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Homeless People as a Vulnerable Population

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Homeless people are a part of a vulnerable population who face a very real risk of developing health issues at a rate higher than the rest of the population due to certain disadvantages and co-morbidities. The homeless population is often exposed to the harsh elements of the weather and lack access to basic necessities such as food, shelter, clothing, and medication. Housing in shelters and transitional homes are not constant and reliable, leaving the homeless population no choice but to spend their days and nights out in the streets.

A vulnerable population is defined as those who are at a higher risk than others of developing health issues due to their social status, personal finances, lack of access to resources, or personal characteristics such as age, gender, and/or race (De Chesnay & Anderson, 2012). People facing homelessness may be suffering from one or all of these risk factors making the barriers difficult to overcome. This paper will present homeless people as a vulnerable population and the demographics of this population on a local, state, and national level. Self-reflection, personal biases, and social attitudes and stereotypes will also be discussed. The Perceived Stress Scale will be presented and applied to this population to evaluate the perceptions of stress and the resources used to combat this threat. Homelessness Demographics

The 2013 Annual Homelessness Assessment to Congress presented by the Department of Housing and Urban Development (HUD) found that on a single night in January 2013 there were approximately 610,042 suffering from homelessness in the United States, with 394,698 of those people in sheltered locations and the remaining 215,344 people residing in unsheltered locations (HUD, 2013). Nearly one fourth of homeless people comprise of children under the age of 18 and families represent 15 percent of the homeless population (HUD, 2013).

On a state level California accounted for more than 29 percent of the United State’s homeless population in 2013 and 66 percent of those homeless people were unsheltered (HUD, 2013). At a local level Los Angeles City and New York City accounts for practically 1 in 5 homeless
people nationally, with more than 12 percent in Los Angeles (HUD, 2013). California contains the largest percentage of homeless people in the United States and Los Angeles has the highest percentage of the homeless people situated within a city, sharing this distinction with New York. Personal Awareness and Prejudices

I have been a nurse in a county hospital for the last 4 years and the majority of my patients have been indigent or from a lower socio-economic population. I have often encountered and provided care for patients suffering from homeless. My honest opinion of this population is they are usually suffering from poor hygiene, are covered in lice and scabies, and can be demanding, rude, and are not always compliant with medical care. Many negative myths about the homeless exist such as “having poor coping mechanisms and not being able to benefit from psychosocial interventions” (Dykeman, 2011, p. 33). There is the pervasive stereotype that homeless people do not want help or are homeless because it is a lifestyle choice (Seager, 2011).

One homeless patient always remains in my mind; she comes to our facility frequently because she lives right outside our doors on the streets. She is an older Hispanic female that suffers from a chronic diabetic ulcer on her leg. Due to poor medication compliance, unsanitary living conditions, and lack of access to basic hygiene her diabetic ulcer frequently becomes infested with street maggots and she develops blood sepsis. I often get the impression that I encounter homeless patients more often than other nurses on a daily basis. I am not surprised to find out that Los Angeles has the highest percentage of homelessness in the state, and is 2nd in the nation. Personal Attitude after Research

After gathering research I have a better sense of empathy and understanding towards the homeless patient. According to Seager (2011) homeless people remain on the streets because of the trauma from their past experiences and are socially incompetent making it difficult for them to trust others and integrate back into society. The biggest difficulty in communicating and helping the homeless population is the psychological exclusion that stems from the correlation between homelessness and mental health issues (Seager, 2011). I often wondered why the homeless patient with maggots did not seek housing arrangements in a shelter where she would have access to free meals, toiletries, a warm bed, and safety from the elements. I know she is competent enough to bring herself in to the ER when she is ill but I could never understand why she chose to stay on the streets. Researching about homeless patients and learning about the rates of severe mental illness, emotional trauma, and personality difficulties has opened my eyes to the constant turmoil they must face.

Now that I have a better understanding of their dynamics and psychosocial needs, I will be friendlier, more considerate, and engage these patients in a manner to enhance their trust in others and health care providers. I will advocate for these patients so that they will have access to services such as housing, clinics, and rehabilitation and encourage medication compliance and health maintenance. Seager (2011) states that by sleeping out in rough conditions and refusing board at a shelter is a form of self-harm and self-neglect, it is an “obvious symptom of a damaged and self destructive mind” (p. 135). Changes in Health Care Delivery

An article written by Burki (2010) singled out the incidence of tuberculosis (TB) among the homeless population of London. Treating TB is a long and arduous process with treatment lasting up to 6 months of daily medications. Treatment of TB in the homeless is often disorganized due to inadequate education and poor medication compliance that will inevitably lead to drug resistance (Burki, 2010). Homeless people often receive treatment late because their health is the least pressing of their concerns and may potentially infect others before they are quarantined and started on treatment (Burki, 2010). The prevalence of TB in the homeless population points to inadequate health care access and services available to this population. Burki (2011) reports that New York City offered incentives for patients to continue TB treatment with food and travel reimbursement that was met with some success. Providing treatment for TB alongside methadone treatment has been largely successful but this is not an option for crack cocaine users.

Compulsory quarantine and required TB screening upon entry to shelters were also possible ideas (Burik, 2011). A study of homeless mortality in England states the common age of death for homeless people is 47-years-old, compared to the national average of 77-years-old (Peate, 2013). According to Dykeman (2011), treatment providers have to address multiple concerns of the homeless patient such as medical, psychological, social, and institutional needs including education, legal aid, housing, rehabilitation, and financial services. Treatment providers must be taught adequate skills on how to manage complex patients, refer them to the proper resources, and advocate so that their patients may stay healthy and avoid homelessness in the future. The HUD reports that between 2012 and 2013 there has been an increase by 27,063 beds, or 4 percent, of beds to house homeless people. Between 2007 and 2013, the number of permanent shelter beds steadily increased annually until an additional 95,662 beds, or 51 percent more beds were added. However considering that in California more than 66 percent of the homeless population remains unsheltered, the supply is not meeting the demand.

The Perceived Stress Assessment Scale
The Perceived Stress Assessment Scale is a popular tool for measuring psychological stress; it is a self-reported questionnaire for individuals to evaluate situations in their lives that cause them stress (Lee, 2012). It is based on a theoretical perspective that stress is not related to changes in environment or a person’s physiologic response to a stressor but rather the person’s perception of that change in the environment (Al kalaldeh & Shosha, 2012). The original Perceived Stress Scale (PSS) consisted of a 14-item scale that was broken down into 7 positive and 7 negative items on a 5-point rating scale. This scale has since been cut down to a 10-item scale and there is also a short, 4-item scale that can be utilized in times of urgency. The PSS was developed to assess the respondent’s response to stressors to evaluate the extent to which they found their lives unpredictable, uncontrollable, and strenuous, which are the three key components of the stress experience (Al kalaldeh & Shosha, 2012).

The PSS is not meant to be diagnostic of any disorders but rather make a correlation between perceived stress and the stressor, a high score would suggest the presence of pre-disposing factors to certain disorders. The responses to this test are categorized as never, almost never, sometimes, fairly often, and very often on the basis of occurrence over a month’s time. Once the scores are tallied into one single store the high score indicates higher levels of stress and low scores indicates lower levels of stress. The financial burdens of this scale is very minimum, takes only a few minutes, and can be scored quickly (Al kalaldeh & Shosha, 2012). According to Lee (2012), “the PSS demonstrated satisfactory test-retest reliability (p.126). The PSS can be applied to any situation and population but was developed for a community population with at least a high school education.

Use of the PSS in Nursing Assessment and Application
Implementing the PSS on the homeless population during the assessment phase would help the nurse discover risk factors for major diseases. According to Seager (2011), mentally competent people who volunteered to sleep on the streets found their mental health, sense of well being and safety quickly diminished over a short period of time. Stress is a health-related concept and has been linked to diseases such as cancer, diabetes, cardiovascular disease, and asthma (Lee, 2012). For example a homeless individual may complain of feeling more anxious than usual which can indicate an underlying medical condition or a decline in mental health. The homeless population does not have routine access to health care services and are not screened for these diseases until it has progressed. Conclusion

The homeless population continues to grow steadily yet remains a vulnerable population without a voice in the community. Health care professionals must provide culturally competent care to the homeless population and continue to advocate for their rights to shelter, health care, and financial assistance. Homelessness may be a difficult cycle to break but health care professionals must continue to be their voice in society so that their needs will be heard and sufficient community resources will be allocated for their use. Currently the homeless population is growing at a rate that cannot be accommodated by shelters and health care centers. Health care professionals can obtain a dependable measurement of stress and its health-related outcomes through the Perceived Stress Scale. The Perceived Stress Scale can be used on field, is quick and easy to use, and the results are immediate making it a cost-effective and reliable measurement scale.


Al kalaldeh, M., & Shosha, G. (2012). Application of the perceived stress scaled in health care studies. An analysis of literature. International Journal Of Academic Research, 4(4), 45-50. Burki, T. (2010). Tackling tuberculosis in london’s homeless population. The Lancet, 376(9758), 2055-6. Retrieved from http://search.proquest.com/docview/821979659?accountid=458 De Chesnay, M. & Anderson, B.A. (2012). Ch. 1: Teaching Nurses about Vulnerable Populations. Caring for the Vulnerable. Perspectives in Nursing Theory, Practice, and Research, 3e. Retrieved from the University of Phoenix online database. Dykeman, B. F. (2011). Intervention strategies with the homeless population. Journal of Instructional Psychology, 38(1), 32-39. Retrieved from http://search.proquest.com/docview/877031438?accountid=458 Lee, E. (2012). Review of the psychometric evidence of the perceived stress scale. Asian Nursing Research, 6(4), 121-127. Peate, I. (2013). The other silent killer: homelessness. British Journal Of Nursing, 22(11), 607.

Seager, M. (2011). Homelessness is more than houselessness: A psychologically-minded approach to inclusion and rough sleeping. Mental Health and Social Inclusion, 15(4), 183-189. The 2013 annual homelessness assessment report to Congress. (2013). Retrieved from https://www.hudexchange.info/resources/documents/ahar-2013-part1.pdf

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