivors who had overcome significant hardships. Higher levels of wellbeing were likely to be achieved when older people sought spiritual meaning through religion, socialising, reading, meditating, volunteering, and introspection practices.

This review synthesised evidence generated from qualitative studies to provide a glimpse into the experiences of homeless older adults. The review has shown that while drivers related to entry into homelessness were diverse, two distinct trajectories underpinned the experience of becoming homeless amongst older adults. Older people that faced a sudden series of losses that completely overturned their circumstances fell into the ‘rapid pathway’ to homelessness. Participants on a ‘gradual pathway’ were shown to become homeless due to a range of factors, for example - addiction problems, physical and mental health issues, relationship break-ups, foster care, poverty, unemployment, and greater housing instability [ 13 , 24 ]. Further to this, homeless older adults were shown to include a significant percentage of separated, divorced, or single individuals [ 28 ]. Likewise becoming single in later life was shown to be associated with homelessness amongst older people. Other studies found that ageing, its associated factors and a lack of stable housing were prominent reasons for homelessness [ 15 , 22 , 23 ].

Housing was perceived to offer a sense of security and a stable environment conducive for safe ageing. Further, housing was identified as offering protection from harsh weather and other dangers. Similar accounts relaying how the health of homeless older adults declined during episodes of homelessness was also reported [ 9 ]. Stable housing played an influencing role in physical health and general wellbeing. Although homeless older adults expressed satisfaction with life, they linked secure housing with healthy dietary habits, proper sleep patterns, enhanced self-care and reduced feelings of stress and anxiety [ 22 ]. In addition, this review found that most homeless older adults were more able to prioritise their health care needs when other necessities such as food and shelter were met. However, research has also suggested that living in scattered-site apartments can reinforce the process of social exclusion, and thus they are not appropriate for older adults living alone, with regard to their additional health and social needs [ 3 , 10 , 28 ].

Ageing intensified the adversities of homelessness experiences and presented a twofold risk where homelessness aggravated the challenges of old age and vice versa [ 15 ]. Old age and its associated conditions intensified older adults’ perceptions of homelessness later in life, including feelings of shame, anxiety, and worry. Studies by Cohen [ 9 ], Kwan, Lau and Cheung [ 29 ], and Molinari et al. [ 13 ], have unanimously shown older adults to perceive homelessness as a dehumanising experience. Homelessness was described as: struggling “to get your basic needs met,” “scrounging, just trying to get by as best I can,” and feeling “desperation,” “humiliation,” “despair,” “a shocking feeling,” “full of dread, turmoil,” “what will tomorrow bring? why am I in this predicament and how can I get over it?” [ 13 ]. For most participants, homelessness was not a preferred option.

The limitations of this review include the predominance of data collected in North America which may reduce the generalisability of the findings. Another drawback is that it presents only a cursory review of issues related to gender, race, and ethnicity. Finally, the qualitative data analysis applied by the majority of studies here is subjective, where outcomes could be affected by authors’ personal biases.

Despite these limitations, the review has conceptualised two divergent pathways into homelessness in later life, as well as the impacts of homelessness, drawing attention to a greater understanding of homelessness experienced by older adults.

The review sought to provide insight into the needs of homeless older adults. Awareness of the complexities faced by homeless older adults need to be acknowledged if policy and research are to support the population and improve access to resources and support. The review has highlighted areas for future research to expand knowledge and understanding of the unique needs and challenges of homeless older adults.

Synthesis of seven studies resulted in the identification of an overarching theme relating to the ‘journey of homelessness’ and three major themes, each with subthemes, to describe older adults’ experiences of homelessness. A broad range of diverse settings, cultures, and countries with a particular focus on homelessness in later life were included. The review has revealed homogeneity of experiences amongst homeless older adults, with the need for access to appropriate and affordable housing and adequate support systems.

The findings have identified pathways to homelessness require different prevention and support measures. People in the study who described a gradual pathway needed social support to address distress, which might have helped them avoid losing their homes. Those individuals with rapid pathways unanimously concluded that homelessness could have been avoided if independence and self-sufficiency were less regarded as a norm by society.

Availability of data and materials

The authors declare that all data generated or analysed during this study are included in this published article.

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Acknowledgements

We would like to acknowledge Lisa Webb, Librarian, Edith Cowan University Library for her support in the literature search and Dr. Michael Stein, HDR Communication Advisor, Edith Cowan University for editing.

There are no separate funding source for this review as it is part of my full-time PhD study with the School of Nursing Midwifery, Edith Cowan University.

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PO, LW, CV, and ATB substantially contributed to the conception and design of the article. All authors critically appraised the searched literature, discussed each item in the appraisal instrument for each study included in the review and interpreting the relevant findings. The primary author PO drafted the article and LW, CV and ATB revised it critically for important intellectual content. The author(s) read and approved the final manuscript.

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The study was classified as exempt from ethical review approved by the Human Research Ethics Committee of Edith Cowan University. All material included in this review are in the public domain and not applicable as it is a review article. Accordance: We declare that this systematic review was conducted in accordance with Joanna Briggs Institute (JBI) method for systematic reviews using the qualitative assessment and review instrument (QARIs) to facilitate the meta-synthesis. This review was followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) (2009).

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Om, P., Whitehead, L., Vafeas, C. et al. A qualitative systematic review on the experiences of homelessness among older adults. BMC Geriatr 22 , 363 (2022). https://doi.org/10.1186/s12877-022-02978-9

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Understanding and Tackling the Complex Challenges of Homelessness and Health

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Homelessness is a complex global public health challenge. There is no universally agreed definition of homelessness, and it may refer to individual rooflessness as well as to the forced displacement of populations. The European Federation of National Organisations Working with the Homeless (FEANTSA) devised the European Typology of Homelessness and Housing Exclusion (ETHOS), which distinguishes between rooflessness, houselessness, living in insecure housing, and living in inadequate housing, there is a dearth of reliable data on the prevalence of homelessness. As a result of the challenges in defining homelessness, data on the prevalence of the phenomenon vary. Moreover, resources and logistics to assess the extent of homelessness diverge among countries globally. Estimates suggest that one percent of the global population is affected by homelessness [ 1 ].

People of all ages and families become homeless for a variety of reasons. Natural or human-made disasters, war, family breakup, forced migration, lack of affordable and adequate housing, loss of employment or a combination of these factors.

There is considerable evidence that people with existing health problems, especially those with untreated mental health problems or inadequate access to health care services, are at greater risk of becoming homeless at some point in their lives. The literature is clear in that the life expectancy of people who have homelessness experiences is lower than that of the general population. We also know that health risk behaviours such as drug, nicotine and alcohol dependency are substantially higher than for people who are not homeless. Suicidality rates are substantially higher in the homeless population. Just as poor health can be one of the risk factors for losing one’s home, physical and mental health concerns are considerably more prevalent in the homeless compared to the general population. In other words, chronic homelessness is associated with a range of negative health outcomes and disabilities.

The experiences of people who live in displaced person camps may be very different from individuals facing urban homelessness. However, what they have in common is the precariousness of their circumstances, the loss of a sense of belongingness and uncertainty of the future.

Being homeless is associated with a plethora of challenges related to the environment that negatively impact health and functioning. Those managing chronic conditions in the context of homelessness are more likely to seek care in emergency departments and have more hospitalisations than people who are not homeless. Access to timely, appropriate and coordinated care is a particular problem for many. Shelter conditions may not be conducive for managing long-term conditions. Increasingly, the impact of adverse weather events and environmental hazards is considered in relation to health and homelessness.

There have been several approaches to tackle homelessness at the systems level. Housing First initiatives place the housing issue at the centre [ 2 ]. However, many well-intended strategies and interventions fail, either by their inability to follow a person-or family-centred approach or by not providing agile and adaptable and integrated support to individuals and families over time as economic, social, health-care and educational needs evolve.

This Special Issue considering health and homelessness coincided with the COVID-19 pandemic and includes research highlighting its impact. The preparation and submission of manuscripts over this period of time represented challenges to authors themselves, and we acknowledge their support and the journal in extending the submission period. In this editorial, we summarise the contents of the special collection and consider future research.

The research includes contributions from the United States, Ireland, Australia, Canada, Brazil, England, Scotland and Spain. Two papers report concurrent challenges due to COVID-19. Parkes [ 3 ] provides insight into the impact of COVID-19 and considers a harm reduction alcohol management programme; Nunes [ 4 ] highlights the impact of Third Sector organisations in supporting socially and emotionally.

The health impacts of homelessness presented by Eshtehardi [ 5 ] examine prescription management in supporting a comorbid diagnosis of depression, Carroll [ 6 ] reports an absence of access to rehabilitation services, Vallesi [ 7 ] identifies tri- and multi-morbidity, identifying the pervasiveness of preventable health conditions that exist for this population and limited access to screening programmes, and Salem [ 8 ] examines the increased risk of latent tuberculosis infection. Broderick [ 9 ] presents the outcomes of a review of physical health screening tests and confirms the challenge in using unsuitable standard tests which add to increased pain and discomfort. Further harm reduction is considered by Durazo’s study [ 10 ], demonstrating the use of e-cigarettes in support of tobacco control.

Three studies provide a broader lens on homelessness. Nourazari [ 11 ] uses a systems approach to consider policy implications, and Calvo [ 12 ] presents a 10-year review of mortality rates and risk factors. Magwood [ 13 ] examines introducing clinical guidelines supporting health equity. This study embeds practitioner responses and those of people accessing services. Warren [ 14 ] presents the voices of people who engaged with a newly established nurse-led support service. Finally, two reviews are included. Murray [ 15 ] presents a lack of evidence of suicide-specific preventions, and Bezgrebelna conducts an umbrella review [ 16 ] of evidence of the impact of weather extremes and the impact for those disproportionately impacted..

The articles in this Special Issue provide an array of innovative research, insights and perspectives from a range of disciplines and perspectives, all of which present extensive challenging experiences, and many studies were not supported by any grant or external funding. We would have liked to have seen evidence from wider groups impacted by homelessness, including families, children and younger aged youths, ethnic minorities, displaced populations, and including a patient and public involvement approach.

Pleace [ 17 ] confirmed the initial gains and continued challenges that exist for the homeless sector in a post-COVID 19 Europe, noting the longstanding tendency to explain homelessness in terms of individual pathology: the choices, actions, needs, characteristics, and experiences of each individual; homelessness as a matter of ‘sin’ and ‘sickness’ rather than ‘systems’ [p.58].

We hope readers use the evidence presented, and we will be issuing a call for a new Special Issue considering a wider systems lens.

This research received no external funding.

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Informed consent statement, data availability statement, conflicts of interest.

The authors declare no conflict of interest.

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