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Management eBrief no. 37

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Management eBriefs
Issue 37May 2011

A Review of the Literature:
Homelessness among Veterans


Investigators at the VA Evidence-Based Synthesis Program in Portland, OR conducted a review of the literature from database inception (earliest 1947) through July 2010 to examine the epidemiology of homelessness among Veterans, as well as risk factors for Veterans compared to the general population. Clarifying what is known, and what is not known, about Veteran homelessness will help guide the development of programs for Veterans at risk. Investigators reviewed more than 100 articles to answer the four key questions described below. Due to the exploratory nature of this review, few restrictions were placed on articles considered for inclusion. [Also see Notes and Limitations section below.]

Question #1A
What is the prevalence and incidence of homelessness among Veterans?

  • Prevalence estimates of the number of homeless individuals are very sensitive to the methodologies used. For example, single-day counts are likely to over-estimate the number of chronically homeless and under-estimate the number of individuals and families who move in and out of homelessness.
  • On a single night in January 2009, there were 75,609 homeless Veterans; an estimated 136,334 Veterans spent at least one night in an emergency shelter or transitional housing program between 10/08 and 9/09.
  • With nearly 23 million Veterans in the U.S. population in 2009, the prevalence of Veterans experiencing homelessness on a single night in January was approximately 33 for every 10,000 Veterans.

Question #1B
How has the prevalence and incidence of homelessness among Veterans changed over time?

  • Because of changes in reporting and in methods for counting the numbers of homeless, estimates of homelessness among Veterans are not comparable over time.
  • In 1996 a national survey estimated that Veterans comprise 23% of the homeless population. The 2009 Veterans Supplement to the Annual Homeless Assessment Report (Veteran AHAR) stated that on a single night in 2009 12% of all individuals -- and 16% of adults experiencing homelessness were Veterans.
  • Demographics are changing: VA facilities recently reported an increase of 24% in homeless Veterans' families seeking services. Also, the percentage of homeless women Veterans is expected to increase, as the percentage of women Veterans has increased in recent years.

Question #1C
How prevalent are psychiatric illness, substance abuse, and chronic medical illness among homeless Veterans?

  • Few studies directly assessed the prevalence of these conditions among Veterans. However, the 2009 Veteran AHAR estimates that about 53% of homeless Veterans have some type of disability, based on a definition that includes substance abuse, mental illness, and physical disabilities.

Question #2A
Which risk factors are associated with new homelessness or a return to homelessness among Veterans? And how do these risk factors differ from non-Veteran populations?

  • Risk factors most strongly and consistently associated with homelessness in both Veteran and non-Veteran populations include childhood risk factors, such as inadequate care by parents, experiencing foster care or group placement, and prolonged periods of running away from home.
  • Low or unstable income, low social support, and a history of incarceration also place both Veterans and non-Veterans at increased risk.
  • While the most important risk factors for homelessness do not differ substantially between Veteran and non-Veteran populations, homeless Veterans tend to be older and better educated. They also tend to have had better, early family cohesion, and are more likely to be or have been married than those in the non-Veteran homeless population.
  • There appear to be unique military-related pathways by which Veterans are exposed to risk factors for homelessness, such as combat injury, intense or prolonged combat, and Military Sexual Trauma.

Question #2B
Have risk factors for homelessness among Veterans changed over time?

  • With the increasing number of women in the military, military sexual trauma (MST) has become an important and prevalent additional trauma-associated risk factor.
  • Because more National Guard members have families, the increased number of National Guard serving in Iraq and Afghanistan may increase the number of Veterans' families at risk for homelessness.
  • In difficult economic times, an increasing number of even the less vulnerable Veterans (and non-Veterans) may be at risk of homelessness.

Question #3
Are there factors specific to military service that increase the risk of homelessness, or is the increased risk a marker for pre-military comorbidities and social support deficiencies?

  • Some studies found that homeless Veterans have lower prevalence of some general population risk factors (e.g., family dysfunction) and higher prevalence of protective factors (e.g., higher education). These findings suggest that pre-military risk factors or comorbidities do not account for the over-representation of Veterans among the homeless. Veterans appear to be at risk for homelessness for much the same reasons as other Americans, but their unique experiences as Veterans, such as combat and an increased risk of injury and trauma, may mean that the pathways through which they become exposed to more broadly shared risk factors (such as low income) may be qualitatively different. This is an area that warrants further research, with a particular emphasis on the emergence of risk during military service and the readjustment/post-deployment period.

Question #4
What is the relationship between incarceration and homelessness among Veterans?

  • There are demographic similarities between homeless and incarcerated populations -- both populations are poor with less education and few job skills, and a high proportion are from minority populations.
  • Factors found to be associated with homelessness among the incarcerated include: ineffective discharge planning, legal and regulatory restrictions, full sentencing laws, and financial instability. This suggests a bi-directional association between homelessness and incarceration.

Notes and Limitations
Although the investigators were asked to focus their review on individual characteristics associated with homelessness, the report notes that any discussion of risk factors for homelessness would be incomplete without acknowledging the complex interaction of individual and structural risk factors, such as lack of affordable housing, cuts in income assistance programs, and labor market changes that have fostered an increase in the homeless population. In good economic times, those most vulnerable because of personal risk factors will become homeless; as economic conditions worsen, an increasing number of those less vulnerable also will become homeless.

In addition, while there is consistent evidence associating specific risk factors such as substance abuse and mental illness with homelessness, there are significant limitations with the data in terms of how well risk factors were defined and prevalence measured. Association does not indicate causality, and very few studies reviewed were designed to measure the direction of associations. Studies also are limited by other factors, e.g., the use of varying and often inconsistent definitions of homelessness, and limitations in study design.

Suggestions for Future Research
This report recommends several areas for future research, such as:

  • Longitudinal studies on OEF/OIF Veterans in order to capture data on exposures before homelessness occurs;
  • Further research on MST, its relationship to homelessness, and appropriate MST prevention and treatment programs;
  • The direct relationship between injury/disability and increased risk of homelessness; and
  • Longitudinal studies with new cohorts of enlisting military service members to better assess the presence of pre-existing risk factors such as low social support or alcohol or substance abuse before military service.


This report is a product of the HSR&D Evidence-Based Synthesis Program (ESP), which was established to provide timely and accurate syntheses of targeted healthcare topics of particular importance to VA managers and policymakers, and to disseminate these reports throughout VA.

Reference
Balshem H, Christensen V, Tuepker A, Kansagara D. A Critical Review of the Literature Regarding Homelessness among Veterans. VA-ESP Project #05-225; 2011.

View the full report online



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This Management eBrief is a product of the HSR&D Evidence Synthesis Program (ESP). ESP is currently soliciting review topics from the broader VA community. Nominations will be accepted electronically using the online Topic Submission Form. If your topic is selected for a synthesis, you will be contacted by an ESP Center to refine the questions and determine a timeline for the report.


This Management e-Brief is provided to inform you about recent HSR&D findings that may be of interest. The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs. If you have any questions or comments about this Brief, please email CIDER. The Center for Information Dissemination and Education Resources (CIDER) is a VA HSR&D Resource Center charged with disseminating important HSR&D findings and information to policy makers, managers, clinicians, and researchers working to improve the health and care of Veterans.

This report is a product of the HSR&D Evidence-Based Synthesis Program (ESP), which was established to provide timely and accurate synthesis of targeted healthcare topics of particular importance to VA managers and policymakers - and to disseminate these reports throughout VA.

See the full reports online.