Psychosocial preparedness among homeless people: A study from an urban rehabilitation center in South India

ABSTRACT

Background:

Homeless people have difficulties in their basic necessities such as food, clothing, and shelter and they are prone to physical abuse and assault. Homeless mentally ill persons are found to have unhealed injuries and they lack help-seeking behavior, which leads to further deterioration of physical and mental health. In view of the alarming increase in this marginalized population, there is a need to understand their psychosocial needs and enhance their well-being and quality of life. The study aims to understand the psychosocial preparedness of homeless people admitted to a relief and rehabilitation center in Bengaluru.

Methods:

The study followed a descriptive research design with 90 participants (10% of total inmates), 45 participants each falling under the categories of homeless persons with mental illness (HMI) and homeless persons without mental illness (NMI), selected using a simple random sampling method. A semi-structured interview schedule was used for data collection. Statistics procedures used frequency distribution, mean, median, and standard deviations and inferential statistics such as the Chi-square test.

Results:

The results of the study show that the majority of the respondents (56% in HMI and 73% in NMI) were male, 62% in HMI and 60% in NMI were literate, 60% in HMI and 86.66% in NMI were employed before institutionalization, 73% in HMI and 69% in NMI belonged to nuclear family. The study also shows that the majority of the HMI (56%) had no plans to start work; however, the majority of the NMI (49%) had plans to start work. Mean scores indicate persons with mental illness have more psychosocial preparedness than persons without mental illness.

Discussion:

The results showed that there was no significant difference between the mean level of psychosocial preparedness among persons with mental illness and persons without mental illness.

Introduction

Homelessness has become an apparently well-known part of the social background of the world, with approximately 6 million people sleeping in the streets or shelters on any given night and millions more having had some homelessness experience during their lifetime. Epidemiological study estimates have indicated that globally, about 25% of homeless individuals have mental disorders.[1,2,3] According to the 2011 Census Report, there are 1.77 million homeless people in India, constituting 0.15% of the country’s total population.[4] It is estimated that 20–25% of the homeless population in India suffers from severe and persistent mental illness.[5] A homeless person is jobless, penniless, functionless, and supports less. They are found in different conditions, as they have no identity. Thus, they are nowhere in the national records. There is no proof of their legal existence.

The reasons for homelessness are multi-dimensional. The reasons vary from family problems to drug addiction to begging. Though the reasons for homelessness vary, the psychosocial problems of homeless people remain the same. The psychosocial issues make homeless people with or without mental illness more vulnerable and susceptible to physical, psychological, and social well-being. Homeless people experience a language barrier, predominant negative symptoms, poor cognition, neglected self-care, and absconding tendency.[6]

Homeless people have extensive unmet needs for housing, job skills, employment, and income.[7] The quality of life of homeless mentally ill people is much worse than that of other homeless people; they face greater difficulties with substance abuse, sexual abuse, physical health problems, legal problems, and contentious prognosis, and experience a higher level of stress.[7,8]

Homeless persons, both mentally ill and mentally sound, pay less attention to their health and their basic requirements such as food, shelter, and safety. There are many institutions in our country for the relief and rehabilitation of the homeless destitute that include both government and non-government agencies. For instance, in the state of Karnataka, there are 14 such governmental relief and rehabilitation centers, which receive homeless persons who are mentally ill as well as normal persons. Due to the unavailability of required manpower and infrastructure, these institutions are finding it difficult to provide necessary physical and mental health care for the inmates. Moreover, all strata of homeless people, that is, mentally ill, non-mentally ill, men, women, and old age people stay together wherein they are not getting adequate rehabilitation measures (occupation, vocational, and milieu therapy) and have greater chances for manifestations of other behavioral problems such as substance abuse, anti-social behavior, and violence among them.[9,10] Thus, it is always better to reintegrate the inmates with their families if family is available or to rehabilitate them in various organisations if they are destitute. This helps the homeless persons to gain self-esteem and live a dignified life in the future with better quality of life.[11] The level of preparedness among homeless persons is an important factor to decide on their reintegration as the reasons for homelessness vary from person to person. This research made an attempt to study the level of preparedness among homeless persons in the Government Relief and Rehabilitation Center, Bengaluru, and thereafter to plan for the reintegration of the homeless persons into community life.

Materials and Methods

This study aimed to understand the psychosocial preparedness of homeless people admitted to the Relief and Rehabilitation Centre, Bengaluru. The objectives were to find the socio-demographic factors of street people, focus on their perception of their lifestyle, find their level of psychosocial preparedness for rehabilitation, and evolve appropriate rehabilitation measures for homeless people in general and homeless mentally ill. The study was conducted in an urban rehabilitation center in 2011 and Institute Ethics Committee approval was sought before the study. The informed voluntary consent of participants was sought for the study and necessary psychosocial intervention had been provided when required.

Under the Prevention of Beggary Act, 1975, Relief & Rehabilitation Centers are functioning in various districts, there are 14 such centers functioning in Karnataka. An urban rehabilitation center was taken as the universe for the study. The study population consists of homeless mentally ill and homeless non-mentally ill persons who have been admitted to the Rehabilitation Center. The descriptive research design was adopted for this study. All homeless mentally ill and homeless non-mentally ill people admitted to relief and rehabilitation centers within the age group of 18 to 60 years were included in the study. Simple random sampling techniques were adopted for selecting the respondents from the population. A total of 90 respondents, 45 homeless persons with mental illness (HMI), and 45 homeless persons without mental illness (NMI) considering 10% of the total number of inmates were taken as the sample for the current study.

A semi-structured interview schedule was used to assess the background of the respondents. It contains both close-ended objective questions and open-ended questions. To assess the psychosocial preparedness for rehabilitation, a questionnaire prepared by the researcher was used. A total of 32 items are rated on a 3-point scale from 2–0 (highly prepared, prepared, and not prepared) and a maximum score of 64 can be obtained. The scoring of the scale indicates that the higher the score, the higher the preparedness, and the lower the score, the lesser the preparedness. The questionnaires were given to seven experts who are having rich experience in this field for face validation. The descriptive statistics such as frequency distribution, mean, median, standard deviations, and inferential statistics such as the Chi-square test were used for data analysis.

Results

The results of the study revealed that the majority of the respondents (31%) from the HMI were in the age group 41–50 years, whereas the majority of the respondents (35.55%) from the non-mentally ill were between 51 and 60 age groups [Figures 1 and 2]. There were more young people (20–30 years) in the group of HMI (22.22%) as compared with NMI (13.33%) [Figures 1 and 2]. There were more elderly respondents in NMI (>60 years). The majority of the respondents (55.56% in HMI and 73% in NMI) were male [Figures 1 and 2]. The majority of the respondents (62% in HMI and 60% in NMI) were literate. The majority of the respondents (60% in HMI and 86.66% in NMI) were employed before institutionalization [Figures 1 and 2]. The majority of the respondents (51.11% in HMI and 37.77% in NMI) were married [Figures 1 and 2], 73.33% in HMI and 68.88% in NMI belonged to a nuclear family, and 88.66% in HMI and 66.66% in NMI had family income of less than Rs. 2000 per month [Figures 1 and 2].

Figure 1.

Sociodemographic details-HMI

Figure 2.

Sociodemographic details-NMI

A Chi-square test was used to find out the significant difference between the different levels of preparedness among male and female respondents. The results showed that there was a significant difference between the number of HMI and NMI respondents at different levels of preparedness. The results show that there was no significant difference between the mean level of preparedness among male and female respondents [Table 1].

Table 1.

Gender differences in level of preparedness

Specific future plan	Homeless mentally ill						Homeless non mentally ill						Chi-square
	Highly prepared		Prepared		Not prepared		Highly prepared		Prepared		Not prepared		Value	df	Sig
	n	%	n	%	n	%	n	%	n	%	n	%
To get admitted to charity home	1	2.2	23	51.1	21	46.7	1	2.2	7	15.6	37	82.2	12.95	2	0.002
To go to work in the daytime and take shelter for night time in this center	7	15.6	10	22.2	28	62.2	2	4.4	5	11.1	38	84.4	5.96	2	0.051
Accepting the friend support for regular treatment	1	2.2	19	42.2	25	55.6	1	2.2	4	8.9	40	88.9	13.24	2	0.001
To adhere to the schedule of treatment prescribed	1	2.2	15	33.3	29	64.4	0	0	1	2.2	44	97.8	16.33	2	0.000
To keep in touch with nearby psychiatric services for follow up	4	8.9	21	46.7	20	44.4	0	0	6	13.3	39	86.7	18.45	2	0.000
Consulting the treating team when side effects occur	4	8.9	16	35.6	25	55.6	0	0	7	15.6	38	84.4	10.2	2	0.006
Not trying out self-medication	2	4.4	17	37.8	26	57.8	0	0	4	8.9	41	91.1	13.41	2	0.001
Abiding by rehabilitation counseling procedure	1	2.2	12	26.7	32	71.1	0	0	3	6.7	42	93.3	7.751	2	0.021
Accepting the community support for regular treatment	2	4.4	16	35.6	27	60	0	0	4	8.9	41	91.1	12.08	2	0.002
To join other inmates to explore new avenues of rehabilitation	0	0	17	37.8	28	62.2	0	0	4	8.9	41	91.1	10.5	1	0.001

To find the significant difference between the different levels of preparedness among NMI and HMI, the Chi-square test was used. The results showed that there was a significant difference between the number of NMI and HMI respondents at different levels of preparedness. The results show that there was no significant difference between the mean level of preparedness among persons with mental illness and persons without mental illness [Table 2].

Table 2.

Level of preparedness among homeless persons without mental illness and homeless persons with mental illness

Specific future plan	Homeless mentally ill						Homeless non mentally ill						Chi-square
	Highly prepared		Prepared		Not prepared		Highly prepared		Prepared		Not prepared		Value	df	Sig
	n	%	n	%	n	%	n	%	n	%	n	%
To join your family members	20	44.4	15	33.3	10	22.2	35	77.8	4	8.9	6	13.3	11.45	2	0.003
To join with close friends	2	4.4	17	37.8	26	57.8	7	15.6	7	15.6	31	68.9	7.383	2	0.025
To return to my previous job	3	6.7	16	35.6	26	57.8	12	26.7	19	42.2	14	31.1	9.257	2	0.001
To work as a cleaner in the hotel	0	0	22	48.9	23	51.1	6	13.3	16	35.6	23	51.1	6.947	2	0.031
To work in a kitchen (hotel/home)	0	0	24	53.3	21	46.7	5	11.1	10	22.2	30	66.7	12.35	2	0.002
Accepting the family support for regular treatment	1	2.2	21	46.7	23	51.1	2	4.4	2	4.4	41	91.1	21.09	2	0.000

Discussion

The demographic profile of the respondents showed that the majority of the respondents (31%) from the HMI belonged to the age group 41–50 years, and the majority from the NMI were between 51 and 60 years of age. There were more young people (20–30 years) in the group of HMI (22.22%) as compared with NMI (13.33%). This shows that the majority of the homeless mentally ill people fall in the productive age category, which is consistent with other studies conducted in India among a similar population.[10,12,13,14]

There were more elderly respondents in NMI (>60 years). The majority of the respondents (HMI: 25, NMI: 33, respectively) were male, which contributed 55.56% of the respondents in HMI and 73.33% in NMI.[9,10,12,14] The reasons that there were more males among the homeless persons could be because of financial difficulties, substance abuse, unemployment, and lack of social support. Studies from India and abroad[11,12,15,16] reported similar results in the socio-demographic variables, especially in unemployment, substance abuse, mental illness, inadequate support networks, and lack of affordable housing. This shows the general characteristics of street people both homeless persons with mental illness and homeless persons without mental illness. Before dislodgements from the family, the majority of the respondents (HMI 60%, NMI 86.66%, respectively) were employed. However, the employment was not very regular and stable. The employment status of the homeless people is generally unemployed before detention, which is being supported by other studies. Risk factors for and pathways to homelessness have been identified as increasing the risk of some people with a serious mental illness becoming homeless.[5,9,13,16] These include being male, single, unemployed, and or having a few or no family contacts, a few or no friends and acquaintances, poor social, planning, and financial skills, alcohol or other drug misuses, lengthy history of mental illness, poor acceptance of treatment, history of brief repeating hospitalizations, functional disability, poor quality of life, history of early discharge, and poor discharge planning.[10,16,17,18,19]

There was a significant level of preparedness among persons with mental illness and persons without mental illness. The respondents reported significant level of preparedness in the areas of getting admitted to a charity home, to go for work in the daytime, taking shelter at night time, accepting friend support for regular treatment, joining with family members, joining with close friends, and returning to their previous job. Mentally ill persons are more prepared, and in some areas, non-mentally ill persons are more prepared. The finding is inconsistent with a study conducted by Ravindren and Kurien in 2020,[12] which shows that 63% of the HMI are willing to go back to the community. The differences in the circumstances in which they are admitted and cared for vary in these two study contexts. In some of the areas, there is really no significant difference between the two groups. The mentally ill are more prepared than the other group because of the level of acceptance from their family members. The persons with mental illness would be out of the family due to the illness even without the knowledge of the family members and thus the family members would accept the respondents, whereas the persons without mental illness are homeless because of the unfavorable situations at home. To reduce functional disability and improve clinical outcomes, greater community integration of the homeless and mentally ill people is essential.[11,20] The current study suggests that psychosocial preparedness among HMI is the most significant aspect when considering independent housing or community living for HMI.

Conclusion

There is a dearth of knowledge in the area of research on homeless persons and the rehabilitation needs in India and across the globe. More research in terms of the psychosocial profile of the homeless persons, the level of preparedness of the homeless persons who are staying in the institutions to get rehabilitated, and the various needs of the homeless persons need to be studied in the future, which would help in improving the services for the homeless persons.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.