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Public Health and Health Policy: Newham’s Cases of Homelessness

Introduction

Homelessness affects many people in Newham, London, and it has health challenges to the affected populations. People who are homeless are at high risk of premature deaths and may experience several health complications. These health challenges may include “seizures, chronic obstructive pulmonary disease, musculoskeletal disorders, tuberculosis, and skin and foot problems” (Hwang, 2001). Moreover, there are also drug abuse and mental problems associated with homelessness. Homeless individuals also experience various challenges that limit their access to health care services.

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Who are the homeless?

The ‘absolute homelessness’ from the UN (the United Nations) refers to homelessness as a “condition of people without physical shelter who sleep outdoors, abandoned buildings, or other places not intended for human habitation” (Hwang, 2001). Some people fall under the category of ‘relative homelessness’ in which they have physical shelters that do not meet safety and health requirements.

In other words, people who experience relative homelessness cannot gain access to safe water, safety, security of tenure, protection, and sanitation. This research considers homeless people in Newham, London as people who experience both absolute and relative homelessness. Jencks notes that the common definition of homelessness for the health-related study is “people who are sleeping in shelters for the homeless and those who are homeless” (Jencks, 1994).

Homelessness is a common problem throughout the world, but this research focuses on Newham, London.

Causes of homelessness

Many factors are wide and complex, which are responsible for homelessness. According to Shelter, structural and personal factors are responsible for homelessness (Shelter, 2007).

Structural factors

  • Poverty
  • Unemployment
  • Inadequate supply of housing or lack of affordable housing
  • National housing policies
  • Changes in social factors, such as the increment in single people and family breakdown

Personal factors

These factors mainly relate to a person, family, and community. It also includes elements of social issues, which contributed to the vulnerability of an individual’s chances of becoming homeless.

Individual factors that lead to homelessness may include:

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  • Drug and alcohol abuse
  • Inadequate social support
  • Mental health challenges
  • Debts, mortgage, and rent challenges
  • Criminal tendencies

Family background factors

  • Broken families
  • Sexual and physical abuse
  • Drug and alcohol problems in homes
  • Past trends of homelessness in families

Other causes of homelessness may relate to institutions such as people who have served in the armed forces or under institutional care may experience homelessness when they return to civil life. Overall, family conflicts are the most common contributors to homelessness in most situations. Such conflicts cause homelessness among the victims regardless of their age.

It is also necessary to note that homelessness may result from cumulative and unresolved factors rather than a single and sudden event. The local authorities note that many people become homeless when their families and friends can no longer support them. However, it is necessary to explore factors that contribute to homelessness on an individual basis because every case may be unique.

Homelessness in Newham, London

Newham has a diverse population because it is a multi-cultural town in the UK. Newham’s two-thirds of the total population consists of “Blacks, Asians and minority ethnic groups known as the BAME” (Newham Homelessness Strategy 2008-2013, 2008). Asian communities in Newham account for the largest ethnic minority group at 32 percent, while Black Africans and Bangladeshi take the second position in England and Wales (Newham Homelessness Strategy 2008-2013, 2008).

According to Newham Homelessness Strategy 2008-2013, the number of homeless individuals in the borough has been approximately 2,500 per year in the past two years. However, there is an acceptance range of 50 percent (1,250) for all homeless individuals. However, by the year 2008, the number of homeless households declined to nearly 400 persons. This is just a third of the homeless persons in the year 2005/6.

The borough has the highest rate of acceptance, which has led to an increment in the number of homeless persons in temporary accommodation. As a result, in April 2008, the number was slightly above 5,500 households. At the same time, people who registered for accommodation increased by 47 percent. The table below shows statistics for homelessness in Newham. The borough expected the number of new applicants to increase in the following years.

Table 1: Key trends in homelessness data.

Homeless Data 2003-8 2003/4 2004/5 2005/06 2006/7 2007/8
Households on the Housing Register 19,503 25,317 29,302 24,159 28,579
Housing Register Annual % increase 20% 30% 16% -18% 18%
Homeless Applications 2,639 2,377 2,630 1,244 1,122
Total Homelessness Decisions 2,903 2,464 2,853 1,263 1,209
Acceptances 1,567 1,294 1,422 446 409
% Accepted 54.0% 52.5% 49.8% 35.3% 33.8%
Households in temporary accommodation 5,042 5,723 6,107 6,036 5,595
Total lettings 1,538 1,564 1,460 1,335 1,050
Lettings to Homeless by Council Stock 140 119 163 170 174
Lettings to Homeless Households by RSL 46 85 69 63 82
Total Lettings to Homeless Households inc. RSLs 186 204 232 233 256
% Lettings to Homeless Households 12% 13% 16% 17% 24%

Health problems among homeless people

Homeless persons have high rates of risk of death compared to other people. For instance, the rate of death among street youths was 40 percent high in the UK as compared to the general population (Boland, 1998). Homeless individuals also experienced high rates of suicide and deaths related to alcohol and drug abuse. Moreover, life expectancy among homeless people was lower than that of the general population. Research by Crisis in 2011 estimated the average age of death of “a homeless person at between 43 and 47 years of age” (Homeless Link, 2012). While some of these data are more than a decade old, they provide insights into the health challenges of homeless people. Still, causes of mortality may vary and include suicide, tuberculosis (TB), HIV, and overdose among others.

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People who lack homes suffer from several diseases. Impacts of their conditions can be devastating due to other factors like poverty, lateness in getting medical assistance, lack of adherence to instructions, mental problems, and consequences of homelessness. Moreover, older homeless people may develop conditions that require confinement in health care facilities. People who live on the streets have poor health than their sheltered counterparts.

Older homeless individuals may also have medical problems, which are associated with “seizures, chronic obstructive pulmonary disease, arthritis, and other musculoskeletal disorders” (Hwang, 2001). Medical problems that relate to anemia, diabetes, and hypertension may be difficult to detect. As a result, the affected persons may go for many years before they learn about their health status. Still, they also have respiratory tract problems, as well as oral and dental problems.

There are also rampant cases of skin and foot problems. Individuals who live on the streets are likely to have cellulitis, scabies, lice, and other skin problems. Moreover, they also experience foot challenges like “onychomycosis, tinea pedis, corns and callouses, and immersion foot” (Hwang, 2001) due to a lack of shoes, exposure to dampness, prolonged periods of trekking and standing. However, homeless people do not have opportunities to get education about foot care and adequate shoes and sock for foot care.

Homeless individuals also experience high rates of contracting and developing resistant strains of TB. Physicians have learned that any homeless person with persistent cough and fever must undergo a test for TB. Homelessness conditions provide an environment that favors the spread of TB, e.g., crowded and poorly ventilated shelters. Most homeless people with TB have a cluster of primary TB. The UK has limited data on TB trends among homeless individuals.

However, in 1994, Celia Hall reported that TB was the major killer of homeless people in London (Hall, 1994). More than two percent of homeless people in London had the disease. This rate was higher than the rate of TB infections in third-world countries. Moreover, it was 200 times more common among homeless people as compared to the rest of the population. The challenge of treating TB among homeless people is a lack of adherence to physicians’ instructions. In addition, homeless people may also experience prolonged infectivity and develop a strain of TB that is resistant to drugs. At the same time, there are also rampant cases of relapse after commencing the treatment.

Such patient requires direct treatment and close observation to avoid relapse and ensure adherence to physicians’ instructions. Moreover, some cases with “positive tuberculin skin test may require direct observation under prophylaxis” (Hwang, 2001). Generally, Wellcome Trust estimated that the incidence of TB among homeless people in the UK was 34 times higher than the rest of the population (Wellcome Trust, 2012).

Homeless individuals also experience a high prevalence of HIV, hepatitis C, and TB than the general population of the world (Wellcome Trust, 2012). This report estimated that there were more than 380,000 homeless persons in the UK. The study did not find any figures for the rate of prevalence of HIV among homeless populations. Edwin Bernard observed that the prevalence of “HIV infection among injecting drug users (IDUs), in England & Wales, is higher than at the start of the decade” (Bernard, 2007).

The trend of HIV infection has increased over the years as many homeless persons begin to inject themselves with drugs. Bernard also noted that London had the highest rate of HIV incidences among the IDUs at four percent in 2006. The rate of IDUs among homeless people in London had increased. As a result, the number of homeless persons in London with HIV may also increase (0.77% in 2006 vs. 0.25% in 2002).

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This study also noted that many homeless people did not know their HIV status. Most IDUs who visited health care centers had tested HIV positive, but only “two-thirds of them were aware of their status” (Bernard, 2007). Homeless people have continued to report new cases of HIV infections. Health care providers believe that such new cases normally take place through the injection of drugs by sharing needles. Meanwhile, the case of hepatitis C infection was almost 50 times higher than the rest of the population.

Homeless people also have health problems that relate to sexual and reproductive health. Most homeless people usually engage in prostitution. This has led to the spread of sexually transmitted diseases among many youths. Many suffer from gonorrhea and Chlamydia but do not report their cases. This suggests that health care providers must rely on anecdotal reports to manage such cases. Pregnancy is also a common reproductive health problem among street youths. Cases of pregnancy are common among females aged between 14 and 17 years old.

Violence has been a major contributing factor to high rates of deaths among homeless people. Most homeless individuals experience assaults from strangers and city authorities. Most women have reported cases of rape. Still, homeless men may experience high rates of murder than the general population.

In some cases, high rates of morbidity and mortality may result from unintended injuries, particularly among men. Homeless persons may fall or sustain injuries from moving vehicles. Some of the homeless individuals cause deaths through unintended drug or alcohol overdose. Moreover, most homeless people expose themselves to dangerous elements that may result in such injuries. Severe weather in London has not spared them. Homeless people suffer frostbite and hypothermia during cold seasons, which has led to deaths. On the other hand, hot weather also exposes them to extreme sunburns and heatstroke.

Cases of mental illness and substance abuse among homeless people may be common, but difficult to determine. However, some past systematic studies can provide patterns of drug abuse and mental cases among homeless people. Some groups of homeless people experience schizophrenia, but the rate may be below ten percent of the total population. Affective disorders have proved to be the most widespread among homeless individuals with a rate above 20 percent.

The challenge of alcohol consumption is the most widespread among disorders related to drug abuse. The prevalence rate is as high as 60 percent among men. This rate is usually six times higher than the rate of the general population. However, it is difficult to obtain data on the abuse of other drugs due to the secrecy of the practice. However, homeless people also use hard drugs like cocaine, bhang, and other illicit drugs available to them. Most homeless people may suffer drug abuse problems alongside mental illnesses. Thus, dual conditions are not rare among such people.

It is important to note that patterns and trends of mental cases and drug abuse differ with the demographic characteristics. Most homeless women are prone to “mental illness even without the use of any drug” (Hwang, 2001). However, the rate of drug abuse among single homeless men is much higher in comparison to those of single women. Homeless women who head their households were not likely to abuse drugs like their male counterparts.

Nutrition problems have also contributed to poor health conditions among homeless individuals.

Homelessness and public health system

Homeless people have an increased need for health care services due to their poor living conditions. In most cases, the needs for such health care services among homeless people are mainly during an emergency. Homeless people have the highest rate of hospital admissions than the rest of the general population. In addition, they also have longer stays at the hospitals than other general populations. As a result, health costs increase significantly because of prolonged stays, but homeless people cannot afford such medical costs. In most cases, homeless people may be discharged from the hospital and return to their shelters.

The ability to cope with shelter lifestyles and recovery may be difficult. Therefore, most people may experience a relapse during treatment. Policymakers in the public health sector should provide respite facilities for homeless individuals where they can recover after discharge from the hospital.

Many barriers limit the accessibility of health care services among homeless people. Homeless people lack medical cover or insurance. However, the UK’s National Health System of providing “free-at-use health care services in which hospitals are open both day and night, and make no charges for treatment” (Moore, 2008) has eliminated the burden of medical costs on health care services. Therefore, homeless individuals may not experience the cost burden. However, other challenges do not relate to the costs of medication.

Homeless life consists of a constant struggle for essentials of survival. Therefore, the use of health care services may not be a priority among homeless people. Still, doctors’ recommendations to observe diet or rest may be beyond reach for such people. For instance, it is almost impossible for homeless people to manage their dietary requirements in cases of diabetes. Further, problems of coordinating meals and medication may also arise.

In most cases, public health care systems have not provided inclusive treatments for cases of drug abuse and mental conditions. Homeless people with drug and mental challenges require constant follow-ups to ensure full treatment. However, this is a major challenge because their whereabouts may be unknown at a given moment. Therefore, policymakers and stakeholders in public health care must formulate strategies to reach homeless people where they could be.

In this case, nurses and other health care providers must make follow-ups and seek out such people to ensure high-intensity case management. Follow-ups and visits are particularly important because homeless people rarely keep their clinical appointments. Moreover, they need constant monitoring to ensure adherence and use of drugs during treatment. Still, physicians may also face challenges of obtaining accurate medical information and the history of the patient because of the crisis they experience, especially people with drug and mental disorders.

Health conditions that affect homeless persons are unique and require specialized care. For instance, many homeless people expose themselves to extreme environmental conditions, which may result into rare conditions or develop strain of resistance disorders. Moreover, homeless people have a major challenge of caring for themselves and may exhibit extreme conditions of any health problem. In most cases, homeless people prefer to seek medical assistance when their conditions are at advanced stage. Still, diagnosis may reveal multiple problems.

Therefore, health care policymakers must formulate specific policies for addressing medical problems among homeless people. Policymakers should also focus on education as a way of emphasising behaviour change among homeless individuals. For instance, high prevalence of sexual and reproductive health problems, HIV, IDUs, early pregnancies, and others may require behaviour change among such homeless people. Any intervention approach should support entry into treatment and ensure completion.

New challenges of HIV emerge from needle sharing. Policymakers and health care providers should develop needle management and exchange programmes for homeless people who cannot resist self-injection. The basic approach is to provide adequate and practical information about injections, its dangers, safe injection, prevention of virus transmission, and safe disposal of used materials. Follow-ups ensure that homeless people get the continued support they require, vaccination services, diagnosis, quick treatment, and accessibility to health care services.

Conclusion

Newham’s cases of homelessness may be on the rise as the report indicated. The problem affects people of all ages in the borough who experience several and unique health problems. However, health care services may not reach or adequately address the needs of this group. We must also recognise that rate of all health problems are high among homeless individuals than in the general population. Most researchers have concreted on the prevalence of infectious disease like HIV, hepatitis C, and TB among homeless individuals. However, there are other severe health problems, such as skin infections, foot problems, mental conditions, drug and alcohol abuse, and diphtheria among homeless people. These conditions require urgent studies in order to assess their prevalence and impacts so that policymakers can target main challenges.

As we review homelessness in Newham, there are “three important priorities, which are “housing, income, and health” (Hwang, 2001). At the same time, we have to recognise special challenges of children and youths who are within or outside homeless families. Though health care services are necessary, it is also important to note that they cannot reduce the problem of homelessness. Thus, policymakers must explore the core root of the problem.

Experts in homelessness assert that it is important to identity prevalence and cases of homelessness so that policymakers can develop effective approaches for priority areas in homelessness. Further studies are necessary in order to determine effective methods of providing health care to homeless people. Overall, addressing the core sources of homelessness is the long-term solution to all challenges associated with homelessness.

Reference List

Bernard, E 2007, UK report highlights homelessness link to IDUs acquiring hepatitis C, but not HIV. Web.

Boland, T 1998, UK street youth death rate 40 times general population’s FWD. Web.

Hall, C 1994, TB epidemic among the homeless feared: London tests find infection rate higher than in Third WorldWeb.

Homeless Link 2012, Health & Homeless. Web.

Hwang, S 2001, ‘Homelessness and health’, CMAJ, vol. 164, no. 2, pp. 229-233.

Jencks, C 1994, The Homeless, Harvard University Press, Cambridge, MA.

Moore, E 2008, No Angels Here: The Closing of the Pine Street Inn Nurses Clinic, 1972–2003. Web.

Newham Homelessness Strategy 2008-2013, 2008. Web.

Shelter 2007, Homelessness. Web.

Wellcome Trust 2012, Study highlights high rates of infectious diseases among homeless populations. Web.

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