Service Needs, Stresses, and Vulnerabilities
Service Needs as Seen by Clients Each client was asked to select from an extensive list of various needs "the three things you need the most help with now." Responses are reported in table 3.2. Currently compared with formerly homeless clients are more likely to report needing help finding a job (42 versus 30 percent), help finding affordable housing (38 versus 21 percent), and assistance with rent, mortgage, or utility payments for securing permanent housing (30 versus 15 percent). Formerly homeless clients are more likely to say they need help obtaining food (32 percent, compared with 17 percent for currently homeless clients). Among other service users, the highest service needs are for help obtaining food (33 percent), and other needs (31 percent). "Other" needs were mentioned by almost one-third of other service users, and by one-fourth of currently and formerly homeless clients. Small proportions mentioned needing help with getting clothing, transportation, legal aid, medical or dental care for themselves or their children, drug/alcohol/mental health treatment, enrolling children in school, and domestic violence, in addition to assistance with job training and managing money. Also many clients mentioned an "other" need that was personal, such as "a good man/woman," "spiritual growth," and "peace of mind." All of these responses are included in the "other" response category.
Food Consumption and Hunger Clients reported whether they (1) get enough of the kinds of foods they want; (2) get enough but not always the kinds of foods they want; (3) sometimes do not get enough food to eat; and (4) often do not get enough food to eat. Currently and formerly homeless clients report a similar likelihood (28 and 25 percent) of sometimes or often not getting enough to eat (table 3.3). This likelihood is much higher than the likelihood of having similar difficulties among all U.S. households (4 percent) and even among all poor households in the country (12 percent).3 Currently and formerly homeless clients are equally likely to report two or more problems getting enough food (38 and 31 percent). Thirteen percent of other service users report this level of problems getting enough food. Individual problems over the past 30 days included in this index are eating once a day or less, being hungry but not having money for food, and going a whole day without eating because of not having money for food. Similar proportions of currently and formerly homeless clients report eating once a day or less (20 and 17 percent). Currently homeless clients are more likely than formerly homeless clients to report the other two measures (39 versus 26 percent for "hungry but not enough money for food," and 40 versus 33 percent for "whole day without eating"). Both are much higher than parallel figures for all U.S. households (2 and 1 percent, respectively) and poor U.S. households (5 and 3 percent, respectively). Other service users report some level of difficulty getting enough food. Sixteen percent report sometimes or often not getting enough to eat, and 13 percent report two or more food-related problems. Specific problems reported for the past 30 days include 10 percent who report eating once a day or less, 11 percent who were hungry but did not have enough money for food (compared to 5 percent of poor U.S. households), and 17 percent who went a whole day without eating because they could not afford food (compared to 3 percent of all U.S. households). Thus other service users also have more problems getting adequate food than do poor U.S. households.
Physical Health Status and Insurance Survey clients were asked about 17 medical conditions, classified subsequently as acute infectious conditions (chest infection/cold/cough/bronchitis, pneumonia, tuberculosis, STDs other than AIDS); acute noninfectious conditions (skin diseases, lice/scabies); chronic health conditions (diabetes, anemia, high blood pressure, heart disease/stroke, liver problems, arthritis/ rheumatism, cancer, problems walking/other handicap, HIV/ AIDS); whether they used drugs intravenously; and other medical problems. Currently and formerly homeless clients report the same levels of acute infectious or acute noninfectious conditions. However, formerly homeless clients report higher rates of chronic health conditions than do currently homeless clients (62 versus 46 percent). Two-thirds of other service users report chronic conditions, 29 percent report acute infectious conditions, and 3 percent report the acute noninfectious conditions about which the survey asked (table 3.4). The most common conditions among all groups are arthritis, rheumatism, and joint problems, although at quite different levels. Currently homeless clients are less likely to report these chronic conditions than are formerly homeless clients (24 versus 37 percent). Currently homeless clients are also less likely than formerly homeless clients to report high blood pressure (15 versus 22 percent), and problems walking or other physical handicap (14 versus 22 percent). Among other service users the rate for arthritis and similar problems is 42 percent, high blood presssure is 33 percent, problems walking/other handicap is 30 percent, and upper respiratory problems is 27 percent.
Similar proportions of currently and formerly homeless clients (24 and 26 percent) needed but were unable to see a doctor in the year prior to the survey (figure 3.3). This figure is much lower among other service users (12 percent). Far fewer of the children living with clients were affected by this lack of access to care, with similar proportions (8 and 9 percent) of parents in each subgroup reporting any problems with access for their children. Coverage by health insurance varies considerably by homeless status (figure 3.4). Clients could report more than one type of insurance, so figures do not sum to 100 percent. Over half (55 percent) of currently homeless clients have no health insurance, compared with 32 percent of formerly homeless clients. More formerly homeless clients than currently homeless clients receive Medicaid (53 versus 30 percent). Other service users report health insurance coverage by Medicaid (43 percent), private insurance (13 percent), other insurance (28 percent), and no insurance (31 percent). The "other" insurance reported by other service users is probably Medicare, given the age of many in this group (28 percent are ages 65 and older). Similar proportions (73 and 74 percent) of currently and formerly homeless clients living in families report that their children are covered by Medicaid. (Clients could report more than one type of insurance coverage.) Only 6 to 7 percent of the children living with currently and formerly homeless clients are covered by private insurance. Twenty percent of currently homeless households with children have no health insurance for their children, compared with 14 percent of formerly homeless households with children. These high levels of health insurance coverage for children living with NSHAPC parents help to explain why parents report that relatively few of their children experienced any problems getting needed health care. Alcohol, Drug, and Mental Health Problems Measures of alcohol, drug, and mental health (ADM) problems are reported for past month, past year (including past month), and lifetime (including past year). These measures are composites of client reports of behaviors, experiences, and treatment, as defined in chapter 1. In general, for alcohol and drug problems in all three time frames, currently homeless clients report higher rates than formerly homeless clients. Currently and formerly homeless clients report similar rates of mental health problems in all time periods (table 3.5). Looking at combinations of alcohol, drug, and mental health problems indicates that for relatively recent time periods, currently homeless clients have higher rates of one or more problems during the past month (66 percent) and past year (74 percent) than formerly homeless clients (59 and 66 percent for past month and past year, respectively). However, when the probability of having at least one of these problems over clients' lifetimes is examined, currently and formerly homeless clients are equally likely (86 and 87 percent) to have had at least one of the problems (figure 3.5). 
Looking at combinations of different problems experienced by the same person, as the time period lengthens from past month to lifetime, more currently and formerly homeless clients report at least one ADM problem (table 3.5). Also, for the longer time periods (past year and lifetime), formerly homeless clients are more likely than currently homeless clients to report only mental health problems (21 versus 15 percent for past year; 17 versus 10 percent for lifetime). Alcohol use problems are more prevalent than drug use problems in each time period for both currently and formerly homeless clients. Alcohol use and mental health problems show the same levels in all time periods for currently homeless clients, but formerly homeless clients report more problems with mental health than with alcohol use for past month (41 versus 29 percent) and past year (46 versus 33 percent). Currently, compared with formerly, homeless clients report higher rates of alcohol use problems during the past month (38 versus 29 percent) and past year (46 versus 33 percent), but are similar over their lifetimes (62 versus 56 percent). Thirty-one percent of other service users report at least one ADM problem during the past month, 36 percent do so for the past year, and 56 percent do so for lifetime problems. Mental health and alcohol use problems appear in this group at the same levels for past month (16 percent each) and past year (17 and 21 percent), but lifetime alcohol use problems are higher (36 versus 28 percent). Drug use problems are less commonly reported (4 percent for past month, 7 percent for past year, and 18 percent for lifetime).
Incarceration Currently and formerly homeless clients are equally likely (49 and 43 percent) to have spent five or more days in a city or county jail, which may be related to their condition of homelessness as well as to other behavior (table 3.6). More currently than formerly homeless clients report having spent time in a state or federal prison (18 versus 9 percent) or in juvenile detention before they reached the age of 18 (16 versus 9 percent). Taking all of their incarceration experiences together, 54 percent of currently homeless clients have spent some time incarcerated, compared with 45 percent of formerly homeless clients. Only 14 percent of other service users have ever been incarcerated.
Adverse Childhood Experiences NSHAPC results indicate that mental health and alcohol and/or drug problems may have roots in the childhood of many clients, as does homelessness itself. Between one-fifth and one-fourth of both currently and formerly homeless clients report that before the age of 18 they (1) started drinking and using drugs; (2) experienced physical abuse, sexual abuse, or both from someone in their household; (3) spent time in juvenile detention; (4) lived in foster care or other out-of-home placement; (5) ran away from or were forced to leave home; or (6) became homeless for the first time (table 3.7). In general, currently homeless clients are more likely than formerly homeless clients to report initiation of drinking and using drugs at younger ages. Analysis of data from the National Household Survey on Drug Abuse indicates that people who start drinking and using drugs before the age of 15 are at significantly higher risk for problems with substance use as adults (Dennis and McGeary 1998). NSHAPC data indicate that 25 percent of currently homeless clients began drinking before age 15, and that 19 percent first started using drugs at this young age. Both of these rates are higher than those for formerly homeless clients (19 percent for drinking and 13 percent for using drugs) (figure 3.6). Twenty-five percent of currently homeless clients and a similar proportion of formerly homeless clients (22 percent) report being physically and/or sexually abused by a household member before reaching their 18th birthday (figure 3.6). Rates that combine neglect with abuse experiences show roughly the same pattern, but for this combination currently homeless clients do report significantly higher rates than formerly homeless clients (29 versus 23 percent). Only 8 percent of other service users report any abuse or neglect experience before age 18 (table 3.7). Finally, 16 percent of currently homeless clients had spent some time in juvenile detention before they reached the age of 18. This proportion is higher than that for formerly homeless clients (at 9 percent). Other service users report a rate of 4 percent for time spent in juvenile corrections institutions. Rates of experiences away from one's childhood family reported by currently and formerly homeless clients are high enough and often similar enough to suggest, as other research has done, that these may be significant risk factors for adult homelessness (e.g., Piliavin, Sosin, and Westerfelt). These questions were not asked of other service users.
More currently than formerly homeless clients (27 and 19 percent, respectively) were placed in foster care, a group home, or other out-of-home placement (figure 3.7). Similar proportions of both groups had been forced to leave home for more than 24 hours (22 and 19 percent, respectively). The two groups differ, however, in the proportion who had run away from home for more than 24 hours (33 percent of currently and 27 percent of formerly homeless clients) and had a homeless experience before the age of 18 (21 and 12 percent). Their answers indicate that many do not consider their runaway experience to be homelessness, since many more in both groups report the former than the latter experience.
3Current Population Survey Food Security Supplement, April 1995, table 1 (Food and Consumer Service 1999).
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