Study type and setting
This study was conducted in Kerman, a city in southeastern Iran with a population of 820,000. Individual interviews were done in a space away from other people in the park or inside the car of the main researcher. The focus group discussion also took place in a quiet room where participants could feel free and we could record their voices. We discussed with men at a comprehensive health center near their gathering place. A room at the Women's Behavioral Diseases Counseling Center was selected to discuss with women.
Sampling, participants and data collection
This purposeful study was performed on young absolute homeless adults aged 18-29 years, who were sleeping in homeless shelters, parks and streets from July 2019 to November 2020. Inclusion criteria included young adults living in one of the main squares of Kerman, or homeless shelters. In the present study, most of the participants were male, single and had primary education. Most of the participants in the study (N=5) had been homeless for less than a year. Table 1 shows the demographic characteristics of the participants. The study was done at nights when charities were distributing food among the homeless people in the squares. After acquisition of informed consent and provision of material rewards, this study was conducted by semi-structured interviews with the homeless to examine the experiences of these people by themselves. Exclusion criteria were the dissatisfaction of these people to participate in the interview.
Thirteen in-depth and semi-structured interviews and three focus group discussions were used as the main methods of data collection. Such interviews are suitable for qualitative research due to their depth and flexibility. At the beginning of each interview, the characteristics of each sample, including age, sex, marital status and education were recorded. The author conducted and recorded all interviews. Each interview lasted an average of 25 minutes. The interview guide consisted of several key questions based on which the participants shared their experiences. According to the answers received, additional questions were asked to find out the different parts of the subject. Some guide questions are as follows: would you please describe your experiences of homelessness and the problems you faced? Would you like to return home? (If yes, how authorities can help you?), please explain more? What do you mean? Why and how? Can you give an example? Then three focus group discussions were used with the same people, who participated in the individual interviews. The samples were also divided into two groups of four men and one group of five women. Two group discussions were used with a group of homeless men and one with a group of homeless women. The criterion for ending the group discussion was saturation of information and presentation of repetitive content. Each session lasted 45-60 minutes. These interviews were also recorded with the full consent of the participants. The co-researcher asked questions during the interviews, and the observer (co-researcher) took notes to better clarify the material and prevent the loss of nonverbal information. Participants freely expressed their views during these sessions.
Data analysis
Data were analyzed by Granheim and Landmann conventional qualitative content analysis(16). The author completely transcribed the recorded interviews and repeatedly read the data obtained from the interviews to get a general perception. Qualitative content analysis is based on the unit of analysis. According to Granheim and Lundman, the unit of analysis is interviews that are large enough to be considered as a whole but small enough to be a relevant meaning unit during the analysis process. In our study, each interview was considered a unit of analysis. After determination of unit of analysis, the text was divided into meaning units. Each meaning unit consists of words, sentences, or paragraphs containing aspects related to each other through their content and context. In the next step, we condensed the meaning units, while still preserving the core. The condensed meaning units were then labeled with a code and sub-categories were created. The next step was to create categories that are the core feature of qualitative content analysis. A category is a group of codes that are similar in a manifest level.
Trustworthiness
Trustworthiness was confirmed based on the criteria proposed by Goba and Lincoln (1981) (17). These criteria were as follows: credibility (acceptability) was achieved by allocating enough time to collect data and conduct interviews in a quiet and comfortable environment and increase diversity in the selection of participants. Dependability (reliability) was done by limited literature review to prevent bias during the research. Confirmability was done by recording and reporting all stages of the research to make it possible for others to follow up and audit the trial if needed. Maximum variability in sample collection was considered to achieve transferability as much as possible.
Findings
Interviews with young homeless adults in the first phase resulted in the extraction of 264 codes. The codes were reduced to 157 after several meetings and discussions with the research team. These codes were classified into 14 primary categories, 3 secondary categories and one main category (Table 2).
Lonely, harassed and abandoned in society
According to the experiences of young homeless adults, they have escaped from community due to SA and addiction, feeling like a burden to others and social isolation, and not only have they been left without support in society, but have also suffered from all kinds of physical and psychological harassments. The main category extracted from their experiences was “lonely, annoyed and abandoned in society.” The main category consists of three secondary categories of Aversion to society, comprehensive harassment and lack of comprehensive support.
Aversion to society
This secondary category includes feeling like a burden to others and social isolation. The majority of homeless people suffered from Aversion to society due to poor appearance, poor health, SA and addiction, unemployment and tensions they had with their families and friends. Sometimes they blame themselves or others for the unhealthy conditions of their lives. Feeling like a burden to family and community, they always try to live alone and away from community. These people leave their homes due to easily access to narcotic drugs and keep themselves away from any pressure and discomfort. A 30-year-old woman, who lost her parents and was living with her sister's family described her experience of feeling like a burden to others as follows:
“My sister's husband kept shouting at my sister and complaint about the presence of me at his house, so I left the house.” (Participant No.3)
“I do not want my family to see me in such condition, I have seven brothers. I used to support them but now all of them are better than me.” (Participant No.11)
All homeless people rejected by their families have such a feeling, and they are sometimes unaware of their families for years and no one pays attention to them. These people are also isolated due to loss of self-confidence and social trust. Participant No.4 was an isolated man, who described his life as follows:
“I have peace of mind here because I have nothing to do with anyone and I am alone. When I was living with my siblings in the parental house, we always struggled with each other.”
A man, who has been homeless for three years, stated his experience as follows:
“I have been rejected because of addiction, I have a family, but I am ashamed of my behavior and my family would not like to see me.”
Comprehensive harassment
This category includes five primary subcategories of social harassment, physical abuse, sexual harassment, psychological harassment and financial harassment.
Social harassment: One of the problems of homeless people is their messy appearance and poor health. In addition, other people always disrespect and neglect them because they have to behave immorally to earn a living. They are always stigmatized and discriminated by the society.
“The staff working in this center sometimes show disrespectful behaviors, which make us upset and anxious.” (Participant No.4).
“We are addicted, so if somebody lost something, we would be blamed for them and nobody would believe us.” (Another participant in the second group discussion).
Physical abuse: Homeless people have always been affected by various forms of harassment and problems due to lack of permanent shelter, lack of money and living on the streets. These problems include victim of street fights, car accidents, and various illnesses. In addition, these people cannot withstand these injuries due to lack of proper nutrition and severe addiction to various substances and poor physical condition.
“A group of people consume alcohol at nights and annoy the unfortunate addicts, and the police do not pay attention to us.” (Participant No.9).
Sexual harassment: Sexual security was used to refer to women, but now it includes both women and men. Everyone in society, whether men or women, children or adults, is afraid of sexual harassment. Sexual harassment is common among women that has caused fear and insecurity among them. This group of people, especially women, are the most defenseless and have realized many problems. One female participant, who was abused sexually, described her experiences as follows:
“When we are sleeping in parks, the drunk boys annoy us, and we can do nothing, we are threatened to be stabbed by them, so we have to let them do whatever they want and rape us.” (Participant No.12).
Psychological harassment: Homeless people have experienced hardships and problems such as family rejection, vagrancy, and all kinds of street harassment throughout their lives. These factors have made them very psychologically vulnerable and the existing anxiety and stress have deprived them of peace of mind.
“I am affected by the earthquake in Bam and lost my family. I am homeless, I was taken to Beheshti hospital because of my illness, and I need to sleep well.” (Participant No. 8)
Financial harassment: lack of financial security and loss of all property is another problem facing homeless people living on streets. Their friends or people like them often grab their belongings.
“We are not secure when we are sleeping in the park at night. When we wake up in the morning, we will see that our friends have grabbed all our property.” (Participant No.12).
Lack of comprehensive support
This secondary category contains seven classes of lack of family support, lack of shelter, unemployment, insufficient access to food, insufficient access to health facilities, lack of medical support and insufficient charitable support.
Lack of family support: homeless people are unwilling to return home because of lack of emotional family support and family problems. Most of the homeless people preferred to live on the streets because of the lack of daily worries, loneliness and no family disputes and conflicts.
A 29-year-old woman described her experience as follows:
“When my parents died, my uncle kicked me out of the parental house; my siblings are married and have nothing to do with me.” (Participant No.12)
“I had to leave my house because nobody paid attention to me.” (Participant No.2)
Lack of shelter, unemployment and inadequate food: Adequate shelter, job and adequate access to food are among the basic needs of these people. The majority of the participants have no shelter and have to live on the streets. Annoying noises such as the sound of vehicles and night fights also discomfort them. They have more problems in finding a place to sleep especially in the cold season, so that they are more willing to use homeless shelters. They also believe that sleeping in the parks has made the city look unattractive. A 30-year-old man participating in the first group discussion described his experience as follows:
“Homeless shelters have been closed and we do not know what to do during rainfall, now we need a place to sleep, they used to give us a bed, we used to consume drugs there and took a shower. Some of these homeless shelters have been closed or relocated due to complaints of neighbors, which have made it difficult for us to access them.”
The majority of these people also considered unemployment as the main cause of their addiction and homelessness and many of them wished to find a suitable job. The experience of the interviewee No. 7 is as follows:
“If addicted people quitted addiction, they would return to it because they are unemployed”
“I wish I was working in a production workshop.” (A female participant No.1)
These people are unable to find suitable jobs due to their messy appearance, addiction, distrust of employers, so they become waste pickers and beggars to earn a living.
“I am begging because I am poor, and all my income is through begging and salvaging reusable materials, and the government does not help me.” (Participant No.8)
The majority of the homeless used their money for narcotic drugs and paid the least attention to their nutrition. They always tried to meet their nutritional needs by salvaging reusable or recyclable materials and preparing junk, harmful food and snacks. As a result, they suffered from malnutrition and digestive problems. Non-governmental organizations sometimes prepare food for these people, the quality of which should be checked, and if possible, they should be prepared purposefully and according to nutritional standards.
“I collected the reusable materials and sold them for 10 tomans, I saved 10 tomans and did not buy anything to eat and waited until they brought us dinner.” (Participant No.10)
Inadequate access to health facilities and lack of medical support were other experiences of the young homeless adults. These people have realized the poor level of health facilities due to the lack of permanent shelter and living on the streets. One of the main shortcomings of these people was inaccessibility to a suitable place for bathing, sanitary services and detergents. The experience of one of the male participants in the first group discussion is as follows:
“A man used to come and cut our hairs for free. He has not visited us for a long time. Women need at least 20000 tomans for threading. Prostitution or smuggling are the things we do to meet our needs.”
Homeless women had more challenges in accessing health services such as sanitary pads. They had to use inappropriate methods and tools due to economic problems and lack of support of the authorities. The experience of a 30-year-old woman is as follows:
“I do not have enough money to spend for sanitary pads every month. I wash napkins and use them as pads or I sometimes use tissue papers.” (Participant No.10)
One of the problems of these people in the field of medical facilities was lack of money and the high cost of medical services, so they preferred self-medication.
“Sometimes we get sick, but God helps us because we do not have anybody. Our pain gets better quickly and we do not visit the doctor, and our illness will be treated with herbal medicines or those prepared from a pharmacy.” (Participant No.13)
Inadequate charitable donations: Most homeless people depend on charitable donations to provide items such as daily food, seasonal clothing, health supplies and free medical care. The lack of this support has made it difficult for them to meet their needs.
“Someone brought me some clothes yesterday; I took a shower and put them on.” (A 30-year-old woman). (Participant No. 3)
“Once every 5-6 days, they come from the camp and give us little equipment.” (Participant No.2).