The primary purpose of this study was to examine whether shelter status the previous night was related to measures of stress, recent utilization of shelter-based services, and current health risk factors. Consistent with our hypotheses, sheltered homeless adults used more shelter-based mental health services, had fewer health risk factors, and reported lower levels of stress than unsheltered homeless adults and unstably housed adults. That is, unsheltered homeless adults were more likely to report not getting enough sleep, binge drinking, using illicit drugs, and experiencing higher levels of daily stress and food insecurity than sheltered homeless adults. Similarly, unstably housed adults were more likely to report inadequate levels of sleep, binge drink, use illicit drugs, and experience a higher level of food insecurity than sheltered homeless adults.
Our findings are consistent with previous research, indicating that homeless adults who receive shelter-based mental health services may demonstrate better mental health, fewer substance abuse problems, and healthier behaviors (16, 17). Sheltered homeless adults may have more access to health care services, and in turn, demonstrate fewer health risk factors and lower levels of stress than unsheltered or unstably housed adults.
To our knowledge, this study is the first to examine levels of physical activity and rates of overweight/obesity among the three homeless subgroups. It is known that insufficient physical activity is common in homeless populations in general (29). Moreover, it has been reported that the rates of overweight and obesity among homeless adults are high and increasing (4, 29, 30). The findings from the current study indicated that sheltered homeless adults are more likely to be sedentary and overweight or obese than unsheltered homeless adults. However, higher physical activity and lower overweight/obesity rates for unsheltered homeless and unstably housed adults do not necessarily mean that they are healthier than sheltered homeless adults. It may be the case that sheltered homeless adults are more likely to have physical disabilities limiting physical activity, resulting in lower levels of exercise and higher rates of overweight/obesity. Further, unsheltered homeless adults may have lower rates of overweight/obesity and greater levels of physical activity because they eat fewer meals and have to travel from place to place to get their basic needs met (e.g., traveling to various shelters to acquire food). Although there is an increasing number of studies that focus on physical activity and obesity among sheltered homeless adults (29–32), we found none that have similarly targeted unsheltered and unstably housing adults. Interventions that target physical activity and overweight/obesity among unsheltered homeless adults are needed.
Findings from this study also indicate that the heterogeneity of this population should be considered when developing policies and intervention tools to address the health care needs of adults experiencing homelessness. Unsheltered homeless and unstably housed adults appeared to have greater need than sheltered homeless adults, yet they received fewer services at shelters. This finding is consistent with previous research indicating that unsheltered homeless adults have greater needs for care and experience longer periods of lifetime homelessness (11). Furthermore, current study findings showed that unsheltered homeless and unstably housed adults reported longer periods of lifetime incarceration than sheltered homeless adults, and unsheltered homeless adults were more likely to report incarceration in the past year than unstably housed adults. This finding is important because many shelters have rules about who can stay there based on sex, arrest history, sexual violence, etc (18). Thus, many unsheltered homeless or unstably housed adults may not have access to the drop-in services that are available to shelter residents due to their incarceration history (11). Barriers that reduce access to care for unsheltered homeless and unstably housed groups should be considered when developing and implementing policies and intervention tools for this marginalized and underserved population.
This study has several limitations. First, we did not assess duration of sheltered status. The three homeless subgroups (sheltered homeless, unsheltered homeless, and unstably housed) were categorized based on participants’ whereabouts the previous night. This definition was based on the U.S. Department of Housing and Urban Development’s point-in-time method for counting sheltered homeless persons, which is utilized to avoid duplicated estimates of homeless persons in sheltered and unsheltered locations.23 Future longitudinal research should measure the duration of current sheltering status to examine how the duration of sheltered status (e.g., number of nights at the shelter in the previous month) relates to the utilization of shelter-based mental health services, stress, health risk factors, and continued homelessness. Second, unsheltered homeless and unstably housed subgroups may have been underrepresented in this study because the study data were only collected at shelters. Third, the data were collected from adults who homelessness in one city, and the findings may not be generalizable to homeless populations in other U.S. cities, or states. However, this study surveyed a large sample of adults experiencing homelessness, representing a range of races as well as other demographic characteristics from an understudied region of the U.S. When this study was conducted in 2016, there were 1,368 homeless people on a single night in Oklahoma City, meaning that roughly 42% of this population were included in the study sample (33). Other study limitations include cross-sectional data collection and health service use, health behaviors, and stressors were self-reported. Thus, participants may have under- or over- reported information, and this may have biased the study findings.
Despite these limitations, findings from this study have notable implications for health research in this understudied population. To best of our knowledge, this is one of the first studies to compare how these homeless subgroups based on where they reside previous night vary in terms of health risk factors, current stress, and shelter-based health service use. Our findings are important as they indicate that unsheltered homeless and unstably housed subpopulations may be more vulnerable and experience greater needs than sheltered homeless adults. Specifically, unsheltered homeless and unstably housed adults are more likely to exhibit lower use of shelter-based health services, higher levels of stress, and more health risk factors than sheltered homeless adults. Homeless shelters play an important role in providing for the basic needs and improving the health of adults experiencing homelessness. Findings from the current study may inform the development of policies and programs that are targeted toward homelessness subgroups.
Additional research is needed to identify barriers to shelter utilization for unstably housed and unsheltered adults experiencing homelessness to inform health promotion and health intervention programs for this understudied and underserved population. Addressing these barriers may improve the health of homeless adults, reduce the duration of homeless bouts, and may ultimately reduce overall homelessness in the U.S.