HOMELESSNESS

Homelessness is a problem, which affects not only the people who are homeless but the whole
society. This problem is not well recognized among the public health professionals. There is lack
of data on the health problems of homelessness from Nigeria. There is no special health or social
programmes or services for this subsection of the society. The existing number of shelters is
inadequate and as there are multiple barriers, which prevent them to have proper access to the
existing health care system. With the changing social and economic scenario, homelessness is
likely to increase. We need to recognize homelessness as a public health problem and attempt to
target this group for special care in order to promote equity in health system

Homelessness has major public health implications for not only those affected but also for the
general population. Homeless people are potential reservoirs of infectious diseases like
tuberculosis, AIDS etc. Homelessness among youth leads to increased crime and substance use
related disorders and is of public concern. Health in homelessness state is compromised by
physical environment including hazards of street life, poor nutrition, lack of facilities to maintain
personal hygiene1 and increased risk of infectious diseases through crowding, negligence
towards disease and enforced lifestyle.
Initial health impairments and disabilities can lead to homelessness and a vicious cycle of
deprivation.
However, homelessness is not recognized as a public health problem. And also inadequate
information base has affected the public health response to homelessness. Health care providers
need to acknowledge that there are an unknown, but large, number of persons who become
homeless as a result of a residual impairment and disability and also as being victim of social and
economic inequity

Homeless Assistance Act of 1987 of USA defined ‘homeless’ as an individual who lacks a fixed,
regular, and adequate night-time residence; or who has a primary night-time residence that is a
supervised publicly or privately operated shelter designed to provide temporary living
accommodations or a public or private place not designed for, or ordinarily used as, regular
sleeping accommodations for human beings.
The Census of India (2001) uses the notion of ‘houseless population’, defined as persons who
are not living in ‘census houses’ but are in houseless households. Houseless household, as the
name suggests is an oxymoron, has been defined as those who do not live in buildings or census
houses but live in the open on roadside, pavements, in hume pipes, under flyovers and staircases,
or in open in places of worship, railway platforms etc. are to be treated as houseless household
By very nature of their mode of living it is very difficult to enumerate the homeless.

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STRATEGIES FOR ENUMERATING
Some strategies for enumerating are: one-night counts or point in time; extrapolations from
partial counts; windshield street surveys; adaptations of area probability designs;service-based
designs5. The most popular method adopted was point in time estimation.
RISK FACTORS
There are a certain subgroups of persons who are of high risk for becoming homeless. These
include persons who live in poverty, have mental disability, victimized persons (domestic
violence), persons with drug and alcohol addiction or health problems, and persons who lack
sufficient social support. Other persons at risk are single women with young children and
unskilled workers and people who are victims of natural disaster, racial discrimination, or those
released from prison.
In pediatric homeless population, it is estimated that 90%of street children are working children
who live with their families. Remaining 10% are abandoned and neglected children with no
family ties. Insufficient research has been done to look for the factors compelling children to
make street, their home. In a study, in Northern Nigeria, it was found that the most common
reason for running away from home was; beating by parents or relatives, followed by a desire for
economic independence, both parents dead, argument with parent etc.
Moreover, all over Nigeria violence, terrorism, insurgencies, activities of gunmen, BOKO
HARAM, MILLITANCY, natural disasters such as flooding etc can render people homeless.
HEALTH PROBLEMS OF HOMELESS PEOPLE
Studies on health of homeless have found that there are high prevalence of premature death and
diseases like respiratory tract disease, sexually transmitted diseases and chronic disease.s In
Baltimore study average number of problems per person in men were 8.3 and in women it was
9.2.Chronic diseases often go unrecognized and untreated. Even if the condition is detected and
treated, lack of compliance and consistent follow-up often results in disease progression,
disability, morbidity,and premature death. Apart from physical health problems, mental health
problems, substance use disorders and behavioral problems are also very high among this
subsection of the society.
Barriers To Health Care Seeking
Homeless people are also plagued by multiple internal and external barriers to obtain effective
primary care. Internal barriers include denial of health problems and pressure to fulfill needs like
obtaining food, clothing and shelter as well as lack of self-esteem and feelings of worthlessness.
External barriers include unavailable or fragmented health care services, and prejudices and
frustrations on part of health care professionals. One-fifth of homeless adults who had not
obtained needed medical care stated that this was due to inability to pay for medical

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Homeless people frequently lack identification or other documentation to prove indigent status in
order to qualify for free or reduced services in mainstream health care settings. For this reason
even if needed they are denied treatment under national programmes like RNTCP (Revised
National Tuberculosis Control Programme). Similar reasons were also found by Heath Need
Assessment Survey team of Aashray Adhikar Abhyan. Often the homeless people are denied
services because of their appearance. Homeless adolescents confront further hurdles stemming
from their age and developmental stage. These include lack of knowledge of clinic sites, fear of
not being taken seriously and fears of police or social services involvement.
More or less the shelters just provide physical protection and are not linked to any health
intervention programs of the government. In one survey undertaken by Institute of Human
Behaviour and Allied Sciences it was found that homeless population considered visit or these
places unfruitful for want of proper identity document and lack of support to guide them through
cumbersome procedure, many feared past hostile experiences of discrimination and neglect.
The issue of homelessness and health system has not been addressed at all in India. Thus, at this
stage we have to learn from the experience of other countries.
The Health Care for the Homeless (HCH), program USA emphasizes a multi-disciplinary
approach to deliver services, combining aggressivestreet outreach with primary care, mental
health and substance abuse services.
In Philadelphia and New York City a pilot project has started with aim to identify
neighbourhoods from where a disproportionate number of homeless come and focus on activities
like job training, health care services, drug and alcohol treatment etc.
High mortality and morbidity rate among homeless population are caused by preventable and
treatable conditions but health care providers need to be aware of the unique difficulties faced by
this subsection. There is need to improve accessibility and availability of health services in order
to serve homeless population.
Medical care facilities for the homeless are inadequate for a number of reasons: first, the
magnitude of homelessness, is under defined.
Second there is lack of studies on health problems of homeless people in India.
Third, the shortage of facilities and the legal complications to provide them treatment.
Fourth, behavior of the homeless and the inability of the providers to deal with such people.
Fifth, in Nigeria there is no proper existing health care services and programmes for homeless,
all that we have are mostly supported by voluntary organizations.
Recommendations
1. There is urgent need of proper definition and development of a methodology to have an
accurate estimate of their number.

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2. A national study to provide reliable data on health problems and health care needs of homeless
people.
3. An attitude of dignity is essential when working with people, who are homeless. Provide
motivational training to health providers (Health Workers, Medical Officers, and Supervisors) to
be more sensitive towards this group.
4. Development of guideline to have a programme, which should be accessible (outreach
services), affordable (free), comprehensive (both curative and preventive component). It should
include mental health and substance abuse problems.
This programmes should also have preventive component such as screening for acute and
chronic health problems, immunization and special services for women including family
planning,antenatal and perinatal care.
5. Linking the programme with programmes such as National Rural Employment Guarantee
(NREG)
Act41 which for rural area provides employment opportunities. Effort should be taken to see that
homeless people can also avail this opportunity and its counterpart in urban area needs to be
implemented.
6. Public health professionals also need to focus into those social and economic issues, which are
compelling people to lead a life of homeless. They also need to focus on operational aspects of
certain programmes (eg, RNTCP, IDP Camps) which need to be modified to include this
particular group and also to have effective control on the disease (IDP) Internally Displaced
Persons.