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What is the greatest need of the homeless?

According to research with homeless individuals, housing is the most essential need, followed by the need for regular meals [31, 32] and adequate clothing [31]. Physical needs revolve around access to health care: medical, surgical, and dental services [33], and substance use treatment [31].

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Sample characteristics and group comparisons

In total, 46 emergency shelter users, 242 temporary housing occupants and 208 permanent housing residents (N = 497) were invited to participate in the study, and 455 participated for a 92% response rate. They represented 45/46 (98%) of emergency shelter users, 229/242 (94%) of temporary housing occupants, and 181/208 (87%) of permanent housing residents. While most participants were male, significantly fewer males were in the permanent housing group as compared with temporary housing or emergency shelters. Mean age of the participants was 48 years (SD: 11.2). Most (86%) were born in Canada, with significantly more Canadian-born emergency shelter users than permanent housing residents or temporary housing occupants. Nearly all (94%) were single, significantly more among temporary housing occupants than permanent housing residents. Compared with permanent housing residents, temporary housing occupants reported significantly more SUD or financial problems related to housing loss. Chronic homelessness was experienced by 48%, more among permanent housing residents (56%) than temporary housing occupants (43%) or emergency shelter users (36%). Regarding health care utilization, 51% had a family physician, and 44% a case manager. Significantly more permanent housing residents had a family physician or a case manager than those in the other groups. Emergency shelter users made significantly more use of emergency departments than either permanent housing residents or temporary housing occupants. Permanent housing residents were also significantly less likely to be hospitalized than emergency shelter users and temporary housing occupants. Overall, 72% of participants were diagnosed with MHD, 39% with SUD, and 36% with co-occurring MHD/SUD; 28% had chronic physical illnesses, and 49% acute physical illnesses. Significantly fewer permanent housing residents reported SUD, or overall physical illnesses than did emergency shelter users or temporary housing occupants. Permanent housing residents also had significantly fewer co-occurring MHD-SUD, and overall physical illnesses than temporary housing occupants (Table 1). Overview of reported needs by category. Table 2 presents summary statistics for the five categories of needs. Basic needs (86%) were most often reported, followed by needs related to health and social services (78%), safety (66%), love and belonging (30%) and self-esteem or self-actualization (20%). Unmet needs were higher than met needs regarding safety (43%), while met and unmet needs were nearly equal for basic needs (59% and 57% respectively). Met needs were higher than unmet needs in the three remaining categories (57% vs 38% for health and social services; 20% vs 11% for love and belonging; 8% vs 2% for self-esteem and self-actualization). PPT PowerPoint slide

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TIFF original image Download: Table 2. Summary of perceived met, unmet and total needs within the five conceptual domains of the Maslow hierarchy of needs. https://doi.org/10.1371/journal.pone.0245088.t002 Percentages of reported needs by category for emergency shelter users, temporary housing occupants and permanent housing residents. Table 3 presents findings for the five categories on total needs and for met and unmet needs across the three housing conditions. Three of the five categories also included sub-categories. Regarding the percentages of participants reporting needs, no significant differences emerged among the three groups. Comparisons of total met versus unmet needs were also similar between emergency shelter users, temporary housing occupants and permanent housing residents. The only significant difference among the three groups concerned total met versus unmet basic needs (X2 = 7.2; p = .02), where total met needs were higher than unmet needs for permanent housing residents (65% vs. 48%) and for emergency shelter users (60% vs 56%), whereas total unmet needs were higher than met needs for temporary housing occupants (60% vs 56%). PPT PowerPoint slide

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TIFF original image Download: Table 3. Perceived met and unmet needs among individuals in three housing conditions based on the five categories in the Maslow hierarchy of needs. https://doi.org/10.1371/journal.pone.0245088.t003 Participant comments on needs for the three housing groups. Regarding basic needs, unmet primary survival needs mainly described feelings of insecurity around food sufficiency, sleep, and shelter in the short and medium term (see S2 Appendix for illustrative quotations). Some emergency shelter users (about 20%) deplored the dangerous conditions on the streets, limited places in shelters, problems with bed bugs, and the obligation to leave in the morning. Temporary housing occupants expressed less stress related to housing, knowing they were secure for some fixed duration. Yet about half of them felt anxious about their long-term situation, and the lack of available places in permanent housing that caused long wait times. Permanent housing residents expressed a greater sense of stability in terms of their ability to fulfill daily needs and worried less about the future. However, close to 30% of users were concerned about their living conditions, as many housing units needed urgent renovation. As almost all received social assistance as their main source of income, they were often forced to rely on food banks after paying the rent. They most often referred to meet needs for housing (about 65%), whereas the two other groups said more about unmet needs (about 60% and 55% respectively). Most of them enjoyed a sense of freedom in having their own housing despite poor conditions. Regarding needs for access to health and social services, participants in all groups reported good experiences with providers who offered information and linked them with services. Unmet needs included: problems of access to specialized MH and addiction services or community-based services, and long waits for treatment due to staff shortages, inability to access professional services not covered by health insurance, and lack of individualized MH services in primary care. Few participants (about 10%) also complained about the need to be proactive in seeking help. Emergency shelter users and temporary housing occupants also feared that leaving these accommodations would jeopardize care continuity. Concerning adequacy of health services, all participants expressed appreciation for the availability and listening capacity of most service providers they encountered. Their unmet needs concerned perceptions of some professional incompetence and poor communication or judgemental attitudes. Lack of supervision and frequent turnover were other negative aspects frequently highlighted. Few permanent housing residents (about 10%) greatly resented apartment checks by staff particularly when unannounced, and over-supervision more generally. As for met safety needs, the sense of physical safety was enhanced for all participants by staff presence and surveillance cameras. However, safety needs were mainly reported as unmet. Unmet physical safety needs concerned instances of theft, violence, and for emergency shelter users and temporary housing occupants, the inability of staff to intervene in crises, which created considerable insecurity. For emergency shelter users and temporary housing occupants, the presence of individuals with MHD or SUD increased fear and insecurity. Regarding administrative/juridical affairs, unmet needs in all three groups concerned paperwork and other problems dealing with government agencies to obtain documents (e.g. health insurance, social insurance cards). Additionally, very few (less than 5%) participants reported receiving guidance on personal financial management or income tax. Similarly, very few (less than 5%) participants reported met needs in the areas of education or employment. Most faced barriers associated with age, permanent disability, or stigma connected with homelessness. Job security was particularly important for permanent housing residents who needed to maintain an apartment and pay bills. About 15% of the study participants said that they faced disability and age-related challenges that impeded their ability to find or maintain employment. Less than 10% of participants reported met or unmet needs for love and belonging. For emergency shelter users and temporary housing occupants, met needs were related to the possibility of meeting people whose experiences were like theirs. Peers could be trusted and were sources of support. However, these two groups were adversely affected by their relationships with individuals having MHD and SUD. For permanent housing residents, meeting love and belonging needs often meant having the freedom to choose their friends and meeting their strong desire for privacy. This led some to prefer isolating themselves and avoiding contact with neighbors. Finally, only 20% of study participants addressed their self-esteem and self-actualization needs, pointing out opportunities throughout their homeless trajectory to build skills such as autonomy, optimism, and resilience. Despite relying on help from various sources, many of these participants acknowledged their personal responsibility for improving their lives. In terms of met needs, permanent housing residents expressed mainly sense of accomplishment, lessons learned, and overall satisfaction at having gained some independence, whereas emergency shelter users and temporary housing occupants tended to be more prescriptive, or wishful about developing skills. Overall, this study identified and compared perceived needs among homeless (emergency shelter users, temporary housing occupants) and recently housed individuals (permanent housing residents) in Quebec, using an adapted version of Maslow hierarchy of needs. Findings validated the relevance of this model for research on homelessness, with met/unmet basic needs most often reported and decreasing numbers of needs identified in ascending the pyramid. Significant group differences emerged for basic needs only, with more met needs among permanent housing residents versus the other two groups. This indicates that, for homeless individuals, meeting basic needs, including housing, was not a sufficient condition for meeting needs in the higher categories. It also underlined that meeting basic needs was not necessary to develop and potentially meet needs in the higher categories, such as health and social services or love and belonging, which confirmed previous criticism of the original Maslow framework [27–29]. Comparison with other study samples. Our sample characteristics reflect differences as well as similarities with samples observed in previous research. The main difference concerned the very high proportion of participants with a history of chronic homelessness in this study, affecting almost half of the sample. This may be explained by the fact that the great majority of participants in this study were temporary housing occupants or permanent housing residents, which would be logical as these programs were geared to chronically homeless individuals [41], and included relatively few emergency shelter users, as opposed to the samples in most previous studies. For example, only 10% of the US homeless populations is estimated to experience chronic homelessness [53]. The over-representation of chronically homeless participants in our study, particularly among permanent housing residents, might also explain the high prevalence of participant health problems [53]. In terms of health and social service use, our sample had the high rates of service utilization typical for homeless populations [4, 54, 55]. The three groups reported twice as much use of emergency departments over a 12-month period relative to the general population, and had more hospitalizations, particularly emergency shelter users whose hospitalization rates were nearly four times the norm for the general population as shown in previous studies [23, 56].

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Sample characteristics and group comparisons. Statistical comparisons among the three housing categories (Table 1) revealed that permanent housing residents enjoyed significant advantages (e.g. more with a family physician and case manager support, lower SUD and co-occurring MHD/SUD rates) as compared with other groups. This supported our hypothesis that permanent housing residents would have relatively more met, or fewer unmet, needs than other groups. Research indicates that having family physicians and case managers likely facilitated residential stability among homeless individuals [57] allowing them to make less use of emergency departments and reducing hospitalizations [44, 55]. The low proportion of permanent housing residents with a case manager seems however to indicate that most did not live in permanent housing with support, as recommended in the Housing First approach. This may partly explain the persistence of several unmet needs in this group. Moreover, the fact that SUD was the main reason for housing loss among temporary housing occupants seems to indicate that homeless individuals with SUD may be viewed as less favorably by permanent housing programs. The original Pathway to Housing model focused on homeless individuals with MHD or co-occurring MH/SUD [58], yet the Housing First approach has since expanded to include other types of clients, and may also include a diversity of organizational features that were not part of the original model. Those with SUD exclusively may have been relegated to other residential settings. Moreover, the greater prevalence of SUD, physical illnesses and co-occurring MHD/SUD among temporary housing occupants and emergency shelter users might explain their greater use of emergency departments and more frequent hospitalizations than among permanent housing residents. The qualitative findings also reflected a distinction between permanent housing residents and others in terms of the greater autonomy and the better level of comfort offered by permanent housing. This coincides with findings in Henwood et al. [59] suggesting that quality of life among chronically homeless individuals would increase mainly in areas related to living situation following transfer to permanent housing. Yet for emergency shelter users and temporary housing occupants, the lack of housing stability ensured a more precarious situation in terms of meeting basic needs.

journals.plos.org - Met and unmet needs of homeless individuals at different stages of ...

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