'Growing Old' in Shelters and 'On the Street': Experiences of Older Homeless People

Incontinence and homelessness

The fundamental principles of why specific people become homeless, can be grounded in a simple rationale or founded within sophisticated reasoning. For instance, people who suffer from substance abuse, addiction, alcohol, gambling, have mental health concerns or financial difficulties may be susceptible to homelessness. It is also identified that persons who experienced violence in their childhood or abuse by a partner are at a higher risk of becoming homeless. Homelessness knows no ethnic, cultural, religious or gender boundaries, and can impact all individuals' health and well-being. A health problem and worldwide phenomenon that affects all cohorts of the population, including the homeless, is urinary incontinence. The aim of this article is to increase the awareness of incontinence and highlight the impact it has on the lives of people that experience homelessness.

Canadian Health Care Providers' Perspectives on Working with Older Homeless Adults in Outreach Settings

Service providers have a unique understanding of older homeless adults' challenges and service needs. However, research on the experiences of health care providers (HCPs) who work with this population is limited. We aimed to gain a better understanding of the experiences (roles, challenges, and rewards) of HCPs who work with older homeless adults (age 50 and over) in outreach settings. We conducted individual semi-structured interviews with 10 HCPs who worked in these roles. Four themes emerged: (a) the client-provider relationship as an essential building block to HCPs' work; (b) progression of care that acknowledges the "whole person"; (c) collaboration as integral to providers' work; and (d) the importance of system navigation. Providers found their work personally and professionally fulfilling but were frustrated by system-level challenges. Findings can be used to identify strategies on how to further support providers in their roles and enhance service provision for older homeless individuals.

Positive health and ageing policies for older Irish travellers and older people who have experienced homelessness in Ireland: Life-course meanings and determinants

Marginalised groups of older people remain neglected in positive health and ageing (PHA) agendas, whether they concern healthy or active ageing concepts. Questions exist around the meaning of such constructs and the factors that enable disadvantaged populations to achieve equitable later-life experiences. Focusing on two such groups in Ireland, this study investigates the constituent dimensions of PHA for older Irish Travellers and older people who have experienced homelessness and the role of life-course and structural determinants in constructing PHA trajectories for these groups. The study involves a qualitative, participatory voice-led methodology, with analysis based on 49 in-depth life-course interviews with people aged 50 years and over from the two populations. Five interconnected dimensions of PHA are identified and presented. Four determinants related to life-course experiences and structural factors are identified as contributing to these dimensions: social relations, material and accommodation circumstances, formal supports and systems, and critical transitions and resilience. While illustrating the validity of PHA agendas for these groups when understood through their lived experiences, the findings highlight the significant deprivations and risks to rights that must be accounted for to secure meaningful gains in PHA for the groups.

Delivering Services to Older Persons Experiencing Homelessness: Providers' Perspectives of What Does and Does Not Work

Older people with experiences of homelessness (OPEH) tend to experience more complex health, social, and psychological issues than people experiencing homelessness at younger ages. Simultaneously, many housing resources (e.g., shelters, temporary housing) are often ill equipped to meet the needs of OPEH. As such, OPEH are often unable to age in the right place (AIRP) - that is, in a place that supports unique needs and vulnerabilities. However, several promising practices exist that deliver housing and services tailored to OPEH. To investigate the aspects of housing and shelter that both promote and impede AIRP for OPEH, this study examines the delivery of services in three such promising practices from the perspective of service providers. Findings from fifteen qualitative interviews revealed three overarching themes: 1) barriers to providing individualized support (e.g., staff turnover); 2) shifting contexts and structures (e.g., housing market changes); and 3) mechanisms of success (e.g., facilitating smooth transitions into permanent housing). These findings provide evidence to support the refinement of service delivery to promote AIRP for OPEH. In doing so, these insights can help to elevate promising practices to the level of best practice.

"A right place for everybody": Supporting aging in the right place for older people experiencing homelessness

While policies and practices that promote aging in place have risen in prominence over the last two decades, marginalised older adults have largely been overlooked. 'Aging in the right place' is a concept that recognises the importance of adequate and appropriate age-related health and psychosocial supports in shelter/housing settings and their impact on the ability of older people to age optimally. To understand the unique shelter/housing challenges and solutions that affect aging in the right place for older people experiencing homelessness (OPEH), we conducted three World Café workshops in three Canadian cities-Montreal, Calgary, and Vancouver. In total, 89 service providers and OPEH engaged in the workshops, which involved guided, small-table discussions with the goal of stimulating creative ideas and fostering a productive atmosphere. Findings revealed two overarching themes 1) Discrepancies, between the need and availability of housing options and community supports for OPEH, such as affordable transportation, case management, access to healthcare, and system navigation; and 2) Desires, for more peer support, participatory planning, service-enriched housing, social programming, and policies that promote agency, independence, and choice for OPEH. These findings provide evidence to inform the development or modification of housing and supports for OPEH that promote aging in the right place.

Life-Course Marginalities of Positive Health and Aging: A Participatory Approach Integrating the Lived Experiences of Older Irish Travelers and Older Homeless Adults in Multistakeholder Research Processes

There is increased emphasis on adopting positive health and aging policy goals for heterogeneous older populations, and recognition of the role that participatory research approaches can play in supporting their implementation. However, questions remain about how to represent the marginalized experiences of some older populations within such processes. With a focus on older Irish ethnic Travelers and older homeless adults as two vulnerable populations in Ireland, this article presents and critically discusses a participatory approach developed to integrate marginalized older adult perspectives on positive health and aging in a multistakeholder research and development process. The qualitative methodology is first detailed, incorporating methods that harness collaboratively derived views and individual narratives (e.g., focus groups; consultation forums; in-depth interviews). Critical reflections on research implementation and specific considerations relevant to these populations are presented (e.g., trust building; one-to-one facilitation), with lessons then drawn for the design of multistakeholder participatory approaches with marginalized older populations.

A qualitative systematic review on the experiences of homelessness among older adults

Adults who experience homelessness for an extended period of time also experience accelerated ageing and other negative impacts on their general health and wellbeing. Homelessness amongst older adults is on the rise, yet there are few systematic reviews investigating their experiences. Thus, this review classifies and synthesises qualitative research findings of studies published between 1990 to 2020 that have examined the needs and challenges of homeless older adults to elucidate their journey of homelessness. Seven papers met the requirements for inclusion. Three main themes were identified in the review: - (1) Pathways to homelessness, (2) Impact of homelessness, and (3) Outcomes and resolutions. This review collates current evidence on what is known about the experience of homelessness among older adults. In this study, homeless older adults identified a wide range of challenges associated with the experience of homelessness.

"Homelessness and Health Problems Are Not Distinct:" the Challenges of Rural-Urban Migrant Homeless Older People in Ethiopia

Compared with western countries, research on homelessness among older people in developing nations is minimal. Unlike in Global North nations that offer income security in late-life, in areas like Sub-Saharan Africa abject poverty contributes to older adults migrating from rural areas to urban centers in search of a means of livelihood. The aim of this study was to explore the challenges faced by homeless older rural-urban migrants in Kobo Town, Ethiopia. This cross-sectional study employed a qualitative descriptive case study. Purposive sampling was used to identify ten older adult migrants who had been homeless for more than a year. Data from in-depth interviews was supplemented with key informant interviews, observation, and document review. The narrative data was analyzed using thematic analysis. Study results revealed that homeless elders faced multiple challenges including lack of necessities such as food, shelter, and water, mobility issues, lack of employment access, social exclusion, and psychological struggles. The findings call attention to the need for practical access to social and economic empowerment responses to prevent and curb homelessness among older adults in developing nations.

Shelter/housing options, supports and interventions for older people experiencing homelessness

While experiences of later-life homelessness are known to vary, classification of shelter, housing and service models that meet the diverse needs of older people with experiences of homelessness (OPEH) are limited. To address this gap, a scoping review was conducted of shelter/housing options, supports and interventions for OPEH. Fourteen databases were searched for English-language peer-reviewed and/or empirical literature published between 1999 and 2019, resulting in the inclusion of 22 sources. Through a collaborative, iterative process of reading, discussing and coding, data extracted from the studies were organised into six models: (1) long-term care, (2) permanent supportive housing (PSH), including PSH delivered through Housing First, (3) supported housing, (4) transitional housing, (5) emergency shelter settings with health and social supports, and (6) case management and outreach. Programme descriptions and OPEH outcomes are described and contribute to our understanding that multiple shelter/housing options are needed to support diverse OPEH. The categorised models are considered alongside existing ‘ageing in place’ research, which largely focuses on older adults who are housed. Through extending discussions of ageing in the ‘right’ place to diverse OPEH, additional considerations are offered. Future research should explore distinct sub-populations of OPEH and how individual-level supports for ageing in place must attend to mezzo- and macro-level systems and policies.

Positive health among older Traveller and older homeless adults: A scoping review of life-course and structural determinants

Concepts related to positive health in later life are increasingly prevalent within community-based health and social care policy. With a greater emphasis on inclusion health for older populations, there is a critical need to understand the determinants of such states for those most at risk of societal disadvantage. Focusing on two such groups, the aim of this article is to synthesise international research on the life-course and structural determinants of positive subjective health for older homeless people and older Irish Travellers. Two scoping reviews were conducted (one for each group) to capture state-of-the art knowledge published from 1998 to 2020. The reviews were completed from July to December 2018, and repeated from March to April 2020. Thirty-eight publications were included in the final sample (older Travellers: 10 sources; older homeless: 28 sources). Specific life-course and structural factors were evident for both groups, as well as commonalities with respect to: accumulated exclusions; complexity of needs; accommodation adequacy/stability and independence and resilience. Research gaps are identified concerning: lack of conceptualisation of positive health; the application of life-course perspectives and the absence of an environmental gerontological analysis of the situations of both groups.

Supporting Older Homeless Persons' Positive Relocations to Long-Term Care: Service Provider Views

BACKGROUND AND OBJECTIVES

This study sought to explore the challenges and opportunities associated with supporting older homeless persons' relocations to long-term care (LTC) from the perspective of service providers. It aims to inform how to improve relocation processes for this vulnerable and growing subpopulation of older persons.

RESEARCH DESIGN AND METHODS

This cross-sectional qualitative study employed semistructured face-to-face interviews with service providers from two Health and Social Service Centres in Montreal, Quebec. All interviews were audio-recorded, transcribed verbatim, and thematically analyzed in five stages.

RESULTS

A total of eight service providers reported on their experiences supporting over 40 relocations of older homeless persons (50+) in the last year. According to participants, older homeless persons' trajectories into LTC typically included a series of neglected medical issues followed by hospitalization and eventual relocation to LTC. Systemic barriers such as limited-time for proper planning, insufficient housing options for persons with minor functional limitations, disregard for preferred geographic location, multiple moves, and staff prejudices worked together to expedite premature relocation and challenge relocation processes.

DISCUSSION AND IMPLICATIONS

Older homeless persons appear to be at heightened risk of premature and challenging relocation processes. Expanding housing stock for persons with functional limitations, strengthening intersectoral collaborations, providing education and training to staff, and ensuring flexibility around rules and regulations in receiving LTC homes would both improve access to aging in place for this marginalized group of older persons and ensure conditions are in place to support positive relocations to LTC for those who require it.

"Just like Jail": Trauma Experiences of Older Homeless Men

People experiencing homelessness often have a history of trauma, and losing one's home is a traumatic event. The trauma of living in emergency shelters and on the streets uniquely impacts older adults, whose experiences of homelessness increase the likelihood of multiple health conditions and premature aging. This paper includes data from 18 men, aged 50 and older, who had experienced multiple instances of homelessness, as part of a larger study to understand the return path to homelessness from permanent housing. When participants spoke with us about their failure to be in housing, their inability to free themselves from reoccurring homelessness could not be discussed without talking about their trauma. Participants spoke of trauma in early life, perhaps precipitating homelessness, as well as traumatic experiences while homeless. The men discussed feeling imprisoned by the systemic issues around homelessness, facing mistreatment by service providers, and being exposed to external threats in their lives on the streets, including violence. Findings from this study lend themselves to the explicit need for trauma-informed care and supportive services that are sensitive to the urgency of homelessness as it is experienced by men in late life.

"We Really Help, Taking Care of Each Other": Older Homeless Adults as Caregivers

Objectives:

Many older homeless adults maintain contact with family. We conducted a qualitative study examining the role of family caregiving for older homeless adults.

Method:

We conducted semi-structured qualitative interviews with a sample of 46 homeless participants who reported spending at least one night with a housed family member in the prior 6 months.

Results:

A total of 13 of 46 older adult participants provided caregiving. Themes included (a) the death of the care recipient led to the participant’s homelessness; (b) feeling a duty to act as caregivers; (c) providing care in exchange for housing; (d) caregivers’ ability to stay was tenuous; (e) providing care conflicted with the caregiver’s needs; and (f) resentment when family was ungrateful.

Discussion:

In a sample of older homeless adults in contact with family, many provided caregiving for housed family. For some, caregiving precipitated homelessness; for others, caregiving provided temporary respite from homelessness, and for others, caregiving continued during homelessness.

'The Thing that Really Gets Me Is the Future': Symptomatology in Older Homeless Adults in the HOPE HOME Study

CONTEXT

The homeless population is aging. Older homeless adults experience premature development of age-related conditions and an elevated symptom burden. Little is known about symptom experience among older homeless adults.

OBJECTIVES

To characterize the experience, understanding, and management of physical, psychological, social (e.g., loneliness), and existential (e.g., regret, loss of dignity) symptoms among older homeless adults.

METHODS

We conducted semistructured interviews from June 2016 to March 2017 with a purposive sample of participants from the Health Outcomes of People Experiencing Homelessness in Older Middle Age cohort, a longitudinal study of homeless adults aged 50 and older. We analyzed data between June 2016 and December 2017 using thematic analysis.

RESULTS

We found four main themes: 1) nonphysical symptoms are interwoven with, and as distressing as, physical symptoms; 2) individuals attribute symptoms to childhood abuse, manual labor, the conditions of homelessness, and aging; 3) symptoms interfere with daily functioning, causing negative changes in personality, energy, and motivation; and 4) individuals cope with symptoms through religion, social support, and substance use.

CONCLUSION

Homelessness causes and exacerbates physical and psychological distress. Interventions should address multiple interconnected dimensions of suffering. Health systems that care for homeless patients should adapt palliative care practices using a stepwise approach. Homeless shelters should adopt policies and modifications that increase privacy and autonomy while promoting community building. Housing interventions should promote community building. All who work with people experiencing homelessness should avoid stigmatizing language and recognize homeless individuals' sources of strength and coping.

Social Isolation in Later Life: Extending the Conversation

Avec le vieillissement de la population canadienne, l’isolement social des personnes âgées constitue une préoccupation croissante et une priorité d’action au niveau national. Bien que les risques individuels de l’isolement social des personnes âgées et les conséquences négatives sur leur santé soient relativement bien connus, les impacts des trajectoires de vie et des expériences collectives sont rarement considérés. Les définitions actuelles et les réponses à cet isolement social se basent sur des programmes qui tendent à privilégier les approches individuelles. Ici nous proposons que la discussion soit élargie afin de considérer les aspects sociaux et culturels de l’isolement social des personnes âgées. En particulier, nous suggérons que les définitions et les approches prennent en compte trois dimensions : les facteurs temporels, les facteurs spatiaux et les liens entre l’isolement social et l’exclusion. Ainsi, nous pensons qu’il serait possible d’élaborer une approche d’intervention plus inclusive face à l’isolement social des personnes âgées, et de développer les capacités en ce sens chez un plus grand nombre d’aînés, en vue de pouvoir répondre, en particulier, aux besoins des personnes âgées les plus vulnérables ou marginalisées.

Senior Services that Support Housing First in Metro Vancouver

Housing First is a model and philosophy for housing homeless people in immediate and permanent housing. In order to implement and deliver Housing First, research is essential to understand the system of support services as they currently exist. Guided by principles of community-based participatory research, this paper presents the findings from a senior-focused deliberative dialogue workshop in Metro Vancouver, Canada. Participants (16 service providers and 1 service recipient) identified services and resources available to support seniors in maintaining housing and barriers and facilitators for accessing services. Broadly, data were organized into seven themes: (1) Housing; (2) Home support; (3) Transportation; (4) Information availability, accessibility, and navigation; (5) Cultural diversity; (6) Discrimination; and (7) Funding and financial support. Results found that affordable housing that adapts to changing health conditions, income supports, health services, homecare, transportation, and culturally appropriate and nondiscriminatory informational resources are among the supports most needed for persons as young as 50 years old to succeed under the Housing First model in Metro Vancouver. Barriers to Housing First service provision, including rigid eligibility criteria for chronically and episodically homeless, should be revised to better support the growing number of older adults who are newly entering homelessness in Metro Vancouver.

Homelessness and aging: The contradictory ordering of 'house' and 'home'

The concepts of 'house' and 'home' are compelling and contradictory. They are compelling because they elicit the desired sentiments of permanence, feeling 'at home', and maintaining continuity in one's life. At the same time, they can be experienced as contradictory where organizational practices and the socio-cultural imperatives of individual responsibility, cost containment, and rationed services are concerned. Where 'house' tends to evoke a sense of permanent stability, 'home' is regarded as the ideal living environment and site of care for older people. Yet, a consideration of the challenges that occur at the intersections of age and homelessness highlights a tension between the taken-for-granted ideal of 'home' for older people, and programs organized around 'housing' for homeless people. To begin, we ground our work in a critical perspective to the study of aging and briefly sketch the state of knowledge on homelessness in late life. We then explore the contradictions that occur at the intersections of age and homelessness, including the discursive ordering of 'house' and 'home,' the configurations of access and barriers, and aging in undesirable locations. In our conclusion, we draw attention to inequalities and the need for a life course perspective to ground future thinking. Our conceptual discussion is based on insights gained from a 3-year project on older homelessness in Montreal, Canada.