https://orcid.org/0000-0002-2968-9564
Over a half million Americans experience homelessness on any given night and more than 1.4 million experience it at some point over the course of a year [1, 2]. Between 2016 and 2020, the number of people experiencing homelessness increased. The homelessness epidemic is intertwined with other epidemics, both infectious and noninfectious. For example, among US veterans who were diagnosed with opioid use disorder in 2012, 35% were experiencing homelessness. Rates of cardiovascular disease in people experiencing homelessness exceed those of the general population [3], and prevalence of invasive cancers have been reported to be significantly higher, with poorer overall cancer survival [4]. Among people with human immunodeficiency virus (HIV), 8.5% experienced homelessness in the last year, and those who experienced homelessness were 48% less likely to sustain viral suppression [5]. Invasive group A Streptococcus, invasive meningococcal disease, and Bartonella quintana infection have all been identified with much higher frequency among people experiencing homelessness than the general population [6, 7].
Over the past two years, the crisis of homelessness has been compounded by the largest pandemic of the last 100 years. Coronavirus disease 2019 (COVID-19) outbreaks have occurred in homeless shelters throughout the United States [8]; at the same time, people experiencing homelessness have been shown to have an increased likelihood of hospitalization due to COVID-19 [9]. The pandemic has laid bare the immense need for improvement in the public health infrastructure at its interface with homelessness.
As public health, health care, and homeless service systems emerge from the height of the pandemic, a conceptual structure in which to apply lessons learned in the COVID-19 response may be useful to ensure that the postpandemic world is a more equitable one. Here, we propose a framework represented by concentric layers (Figure 1). The overall objectives of this framework are to protect the health of people who are currently experiencing homelessness while also supporting the end of homelessness. The internal layers represent fields traditionally within health care and public health, while the outer layers represent areas where public health can partner with housing and homeless services providers, policymakers, and others to address social determinants of health and support the end of homelessness. This framework offers a public health approach and outlines opportunities to build the evidence base through research, surveillance, and assessment.
A layered public health approach to address health and homelessness. The innermost layer represents health care and individual-level treatment of disease, tailored to people experiencing homelessness. The next layer represents traditional public health disease prevention, such as vaccination, with a focus on how to reach people experiencing homelessness. The third layer represents housing and service support for people who are experiencing homelessness. The outermost layer represents prevention of homelessness itself.
HEALTH CARE FOR PEOPLE EXPERIENCING HOMELESSNESS
Improving access to health care services forms the inner core of this framework. In the United States, Healthcare for the Homeless clinics have been providing medical services to people experiencing homelessness since the early 1980s. In addition to patient-centered primary care access, integrated care including mental health and substance use services, infectious disease treatment, injury treatment, and chronic disease prevention and management is necessary to improve baseline health for people experiencing homelessness. Expansion of street medicine and pop-up clinic options can create additional touch points to provide linkages and follow-up to care [10]. Respite care clinics provide temporary shelter for people requiring low levels of care following hospital discharge, creating a bridge between the hospital and the street, which may help decrease hospital length of stay and reduce the need for readmission.
PREVENTION OF DISEASE AMONG PEOPLE EXPERIENCING HOMELESSNESS
The next layer in the framework addresses the opportunities through traditional public health prevention approaches. Recent evidence showing the burden of COVID-19, Bartonella quintana, Neisseria meningitides, hepatitis A, and invasive group A Streptococcus demonstrate widespread transmission of infections that are preventable through basic public health actions [7, 11–14]. These outbreaks could be avoided through vaccination, encampment and shelter sanitation, improving access to wound care, and nutrition support. However, data systems often do not include indicators for homelessness, making it difficult to identify outbreaks involving people experiencing homelessness or understand the true burden of disease. Integrating data across homeless management and public health data systems and tailoring public health interventions to the needs of people experiencing homelessness could have a major impact on the disparities associated with homelessness.
HOUSING AND SUPPORT SERVICES FOR THOSE CURRENTLY EXPERIENCING HOMELESSNESS
Even if there were an abundance of traditional health care and public health services to help improve health of people experiencing homelessness, stable housing is a key requirement for health. Addressing this layer entails partnerships between public health agencies and organizations providing homeless services to ensure that shelters are safe, promote rapid rehousing, and address aligned issues like transportation, education, and employment. Housing First programs fall into this layer; these programs provide unconditional, permanent supportive housing to persons with substance use disorders and to individuals and families in which the head of household has a disabling condition. These programs have been associated with decreases in health care utilization for hepatitis C [15]. A coordinated strategy where health care and public health practitioners can help identify those experiencing homelessness and provide connections to housing and homeless services is a potential way to support the response to homelessness.
PREVENTION OF HOMELESSNESS
The final layer of the framework represents supporting the prevention of homelessness before it begins. Public health research could guide appropriate investment of resources to support increasing the availability of safe, sustainable, affordable housing. Racial minorities are overrepresented among people experiencing homelessness; public health research and practice can shed light on the intersections of these inequities with health outcomes and support the resolution of discriminatory housing practices [16]. Finally, many upstream social determinants that lead to homelessness also influence health. Public health research and policy focused on prevention of poverty, adverse childhood events, racial discrimination, intergenerational trauma, unhealthy neighborhood conditions, unemployment, and inequitable access to education can provide an evidence base to prevent homelessness from the outset.
CONCLUSION
Hundreds of thousands of people in the United States experience homelessness every night. Using the partnerships and lessons learned during the COVID-19 pandemic, public health practitioners, clinicians, and social service providers can coordinate their efforts to support the end of homelessness while protecting the health of those currently experiencing it. This public health framework can serve as a roadmap for improvements in research, practice, and communication to better serve those experiencing homelessness.
Notes
Disclaimer. The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.
Financial support. No financial support was received for this work.
Supplement sponsorship. This article appears as part of the supplement “Homelessness and Infectious Diseases: Understanding the Gaps and Defining a Public Health Approach,” sponsored by the Centers for Disease Control and Prevention.
References
Author notes
Potential conflicts of interest. All authors: No reported conflicts. All authors have submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Conflicts that the editors consider relevant to the content of the manuscript have been disclosed.
