The key factors contributing to the persistence of homelessness

ABSTRACT Homelessness is a long-standing social problem in many countries. People who work and volunteer in homeless shelters struggle with the question of how to help homeless people lead an independent life. We sought to answer this question using insights obtained from Google Scholar literature searches and personal experiences with homeless people. In this brief research, we explored the main causes of homelessness in the United States for children, youth, adults, elderly, women, and veterans, over the past decade. The results showed that the three leading causes of homelessness were substance abuse, domestic violence, and mental illness. These problems lead to the initial homelessness, and in turn, homelessness further exacerbates these problems. Preventing and reducing homelessness requires effective policies and community interventions, such as rehabilitation facilities for people with substance abuse, job placement assistance and accommodation for homeless people, and homeless camps in designated areas to serve as bases to help homeless people rebuild their lives. Solving the issue of homelessness will contribute to achieving the UN’s Sustainable Development Goals.


Introduction
The definition of homelessness includes rough sleeping, couch surfing, and living in shelters, women's refuges, cars, caravans, and tents (Amore et al. 2013). Recently, the issue of homelessness has become increasingly prevalent in the US (Khatana et al. 2020). Nationwide, between 2007 and 2019, there were over half a million homeless people per night living on the streets (The Council of Economic Advisors 2019); the sight of these individuals is particularly common in the downtown areas of large US cities. Many of these individuals may have been suffering from homelessness for years -a condition known as chronic homelessness -which has simply become their norm. Chronic homelessness has been widely observed by homeless-shelter workers and volunteers.
Homelessness began to substantially plague the US in the 1980s when severe funding cuts took place at the US Department of Housing and Urban Development (HUD), resulting in an increase in the homeless population of 200,000-500,000 per night (Jencks 1995). Recent studies show that for every 25 Americans, one has experienced homelessness at least once (Tsai 2018). From 2007-2015, as house costs increased in many cities, the number of homeless people increased every year (Koh and O'Connell 2016). In 2018, shelters in New York provided individual services for more than 130,000 people, a 59% increase from the previous decade (Coalition for the Homeless 2019). In 2019, an additional 3,588 people were experiencing homelessness in New York City, which may underestimate the actual increase (NYC Department of Homeless Services 2019). Homelessness brutally impacts people's happiness and emotional well-being (Aaronson 2000), affects children's growth, induces cognitive impairments, and produces physiological problems (Bassuk et al. 1997;Mohanty and Raut 2009). Due to these farreaching effects, homelessness can create long-lasting challenges to the US public and social welfare.
Motivated by a two-year experience as New York City homeless shelter volunteers, we surveyed literature to determine if personal observations of homelessness can have general implications for improving this condition. We selected literature relevant to the causes of homelessness in various populations and analyzed the findings from these articles. The objective of this article is to combine literature findings with personal observations to improve the understanding of the current state of homelessness in the US.

Method
In June 2022, we searched Google Scholar to identify relevant literature using the keyword 'homelessness'; we subsequently refined these results using the keywords 'drugs', 'women', 'children', and 'diseases'. Based on the number of citations, we selected 12 representative papers for our study. Being cited more than 100 times, most of these studies were published between 2011-2022 and focused on homelessness in the US. We summarized the research results by category, and then used this information to analyze the main causes of homelessness and the differences among the various groups.

Results
The literature showed that the most common causes for homelessness were drug abuse, family violence, psychological problems, education level, and poverty. We summarized the 12 papers based on geographic location, target group, and causes of homelessness (Table 1).

Substance abuse
Substance abuse was the most common cause of homelessness (Greene et al. 1997). Two-thirds of homeless people reported that drugs and/or alcohol were a major reason for their becoming homeless (Didenko and Pankratz 2007). Yoo et al. (2022) reported that, among emergency patients with the most severe drug-related problems, 40.9% entered a shelter within 12 months. Finfgeld-Connett et al. (2012) suggested that parental drug abuse in the presence of their female children could in turn lead to drug abuse and homelessness of these children years later. Substance addiction often causes the addicted individuals to have strained relationships with friends and family and to lose their jobs. For those already struggling financially, the loss of a job leads to overdue bills and often the subsequent loss of their home. Combined with the strained relationships, many addicted individuals find themselves without a plan to overcome their situation. In fact, once homelessness occurs, most people will lose everything, even if addiction was not the causative factor. Burdened by the never-ending hardships homelessness places on its victims, many of those suffering seek an escape, often through drugs and alcohol. In general, older individuals (50 and older) experiencing homelessness tend to depend on alcohol while younger individuals depend on drugs. Drugs and alcohol are expensive, especially for those who need to buy it frequently due to their addiction. Most of the money that homeless people manage to obtain is spent on their drug and alcohol addiction, which keeps these individuals stuck in that condition. This dependence on an illicit substance further exacerbates their problems, thereby decreasing their chances to achieve employment stability.
Because survival is their primary focus, many homeless people do not consider this spiraling effect of substance abuse on their current condition. Additionally, many of these individuals have lost the support of friends and family, making it even more difficult to break their addiction. Without a strong support group, the likelihood of achieving and maintaining sobriety is virtually impossible, especially on the streets where drugs are so widely available and accepted.

Domestic violence
Half of American's homeless population is comprised of women and children. In fact, homelessness among women has seen the fastest growth relative to other groups. From 2012 to 2013, the number of children experiencing homelessness increased by 8% in the US and represented 1 out of every 30 children (Bassuk et al. 2014). For women and children, domestic violence is often considered the significant cause of homelessness (Chanmugam et al. 2015;Bretherton 2017;Reeve 2018). Embleton et al. (2016) revealed that family violence is the most frequently reported reason for homelessness in most technologically advanced countries. According to the US Bureau of Statistics, although the total number of homeless people in the US decreased from 637,077 in 2010 to 549,928 in 2016, the proportion for whom their homelessness was due to family violence increased from 10.5% in 2010 to 12.5% in 2016. Unhoused children typically roam throughout a complex street environment characterized by food scarcity, increased disease, and extreme stress (Fauk et al. 2017). These harsh conditions make it impossible for these children to receive social support, which further reinforces their poor financial and living conditions (Nell et al. 2016), resulting in precisely the opposite of the UN Sustainable Development Goals, namely, to strengthen universal health coverage and overall population wellbeing (Fullman et al. 2017).

Mental health
Of the 12 studies included in this report, 8 suggested a correlation between mental health problems and homelessness. We found that regardless of gender or age, people experiencing homelessness often suffer from mental illness, with 42-80% having experienced mental health problems. Mental illness can lead to homelessness, and homelessness can exacerbate psychiatric problems (Hodge et al. 2012;Fraser et al. 2019). Nilsson et al. (2019) reasoned that drug use and mental health problems reduce the likelihood of escaping homelessness. Hamilton et al. (2011) and Tsai and Rosenheck (2015) showed that veterans account for a considerable proportion of the homeless population, and that female veterans are four times more likely to be homeless than non-veteran females. Due to lack of social support and resources, loneliness, and barriers to receiving treatment for injuries, veterans may experience mental health problems and substance abuse, which contribute to chronic homelessness. Additionally, people who face greater long-term psychological problems, such as those in the LGBTQ community, are more likely to develop depression, PTSD, and even suicidal thoughts (Fraser et al. 2019).
It is worth noting that drug abuse, violence, and mental health problems usually occur in combination. In addition to these three more common factors, other factors such as poverty, education, and ethnicity require attention. Together, these complex factors contribute to homelessness.

Discussion and concluding remarks
Although homeless people comprise only a small percentage of the US population, it is quite difficult to help them become functional members of society. There are different programs in place, such as emergency shelters, transitional housing, and safe havens, which provide temporary housing. The problem, however, is that there are not enough beds or rooms available to accommodate the homeless population; furthermore, most of these sites require their boarders to be sober. Since more than half of the homeless population suffers from addiction, these options for shelter are out of their reach. A better approach to eliminating homelessness is the development of rehabilitation facilities specifically for this population. Most rehabilitation facilities are cost-prohibitive for those in the homeless population, making the desire to achieve sobriety less appealing. However, affordable, or even free, rehabilitation facilities strictly for homeless people would increase their chances to achieve sobriety and subsequent improvement of their lives. The US National Health Care for the Homeless Council has emphasized the importance of integrating substance abuse treatment -addiction recovery services such as detoxification, rehabilitation, Alcoholics Anonymous meetings, counselling, and medication management -with mental healthcare and housing to provide a comprehensive, effective treatment strategy.
Another successful method of reducing homelessness is by building career pathways with benefits that include housing and homelessness assistance. Attention may be focused on those who are most at risk or are already experiencing homelessness. Having a steady place to live while working allows these individuals to focus primarily on their occupation, ideally allowing them to own their own housing once they accumulate enough money. Moreover, the ability to live indoors drastically decreases the individual's chances of developing illness or accessing drugs, thereby increasing their overall health. Organisations such as HomeFirst, based out of Santa Clara County in California, have recognized this need and now provide at least 350 beds in each of their 7 locations, including 18 beds reserved for the mentally ill, 20 beds for the medically respite, and 48 beds for veterans. According to their fact sheet, HomeFirst's Boccardo Regional Reception Center is the largest homeless service centre in Santa Clara County. It provides shelter and transitional housing, housing search services, mental health counselling, a medical clinic, and employment search services, and has the area's most comprehensive set of programs for homeless veterans. In just two years (2013-2015) Santa Clara County witnessed a 14% reduction in homelessness (ASR 2015). If more organisations provide similar assistance for finding reliable shelters while also providing job opportunities, the homelessness percentage is likely to decline within a few years. Regardless of policing efforts, homeless camps will continue to persist in cities. However, by designating certain areas for people to make camps will not only provide shelter off of the streets, but will also improve the city's curb appeal. Understandably, the city should establish rules and regulations for the camps to promote the health and safety of its residents and prevent crime. These rules could include guidelines for camp cleanliness, establishment of a strict no-crime policy, and implementation of random searches. Giving homeless people a place to call their own will not only improve their mental and emotional health, but will also alleviate the burden of having nowhere to go. Currently, the homelessness rate in the US is steadily increasing and sidewalks in some areas have become homeless camps. According to the Affordable Housing Finance, one out of ten people will experience some form of homelessness in their lifetime, which could theoretically put anyone at risk. Although there are many factors that can render one homeless, the most common is substance abuse. Not only is it a primary cause of homelessness, it is also a reason many homeless people remain that way. To effectively re-integrate homeless people into society, it is important to provide them with support and resources for addiction treatment through a targeted program specifically designed for their needs. Additionally, more organisations should be formed that simultaneously provide free housing and job placement assistance. At a minimum, legalising certain homeless camps and giving homeless people a designated place to stay will decrease the number of people living on the streets. Once they are sober and housed, these individuals can focus on rebuilding their lives, ultimately benefiting themselves and inspiring others struggling with homelessness.
In summary, homeless people are at high risk of suffering from hunger and poor health, and lack access to education, clean water, and sanitation, all of which contribute to rising inequalities and prevention of social sustainability. The lessons from the US have general implications worldwide, particularly to other developed nations. Solving the issues related to homelessness is not just the responsibility of the healthcare or food provision sectors, but rather is the responsibility of society as a whole. Policy makers, social managers, and the general public should all work together to provide assistance to homeless people through coordinated efforts.