Voices From the Street: Exploring the Realities of Family Homelessness

Abstract

Homelessness threatens the health and well-being of thousands of families in the United States, yet little is known about their specific needs and how current services address them. To fill this knowledge gap, we explored the experiences of homelessness families in Detroit, Michigan. We targeted homeless mothers and their caseworkers for study to see if the perceptions of needs and services were in alignment. Using focus groups and content analysis, we identified four overarching themes that illustrate homeless mothers' experience with homelessness. We then analyzed data from caseworkers to look specifically for similarities and differences in their perceptions. Key findings included reports of family histories of violence, poverty, social isolation, and a lack of informal support as contributing to homelessness. The differing perspectives of mothers and their caseworkers regarding how best to move forward highlight how current programs and services may not be meeting the needs of this growing and vulnerable cohort.

Background and Significance

In 2013, the U.S. Department of Housing and Urban Development (HUD) reported a 13.1% rise in the number of persons in families experiencing homelessness over the prior 5 years (2007-2012). Now the fastest growing segment of the homeless population, homeless families comprise 36% of the United States's 1.5 million known homeless (HUD, 2013), with another 7.5 million families doubled up with family and friends, at imminent risk for losing their housing (National Alliance to End Homelessness [NAEH], 2014). The majority of these families, whether literally homeless and living in shelters or precariously housed with friends and relatives, are headed by young (below age 30), unpartnered women (77.9%) who are disproportionately of a minority racial or ethnic status (72.3%) with two or more children below the age of 6 (HUD, 2013).

Despite the magnitude of this national trend in the United States, little is known about the specific needs and struggles of this emerging cohort. In fact, national efforts to reduce homelessness have been successful in producing modest declines in the number of individuals experiencing homelessness even as the number of families experiencing homelessness has increased (HUD, 2012). This suggests that current programs and interventions are not successfully targeting the needs of this unique family population. Without a better understanding of these needs, there is a real risk that current programs will continue with little if any value to those they are meant to serve. We aimed to fill this gap in knowledge by asking homeless women with children and their caseworkers to talk with us about the pathways that initially led families to homelessness, the day-to-day circumstances mothers and their children encountered while living in shelters, their experiences during the rehousing process, what the mothers felt they needed most to change their current situations, what were some obstacles that they encountered, and how homelessness, more broadly, affected health and well-being. Data collected from these “voices from the street,” we argue, are essential to understanding how best to devise approaches that can help homeless families return to stable housing, increase their overall health and well-being, and prevent future episodes of homelessness.

Precipitators of Family Homelessness

Given that the primary cause of homelessness is one's inability to pay for housing and related expenses, it is not surprising that during the United States' recent recession the combined influences of unemployment and lack of affordable housing contributed to the swelling ranks of homeless families (U.S. Conference of Mayors, 2011). Indeed, according to HUD (2014), few households with only one full-time worker earning minimum wage (US$7.25/hr) can afford to rent a two-bedroom apartment anywhere in the United States. With nearly one sixth (15%) of the nation currently living at or below the poverty level (DeNavas-Walt, Proctor, & Smith, 2013), moreover, it is projected that more low-income families, especially those headed by single minority mothers, are at risk for homelessness every day (NAEH, 2014).

Research over the past 20 years has shown that mothers experiencing homelessness are contending not only with poverty but are also frequently struggling with past traumas, broken family relationships, and fractured social support systems. Seminal work by Bassuk and colleagues (1996), along with more recent studies of homeless families (Anderson, 1996; Anderson & Imle, 2001; Anderson & Rayens, 2004; Finfgeld-Connett, 2010; Grant, Gracy, Goldsmith, Shapiro, & Redlener, 2013; Kilmer, Cook, Crusto, Strater, & Haber, 2012), demonstrates that a large percentage of homeless mothers have histories of severe physical or sexual abuse as well as isolation or alienation from their families of origin. The net effect of these physical, emotional, and social stressors puts them and their children at greatest risk for homelessness and its related health consequences and may affect how, when, and why women utilize or fail to utilize formal (e.g., housing and employment assistance programs) and informal (e.g., assistance from friends or family) support services.

Health and Safety Issues and Concerns in Homeless Families

The relationships between family homelessness, health outcomes, and patterns of health care utilization have been studied although not well understood. What is known is that families experiencing homelessness suffer disproportionately from numerous acute and chronic health conditions that may contribute to poorer short- and long-term health outcomes for families. It has been reported, for example, that homeless children are hospitalized for illness at twice the rate of housed children and are half as likely to be up-to-date on immunizations (Karr & Kline, 2004). Homeless children also suffer disproportionately from asthma (Buu et al., 2014), anemia, malnutrition, lice, scabies, depression, anxiety, dental problems, ear infections, and respiratory infections (Briggs, 2013; Grant et al., 2013; Morris & Strong, 2004; Park, Fertig, & Allison, 2011) and are at increased risk for trauma-related injuries and skin infections. With limited access to primary care providers (Nabors et al., 2004), they are also higher contributors to increased utilization of more costly emergency room services (Morris & Strong, 2004; Park et al., 2011). School-aged children who spend time living in homeless shelters are also more likely than housed peers to be exposed to severe psychosocial stressors, including violence or a major loss or separation (Harpaz-Rotem, Rosenheck, & Desai, 2006; Nabors et al., 2004; Zima et al., 1999; Zlotnick, Tam, & Zerger, 2012). Little is known about the long-term impact of homelessness on pre-school aged children and its social, emotional, and fiscal costs on family health.

Homeless parents are at equal risk as their children for increased episodes of acute illness and unmanaged chronic disease (Caton et al., 2012; Koh, Hoy, O'Connell, & Montgomery, 2012), often leading to difficulty maintaining employment, thus perpetuating the cycle of poverty and homelessness (Morris & Strong, 2004). Homeless mothers are particularly vulnerable to mental illness, suffering from diagnosable mental illness at a rate 2 to 6 times higher than that of the general population (Weinreb, Buckner, Williams, & Nicholson, 2006; Zima et al., 1999) and to domestic violence, which is often the primary cause for housing displacement and instability (Hill, Schroeder, Bradley, Kaplan, & Angel, 2009). Homeless mothers can suffer from post-traumatic stress disorder, untreated mental illness, and substance abuse; therefore, many homeless mothers exhibit diminished parenting skills (Fonfield-Ayinla, 2009; Paquette & Bassuk, 2009). Without adequate parental support, children of homeless mothers may develop behavioral difficulties (Gewirtz, DeGarmo, Plowman, August, & Realmuto, 2009; Howard, Cartwright, & Barajas, 2009; Tischler, Karim, Rustall, Gregory, & Vostanis, 2004), truancy issues (Harpaz-Rotem et al., 2006), and academic under-achievement (Fiscella & Kitzman, 2009). Thus, a family experiencing home-lessness is not only at risk for the short-term health implications of housing instability, but they are also at risk for diminished educational and mental health outcomes as well as increased behavioral problems. Nursing professionals are encountering families experiencing homelessness in acute care, public health, and primary care settings. In light of the goals established by Healthy People 2020 (U.S. Department of Health and Human Services [USDHHS], 2010) to reduce health disparities and improve the overall health and well-being of vulnerable families, nurses have a responsibility to assess, recognize, and utilize interventions that improve the lives of families experiencing homelessness and housing instability.

Method

The specific aims of this study were to conduct focus groups with mothers experiencing homelessness and their caseworkers, separately, to (a) explore individual pathways into homelessness, (b) understand the day-to-day experience of living in an emergency shelter and the process of rehousing, (c) identify real and perceived barriers for families attempting to reestablish stable housing, and (d) understand the impact of homelessness on families' overall health and well-being.

Given our study's specific aims and the population of study—homeless mothers and their primarily female caseworkers—we abided by the tenets of feminist participatory action research (FPAR) to capture the experiences of a typically marginalized subject pool (Ponic, Reid, & Frisby, 2010; Salmon, Browne, & Pederson, 2010). This required acknowledgment of power differentials between the participants and the research team, including attention to maintaining confidentiality of focus group participants and utilizing focus group input to clarify and verify statements to capture the true intention of statements by focus group participants. To engender trust with the study subjects, our research team was embedded in the community as part of an academic/community partnership whose members worked together to design and implement the research approach (Baiardi, Brush, & Lapides, 2010; Brush, Baiardi, & Lapides, 2011). Adhering to feminist research methodology (Hesse-Biber & Leavy, 2007; Jagger, 2007), we used focus groups to capture the how and why of individuals' lives as either homeless mothers or caseworkers.

Focus groups are arguably the best way to give voice to disenfranchised individuals and populations, provide important context for designing programs to meet community-identified needs, and build trust between individuals, communities, and the services intended to support them (Freimuth & Quinn, 2004; Ruff, Alexander, & McKie, 2005; Sullivan-Bolyai, Bova, & Harper, 2005). Thus, the use of focus groups in our study created an avenue to collect and analyze data that could be shared with the partnership to develop interventions to reduce health and social disparities among homeless families (Christopher, Watts, McCormick, & Young, 2008; Fowles, 2007; Rashid et al., 2009).

Setting

Focus groups were conducted between November 2008 and January 2010 at a service agency in Detroit, Michigan, that provides emergency financial assistance, job training, fiscal planning, life skills classes, and a wide array of social services to homeless families. One of the agency's major programs is directed toward providing housing and employability services for homeless adults (primarily African American women), which include career development training and household management. Families who meet the HUD definition of homelessness are eligible for services. Between April 1, 2010, and January 31, 2011, the agency enrolled 159 new families with 334 children (average 14 families per month), up almost 35% from the prior year. This nonprofit agency is supporting largely through HUD and foundational monies. Families are typically followed from their point of entry into emergency shelters until 6 months after rehousing, although longer term follow-up can occur as needed.

Design and Sample

In conducting the focus groups with homeless mothers and their caseworkers, we followed a simple qualitative, descriptive design. Inclusion criteria for mothers included being currently homeless, female, 18 years of age or older, and residing with, and caring for, at least one dependent child. Caseworker participants needed to be currently employed, either part- or full-time, at the study agency and actively engaged in providing supportive services to families experiencing homelessness. Participants in both cohorts were excluded if they were unable to speak English or if they were unable or unwilling to consent to participation. The study was approved by the University Institutional Review Board (IRB) at both the University of Michigan and the University of Detroit Mercy.

Participant focus groups were conducted separately from the caseworker focus group. Potential focus group participants were recruited in two ways. Caseworkers were asked directly to participate in the focus groups by the study project manager. They were informed that their participation was approved by the agency CEO, that focus group times would be adjusted to their work schedules, and that they would be paid for that time along with a small stipend in appreciation of their participation. They were also assured that their responses would be confidential, viewed only by the project researchers, and would not be shared with their supervisor. Mothers experiencing homelessness were recruited through the agency's caseworkers and through a Life Skills Support Group that met every other week. This was a purposive approach to allow prospective participants to be identified and invited to participate by trusted caseworkers who knew the inclusion criteria and the participants' ability to act as key informants. Importantly, women asked to participate were informed that their choice of whether or not to participate would in no way affect the quality or range of services provided by the caseworkers. To ease potential participant burden, they were informed that the focus group sessions would be held immediately after the bimonthly life skills workshop, that their transportation costs to and from the session would be paid, and that they would be offered a moderate incentive. Seven caseworkers and 21 homeless mothers were recruited to allow for four groups of 7 participants each.

Data Collection

Semi-structured interviews were used to guide the focus group sessions for both homeless mothers and their caseworkers. Focus group questions for the mothers experiencing homelessness included questions about reasons for becoming homeless, experiences within the shelter and during the process of rehousing, impacts on their health and that of their children, and hopes for the future. Questions for the caseworkers included questions about their roles as caseworkers, their perceptions of barriers to aiding families, and their perceptions of threats to the health and well-being of homeless families. Participants were consented prior to the beginning of each session, informed that they would receive a US$20 gift card for their participation, and provided with healthy refreshments. Each focus group averaged 90 min in length, was digitally recorded, and was held in a private conference room in the study agency building in downtown Detroit. A research assistant was also present to take notes and document directionality of conversation not captured through digital recording.

Data Analysis

Qualitative thematic analysis for each group was ongoing, so that the interview guide questions could change or expand as needed for subsequent groups. Digital recordings of each focus group were also transcribed verbatim immediately after the session and field notes were utilized to identify nonverbal communications and interactions not captured in the transcript. To facilitate a structured, coherent coding process after data collection was completed, the investigators revisited the study aims and organized the data into four major themes: Pathways to and the Meaning of Homelessness, Daily Shelter Life and the Rehousing Process, What Mothers and Caseworkers Need and Want, and Impacts on Health and Well-Being. In keeping with procedures outlined by Graneheim and Lundman (2004), all research members independently coded and identified meaning units from the data. This involved all study team members carefully reading through the focus group transcripts noting words or concepts that were repeated by multiple participants or that emerged across multiple focus groups in relation to the intended themes as defined by the specific aims of the study. This process led to the identification of potential subthemes. Once those key subthemes emerged, each team member selected participant utterances or phrases that embodied the subthemes they identified and developed formulated meanings for each statement. The entire team then met to compare findings and reach consensus on subthemes, significant statements and formulated meanings. This process occurred over the course of several weeks through round table discussions utilizing poster board and sticky notes to visualize each team member's findings and recognize areas of divergence and convergence.

Findings

Description of Study Participants

Five caseworkers and 13 mothers of the originally recruited sample ultimately participated in four separate focus group sessions. Due to absence or the need for exclusion (i.e., 2 recruited homeless mothers were below the age of 18), our projected numbers were lower than expected. The five female caseworkers, who were employed at the study agency between 2 months and 25 years, were focused in one group and the 13 homeless mothers (ages 19-50) were focused in three groups with 2, 7, and 4 participants, respectively. Each mother had at least one dependent child and as many as six. Twelve of the 13 mother participants self-identified as African American and one self-identified as Hispanic. Seven of the 13 homeless mother participants were experiencing homelessness for the first time and 6 had been homeless more than once, including 1 woman who reported three prior homeless episodes. All participant mothers identified themselves as single, divorced, or separated with children ranging in age from 4 months to 32 years of age; the oldest child receiving direct care from her mother was 16. Two participant mothers were in their last trimester of pregnancy and planned to bring their newborns to the shelter after delivery. All were involved in the agency's Life Skills program and thus were somewhat familiar with each other. The homeless mothers were all in different stages of the rehousing process but all were within the 6 months of their most recent homeless episode. While most were still in an emergency shelter, 3 of the women had recently reestablished housing.

Themes

As noted earlier, we coded the focus group data under four main themes to gain a broad understanding of participants' perceptions of the experience of homelessness, the rehousing process, and the needs and health consequences of housing instability. Themes and subthemes are depicted in Tables 1 and 2. Within each of the four themes, several subthemes emerged that provide further insight into the complex and nuanced world of family homelessness. Data from the three homeless mother focus groups are presented together in Table 1; data from the caseworkers are presented in Table 2.

Table 1.

Significant Statements and Formulated Meanings From Participant Mothers.

Theme	Significant statement	Formulated meaning
Pathways to and the meaning of homelessness	Subtheme: Pride as a Last Stand Against Powerlessness “If it weren't for my babies, I wouldn't be anywhere.” “I had a pride problem … I had too much pride to call any of my friends …”	Women expressed pride and self-worth in their roles as mothers. However, they also found that their pride stood in the way when they needed to reach out and ask for help.
	Subtheme: On Our Own “I'm in the situation because I don't have a mother–daughter relationship … she put me out for her boyfriend.” “I came home one day and my husband told me he no longer wanted to be married and to get out.”	Most women lacked a safety net; they did not have family and friend support to count on when they needed it. Family relationships were often fragmented or nonexistent.
	Subtheme: Family Legacies of Poverty and Violence “I moved in with my mom … my mom lost her property because the landlord was a slumlord and wasn't paying taxes.” “I was also the bad mom. I was out on drugs, left my kids … she [16-year-old daughter] really don't care about me … she's turning out to be the child that I don't like …. I popped her in the mouth.” “He [formerly estranged father] decided to jump on me with my son on my hip, with an open stove. And my mom … didn't even care that I'm beat up and bloody.”	Many women shared stories of intergenerational poverty, substance abuse disorders, and family violence. The women identified how these legacies affected them, and their stories highlighted how the next generation was affected.
Daily shelter life and the rehousing process	Subtheme: I Am More than Just “Homeless” “I got disability problems. Ok, I don't have my GED, but I'm only 30 points away from it … it's $10 a point, and paying the bills …” “So if I have to get up 2-3 hours earlier and catch that bus to get them [her kids] on the other side of town [to their old school], that's what I do.”	Women felt misunderstood and labeled as they faced complicated choices about their futures. They valued education and job training, and saw that as the pathway to a stable future. They sacrificed to keep children in familiar, good schools.
	Subtheme: Rules, Rules, Rules “I don't know how it's been for everyone else, but the staff got attitudes.” “I asked for a pass [from the shelter] because I had a job interview and wanted my baby to spend the night with his grandma, and they told me ‘no.’ So I didn't even go to the interview, because I didn't have nobody to watch him.”	Women encountered shelter staff who treated them with disrespect. Individual needs or circumstances were not considered when rules were enforced.
What women need and want	Subtheme: Moving Up is the Only Way Out “I want more for myself, more for my children.” “Before I got put out of my house, I was just like living every day for the day. And now, I'm living for normal time, you know, instead of just today and 6 months from now.”	Being homeless made many women start thinking more futuristically, setting goals, moving beyond day-to-day survival toward making plans for education, employment, and healthier lives.
Impact on health and well-being	Subtheme: Health in Decline “My life has been unstable.” “It was too stressful to keep going through that with her [mom].” “You gotta laugh to keep from crying.” “Mentally, physically, emotionally, it's taking a toll on me. I'm steadily losing weight. I can't eat. I'm barely sleeping.”	Women spoke openly of their struggles with managing stress, anxiety, and depression. Many had no access to mental health services, but relied on inner strength and humor to get them through the hard times. Women were physically and emotionally exhausted from their ordeals.
	Subtheme: Hope, Optimism, and Spirituality “Thank God for Jesus.” “They haven't found me a house yet, but they're working on it. I'm blessed.” “For those this situation falls down upon, we have to stop asking, ‘Why me?’ and make a plan to dig ourselves out of where we are.”	In spite of their hardships, women looked to a brighter future. They relied on their spirituality to get them through the day-to-day struggles, and planned for a better future for themselves and their children.

Table 2.

Significant Statements and Formulated Meanings From Caseworkers.

Theme	Significant statement	Formulated meaning
Pathways to and the meaning of homelessness	Subtheme: Pride as a Last Stand Against Powerlessness “Another thing I see, is that when they do call, people are ashamed of their situations … They don't want to be judged by what's going on in their lives.”	Caseworkers noted that women were embarrassed to admit that they needed help. While asking for help may have made women feel powerless or out of control, caseworkers noted how truly out of control their lives were once women became homeless.
	Subtheme: On Their Own “It's a lot of them in shelters that cannot go back to their families.” “Every mother should take responsibility and do her part in caring for her family … I'm not taking guys off the hook, but a lot of times, they're just not there.”	Many of the homeless clients were single women with no family support. Caseworkers recognized this and tried to engage mothers in self-sufficiency.
	Subtheme: Family Legacies of Poverty and Violence “If you haven't been taught that you have to work for what it is you want, then your whole mindset has to change.” “Some are chronically homeless just to get money. One at [local shelter] with her granddaughter. The girl's not with her mother so she can get more money. Wants help, but she'll be back in the same position in 6 months, because this is what she's been doing all of her life.”	Caseworkers noted many examples of multigenerational housing instability and poverty. They felt that many of their clients were facing housing instability because they had never been taught the skills (financial and otherwise) needed to maintain a home.
Daily shelter life and the rehousing process	Subtheme: They Have to Work to Change “We're just out there trying to get work or find work and some of them don't want to work. And you just have to give them a different mindset.” “We give them too much and don't empower them.”	Caseworkers worried that mothers experiencing homelessness were not pushed to achieve, and not recognized for their agency and self-efficacy. This led to powerlessness that left women unable to consider the actions necessary to better their own lives.
	Subtheme: Rules, Rules, Rules “I have two people ]clients] who work midnights, and the shelter will not let them back in …. they have to be back at 9 p.m.” “Unemployment and child support is considered temporary income. A lot of landlords do not want to deal with that.”	Caseworkers recognized that shelter rules often did not meet the needs of women with children, and did not allow flexibility for special circumstances. They also faced difficulty in finding housing for women when restrictive rules on income further limited an already desolate housing landscape.
What women need and want	Subtheme: Moving Up is the Only Way Out “We do have our job development program, but the job development program is still more time. And time is what they don't have.” “She has no idea what success is or how to achieve it or if it's even possible for her.”	Caseworkers knew that minimum wage jobs were not the answer for long-term housing stability, but had to accept the realities of bleak employment prospects. They also knew that women needed to believe in themselves to build a brighter future.
Impact on health and well-being	Subtheme: Health in Decline “I have a situation with this client. Every time I go see her, she just busts out crying.”	Caseworkers worried about the mental and emotional health of their clients.
	Subtheme: Hope, Optimism, and Spirituality “If a person can't support themselves, we create the steps to achieve your success once we identify the barriers and address how to overcome the barriers.” “You have to ask the right questions and they come up with [solutions] by themselves.” “We assist them with resources in different areas once they move, like churches and schools, show them grocery stores.”	Caseworkers saw the importance of developing community, fostering hope, and nurturing self-efficacy within their clients.

Pathways to and the meaning of homelessness

Many women experiencing homelessness reported shame and embarrassment when asked about their current homeless situation (Subtheme: Pride as a Last Stand Against Powerlessness). They were particularly vocal about their identities as mothers, which many viewed as central to their being and the stabilizing force within their families. Many mothers expressed inner conflict as they knew they needed to be and were expected to “stay strong” for their children but felt their parental power was compromised in shelters or in situations where they needed to depend on others (i.e., friends or family). Thus, they were proud of their roles and strengths as mothers but felt that their parenting abilities were diminished because of their current circumstances. This conflict is best expressed through the words of two participant mothers. One mother stated, “I'm trying to stay strong for my [two] boys … they're so used to seeing mommy do it: mommy being the strong one.” In contrast, another mother reported, “I feel like a bad mother because I can't even provide for my children.” Being unable to provide housing and fiscal stability for their children made them feel like “bad mothers,” lowered their self-esteem, and diminished their pride, which many leaned on as a proxy for power and control. This same pride, some noted, also prevented them from seeking support from others that might have staved off homelessness in the first place. As one woman put it, “I had a pride problem … I had too much pride to call any of my friends.”

Reports of social isolation and being “all alone” were also common (Subtheme: On Our Own). The majority of homeless mothers reported few friends or reliable relatives to which they could turn. This pattern often began early in their lives and repeated into adulthood. For example, many felt “singled out” in their families and “unloved,” particularly by their mothers. Several participants disclosed their mother's abandonment and/or lack of protection or support when they were exposed to violence, sexual abuse, and other traumatic situations as children. One woman described in detail how her family was separated through divorce. Being the second to oldest in a family with nine children, she stayed with her father. “We were split up. My mom would always take the ones that's younger than me with her; she never took me. So I felt unloved by my mom.”

As adults, nearly all (11 of 13) reported involvement in abusive relationships and all defined themselves as single or divorced. One participant mother shared how her fiancé had abandoned her on the day of her community college graduation, wiping out their bank account and leaving her 9 months pregnant with a 2-year-old son and nowhere to go but the emergency shelter. “I left the house with a pack of diapers, a car seat, my car, and maybe $10 to my name. I didn't have anything.” Two participants were homeless after their male partners were incarcerated and they could no longer maintain their homes.

Family instability and associated issues such as poverty and maternal substance abuse (Subtheme: Family Legacy of Poverty and Violence) also led many women to live under precarious housing situations as children. One mother described being abandoned by both her parents. “My mother, she was a heroin addict. My, my father, I don't have a relationship with … When I was younger, I got took from my parents … been a ward of the state.” Another described her volatile relationship with a gambling-addicted mother.

My mother didn't even like me … if anyone here was to meet her, she'd tell you, she does not like me … My relationship with my mother is nothing like my siblings'. My siblings can go and get anything from her. If I ask, [it's a] whole different story. (Participant mother)

Several women noted that they were unable to turn to family for financial support due to their family's ongoing financial struggles. Doubling up with family members was common practice, and had often occurred at different points throughout the women's lives. Participant mothers also spoke of violence within their family of origin as a tipping point that initiated their housing instability. One young woman shared that her homelessness began after she was physically abused by her previously estranged father when he returned to the family home. Another revealed that she had recently been detained by the police after punching her daughter in the face while out in public. Violence was commonplace, and happened across generations.

Caseworkers supported mothers' family legacy reports. Many had served multiple generations of families struggling with housing stability and fractured relationships. Although they often encouraged women to seek assistance from family members while waiting for permanent housing to be established, they were aware that their clients' families often faced similar problems. As one caseworker shared, “They'll say, ‘Well, my mother was in the shelter, my sister doesn't have any place to go, and my grandmother already has 12 people living at her house’ … so it's a cycle.” This reality was a particular source of frustration for caseworkers who saw few options available to help families break free of these long-standing patterns.

Daily shelter life and the rehousing process

When asked about their experiences in the shelter and the rehousing process, mothers reported feeling stereotyped or labeled as “just another statistic,” mislabeled as “lazy” or “incompetent,” and feeling like society “expects us to fail” (Subtheme: I Am More Than Just “Homeless”). One young mother shared her experiences when trying to access public assistance. She described working three jobs to make ends meet for her family, until her father, absent for her entire childhood, reentered her life and reconciled with her mother. When an argument escalated to an assault by her father, her mother sided against her and kicked her out of the house. When she ultimately sought support for public assistance, she was dismayed by the treatment she received:

They stereotype … It's “Oh, this Black girl, she just wants to sit here and be on FIA,” [FIA is the Michigan Family Independence Agency, which manages welfare and welfare reform]. Like I said, I been on it for five months; I hate it. There's nothing I can do with $400 a month. I've been working since I was 14. … There are limitations and circumstances that hold people back. It's not just because you want to be trifling and lazy. (Participant mother)

Caseworkers, however, perceived many homeless mothers as “resistant” to lifestyle changes needed to reestablish housing (i.e., to take any job to bring in an income) and in need of “tough love” (Subtheme: They Have to Work to Change). Several caseworkers identified difficulty in relating to homeless mothers' life circumstances and choices. Rather than empathizing with their clients' situations, they saw the women as possessing self-defeating attitudes. One caseworker noted, “Our biggest barrier is the head of household doing what she needs to do. Whether it's saving money, making doctors' appointments, staying clean … whatever they are, that is our biggest barrier.” Caseworkers noted that most of their clients were unable to recognize their own potentials and lacked commitment to make changes to improve their own lives. Although they recognized that mothers had few role models for doing so, they maintained that development of a stronger work ethic was key to women's successful transition to long-term housing stability.

If work was not foremost on their minds, it may have been because mothers had greater concerns about their children. Mothers and caseworkers universally agreed that existing family shelters did not support family cohesion or function (Subtheme: Rules, Rules, Rules). Mothers reported hardened and unsympathetic shelter staff and rigid rules that undermined their parenting abilities or diverted resources that compromised their family's comfort. Many felt belittled and discriminated against because of their new found “homeless” identities. One woman, homeless for the first time, reported her upset upon entering the shelter and the way her tearful admission interview was handled by the shelter intake worker: “One lady came in, and she was like, ‘What are you crying for? It's just a shelter. What, is this your first time here or something?’ And I'm like, you act like this is something normal.”

Another woman was separated from her teenage son because of shelter policies that restricted the age of boys living with their families to age 12. At 19, he was living in a shelter for single men and isolated from the rest of the family. With little direct contact over his daily life, his mother worried about his well-being. Caseworkers too bemoaned this policy and the real effect it had on fracturing already vulnerable families. In the words of one caseworker, “So already, at 9, 12, 14, 15, we're teaching our boys to be separate from the family … we're acting against the very dynamic that we are supposed to promote.”

Housing after sheltered living was also generally viewed as substandard. Mothers worried about the neighborhoods to which they were relocated and its safety for their children. Caseworkers highlighted a critical lack of safe, affordable housing in the city that challenged their abilities to assure low cost but high quality and safe housing. A major concern, voiced by both homeless mothers and caseworkers, was that families were relocated to empty apartments and that acquiring affordable appliances, bedding, chairs, and other basic furniture was problematic. In fact, asked what presented the greatest problem during rehousing, women and caseworkers consistently rated “furniture” at the top. Previous low-cost-used furniture suppliers in the city were plagued by bedbug epidemics and those in operation suffered from low inventories. Still, establishing a sense of “home” and “normalcy” was utmost in the minds of women in the immediate future; sustaining it through employment and education was a next step.

What women and caseworkers need and want

Focus group discussions related to how best to overcome homelessness centered largely on issues of work and education. Mothers generally saw education as the path to a better future for the entire family because it enhanced one's ability for gainful employment (Subtheme: Moving Up Is the Only Way Out). Although some women were unable to achieve their intended educational goals, most (9) of the 13 mother participants had completed high school or a GED and were working toward better education or work opportunities even though they reported numerous obstacles to doing so (i.e., money for tuition, transportation, child care). All wanted their children to achieve greater educational success than they themselves have achieved. One participant, who had recently enrolled in a nurse assistant program, reported that doing so made her, “feel good about myself,” because she wanted “more for myself and more for my children.”

But here again, caseworkers' perceptions often contrasted with those of mothers. Caseworkers described some women as “too selective” in job choices and unable to successfully meet the time demands necessary for job training and career development. One caseworker reported that many of the women she tried to assist with job placement resisted offers of minimum wage jobs.

Some of them don't want to work in a specific area, job. And they don't have the training to do another job. They don't want to work at McDonalds or Burger King, but they're not trained to be a CNA [certified nursing assistant] or home health aide. (Participant caseworker)

Caseworkers worried that women failed to see the urgent need to gain employment to stabilize their present situation, while participant mothers voiced a need to improve their employment possibilities to stabilize their future. Thus, while caseworkers thought any job was better than no job, women expressed wanting something beyond entry level and low paying positions.

Impact on health and well-being

The negative impact of homelessness on participants' mental and physical health was noted across all three focus groups with homeless mothers (Subtheme: Health in Decline), with several women reporting a history of depressive symptoms and even suicidality (although all participants denied suicidal ideation at the time of the focus group). While some reported transitional despair (“Last week I was going to jump off a bridge, but I got through it and I'm ok today”), others were more globally affected by their situations. They reported physical and mental exhaustion, an inability to eat or sleep, and awareness that their circumstances were negatively affecting their health.

As the sample of homeless mothers averaged 28 years of age, they reported few physical health issues and limited problems with health access for primary or prenatal care. Still, mothers raised concern about the potential long-term implications on the health of their children as well as the short-term effects of inadequate nutrition while in the shelter and the effects of relocation on schooling. One woman reported that her 1-year-old son had been placed in foster care when she and another child went into the shelter because his congenital heart condition could not be safely managed in a shelter environment. Another mother worried about the adequacy of the shelter feeding schedule for her 3-year-old son. Meals were served only twice daily; breakfast in the morning and dinner at 4:00 p.m., with an 8:00 p.m. snack of peanut butter crackers. Shelter policy forbade private stocks of food or beverage, so there were no other in-house meal or feeding options.¹ The participant's son, a typically picky eater, often refused the meals and then cried out in hunger during the night.

He cries all night because he don't want to be there. And, he's hungry at 9 o'clock and now I can't give him no help … you can't bring nothing in there to eat. So it hurts when you can't feed your child. (Participant mother)

Mothers were hopeful that their children would be “alright” following homelessness and discussed their faith as a source of strength in pulling themselves and their families through a difficult time (Subtheme: Hope, Optimism, and Spirituality). Although there was limited discussion of “God” or religiosity, women generally agreed that prayer and community were important aspects in looking beyond their present situations. There was a tone of certainty, punctuated by hopefulness as is apparent in the words of one mother, “Hopefully, my son, it [being homeless] doesn't affect him at all. Hopefully, he was too young to remember.”

Discussion

Many powerful themes and subthemes were identified in our analysis, providing an important beginning step in understanding families' pathways into and out of homelessness. Our findings also reveal the complex interactions between individuals, families of origin, and social and institutional arrangements and how they manifest in identity and social standing.

A powerful subtheme that emerged across all groups of women was a persistent lack of social support. With the exception of one participant, all shared stories of family dysfunction, broken relationships, manipulation, and mistrust consistent with the literature (Finfgeld-Connett, 2010). Many described generations of homelessness and poverty and difficult mother–daughter relationships. Only one participant explicitly discussed her father and few described the fathers of their own children. When they did, they noted them to be peripherally involved at best with most providing no financial support. Addiction, violence, poverty, lack of education, and “feeling different” were common threads that clearly contributed to poor outcomes for the participants and their children.

Women in our study also expressed reliance on various institutions in which they were prey to rules and regulations that did not consider the unique needs of families. Participants shared experiences of filthy, cold, restrictive shelters that lacked in resources and support needed to meet the needs of young children. Participant mothers viewed the lack of child care, laundry, and transportation as hindering their ability to attend job fairs or employment interviews.

Participant mothers were acutely aware that homelessness could or had affected the well-being of their children. Still, they hoped that their own efforts at self-improvement would overshadow any negative impact. They were hopeful that participation in the focus groups would inform future efforts to prevent homelessness in women like themselves as well as improve housing accessibility and affordability for at-risk families. They looked forward to rising above their current situations and hoped for a better life for themselves and their children. They viewed peer-led or peer-matched groups with women who had successfully navigated the system before them as potentially powerful tools to move them forward.

Focusing the caseworkers working most closely with homeless families provided additional information that has been previously unexplored. While many of the perceptions of the process of rehousing converged thematically between mothers and their caseworkers, there were also conflicting views that may affect how services are provided and whether they meet the real needs of those they are intended to serve. Caseworkers questioned whether their interventions supported or hindered agency and self-efficacy within the population they served, concepts that are critical to the process of successfully overcoming homelessness (Brush, Kirk, Gültekin, & Baiardi, 2011). The caseworkers providing services to homeless families clearly cared about the work they performed but experienced difficulty with limited available resources. There was also some disconnect in their views of women's capacities to learn, work, and move beyond the family patterns that defined them.

Despite these rich preliminary data, more research is needed to better understand support systems needed for families facing homelessness. We recognize that our findings were limited due to the small size and heterogeneity of the sample as well as that the participants were drawn from a single support agency. Our study sample also consisted of participants in a Life Skills program who might have been more motivated to seek support services or were higher functioning compared with other homeless women. Thus, while these findings cannot be generalized to larger populations, they form a basis for further inquiry. More diverse samples of homeless families may yield different issues or complement those found in our study. Studies evaluating rehousing support and long-term housing stability for homeless families are also needed, as there is little long-term research on preventing recurrence of homelessness in families. More research is also needed to determine the long-term effects of homelessness on children and how to identify at-risk youth who may cycle into poverty and homelessness as adults. Interventions aimed to lower the risk of homelessness must be carefully crafted to meet the unique needs of local communities and must consider input from both service providers and recipients of services.

Services currently in place for homeless families must not only address practical aspects of rehousing, strengthening personal management skills, and procuring sustainable employment for those who are homeless but also be trauma-informed, help build self-esteem, repair and rebuild family relationships, and develop healthy communities for future generations. Power differentials within shelters and service agencies between providers and clients must be acknowledged and minimized to create equitable opportunities to overcome housing instability. It is also critical that homeless service providers, from shelter staff to caseworkers, recognize the experience of homelessness as a traumatic one with potential for devastating effects on the health and well-being of women and children and that most mothers experiencing homelessness want to be recognized for their personal agency rather than labeled for their past failures.

The availability of safe, stable housing is critically connected to family health outcomes. The increased rates of illness and hospitalization, as well as diminished mental health, educational, and social well-being outcomes associated with homelessness should serve as a call to action for nurses to recognize housing as directly related to health care. Pathways into and out of homelessness are stressful and isolating. Nurses in all aspects of health care—from primary to acute to chronic care—encounter patients and families facing housing instability and are thus poised to assess basic housing safety and stability. Our professional commitment to praxis further prompts us to promote research and policy that protects the health and well-being of families affected by housing instability and homelessness.

Listening to and sharing these “voices from the street” is a beginning step in designing interventions and services that meet the real needs of homeless families. Our findings also support the call for a new theoretical dialogue between gender, race, class, and homelessness, such that local, state, and national policies address the reality of current trends; that is, that homeless families are predominately comprised of poor minority women with children (Grant et al., 2013; Paradis, 2000). New policies for homeless families must diverge from the social patterning of single men's experience and be informed by the experiences of homeless women and children, so that they address how and when to make services accessible and to ensure that the overall environment is conducive to maintaining them (Grant et al., 2013). Thus, we argue for FPAR, engaging both families experiencing homelessness and their service providers, as both a conceptual and methodological framework for future research with homeless families. Only then can we stem this growing tide of homeless families in cities across the nation both now and in the future and reduce health disparities that diminish the health and well-being of thousands of families.

Biographies

Laura Gültekin, PhD, FNP-BC, is a family nurse practitioner and a research scientist at the School of Nursing, University of Michigan. She has been involved in community-based participatory research focusing on the needs and experiences of homeless families in Detroit for the past 5 years. Prior to that, she worked as a nurse in pediatric intensive care and pediatric home care. Her recent publications include “Family Homelessness, Housing Insecurity, and Health: Understanding and Acting on What We Know” in National Council on Family Relations (NCFR) Report (2012, with B. L. Brush) and “Overcoming: A Concept Analysis” in Nursing Forum (2011, with B. L. Brush, K. Kirk, & J. M. Baiardi).

Barbara L. Brush, PhD, ANP-BC, FAAN, is the Carol J. & F. Edward Lake Clinical Professor of Nursing in Population Health at the School of Nursing, University of Michigan. She has extensive experience with community-engaged research involving the development of community–academic partnerships, most recently with local agencies providing services to families experiencing housing instability and home-lessness in the greater Detroit metropolitan area. Her recent publications include “Family Homelessness, Housing Insecurity, and Health: Understanding and Acting on What We Know” in NCFR Report (2012, with L. Gültekin), “Moving Toward Synergy: Lessons Learned in Developing and Sustaining Community/Academic Partnerships” in Progress in Community Health Partnerships: Research, Education, and Action (2011, with J. M. Baiardi & S. Lapides), and “Overcoming: A Concept Analysis” in Nursing Forum (2011 with K. Kirk, L. Gültekin, & J. M. Baiardi).

Janet M. Baiardi, PhD, FNP-BC, is a professor of nursing at the University of Detroit Mercy. She has partnered with the research team to develop community–academic partnerships between local universities and community agencies providing services to families experiencing housing instability and homelessness in the greater Detroit metropolitan area. Recent publications include “Overcoming: A Concept Analysis” in Nursing Forum (2011 with B. L. Brush, K. Kirk, & L. Gültekin), “Moving Toward Synergy: Lessons Learned in Developing and Sustaining Community/Academic Partnerships” in Progress in Community Health Partnerships: Research, Education, and Action (2011, with B. L. Brush & S. Lapides), and “Common Issues, Different Approaches: Strategies for Using CBPR With Vulnerable Populations” in Nursing Inquiry (2010, with B. L. Brush & S. Lapides).

Keri Kirk, MS, is a graduate student in clinical psychology at Howard University in Washington, D.C. She has worked as a clinical research project manager at the University of Michigan School of Nursing, participating in building community–academic partnerships, conducting focus groups with homeless mothers in Detroit, and working to engage women of racial and ethnic minorities in community-based research. She is now developing community-based health psychology research to increase physical activity adherence among urban-dwelling adolescents. Her recent publications include “Overcoming: A Concept Analysis” in Nursing Forum (2011 with B. L. Brush, L. Gültekin, & J. M. Baiardi).

Kelley VanMaldeghem, BS, RN, is a recent graduate of the School of Nursing, University of Michigan, and is currently a graduate student at Emory University studying global public health. She has participated in research analysis and dissemination related to family homelessness and housing instability, and is currently focused on maximizing the health and well-being of vulnerable populations internationally.