c_s welcome

Background

Rural and urban alike, the health-related and human service needs of the homeless are numerous. Individually, and as a group, the health status of the homeless is influenced by genetic, demographic, behavioral, and environmental factors. Some are healthier than others, and there are wide variations in the health status of the homeless population from community-to-community. For example, strep throat may be more prevalent in children living in the rocky mountain area, scabies in other regions, poorly managed hypertension in elderly people of color in southern states, and uncontrolled diabetes with its associated complication in homeless Native Americans in the midwest. In general, compared to the general population, health professionals can expect to encounter a high prevalence of infections, chronic illness, substance abuse, tuberculosis, HIV/AIDS, hepatitis and chronic mental illness among the homeless (APHA, 1997; Bolla, 2000; Clark, 1996; Jencks, 1994). Figure I highlights some of the more commonly encountered health problems in the homeless population.

Access and availability of resources

A continuum of services for homeless persons is recommended ranging from emergency shelters, extending to rehabilitation services, and ultimately, permanent housing. Once immediate shelter is provided, attention must be devoted to issues associated with
joblessness and work/life-skill deficits that keep people homeless and in chronic dependency. People who are homeless in rural areas encounter some other unusual obstacles when seeking social services and public assistance (Bushy, 2000; Gladden, 1999).

For example, inherent in traditional rural culture is an unstated admonishment that an adult should be able to deal with his or her own problems. For those unable to care for themselves and their family, there is the fear of being perceived as being lazy, weak and immoral. A cultural-based expectation of self sufficiency deters an unknown number of needy families from reaching out for help even when services are available in the community. Sometimes, children suffer the consequences for parents reluctance to seek available services that are publicly funded even when these are available in their home community (Lamel, 1998; Wagner, Menke, Cicone, 1994).

Threats to anonymity and confidentiality, associated with personally knowing the employees in an agency is another deterrent that may not exist in a more populated setting. A few rural people distrust anyone who works for the government. In brief, a distrust of ‘outsiders’ coupled with a work ethic contributes to the stigma associated with accepting charity or public assistance among some rural people who are on the verge of homelessness (Loy, 1997; Mooneyhan, 1997; Wagenfeld, 2000).

In rural areas health care and social service delivery systems often are organized in a somewhat unusual manner. For example, a social service or mental health agency may have its ‘main office’ located in a nearby city. Providers from these facilities may provide outreach services - on certain days, at specific times, in a particular community. Or, a social service agency in the community houses a number of publicly funded services, and the providers who work there wear several hats. Hence, a homeless person may not know where an agency is located, or how to access services that could be of benefit.

There are other more subtle deterrents for services not being available in rural communities. For example, local elected officials may be unaware of state and federal monies that could be available to assist rural communities. Sometimes, writing a competitive grant or completing required paper work may be the only obstacle in developing or enhancing services for the vulnerable. Additionally, formal leaders in small communities tend to be of higher socioeconomic status; hence, may be unaware of the needs of poor people among them.

The client-base for health and human services tends to be low in rural areas compared to urban. Often renewed federal and state funding, which may be an agency’s principle source of revenue, is tied to ‘numbers’ of people who use its services. Turf-guarding by staff often is an outcome of capitate funding models. The loss of even a few clients can result in decreased funding to a small agency; which can eventually lead to the elimination of staff positions. In turn, this could mean that a local resident may lose his or her job. Such an outcome is a serious concern for residents of a rural community that has few employment opportunities! Consequently, associated with economic and employment factors, there is a duplication of some social services accompanied by deficits in others.

Still, in spite of seemingly sparse resources, even the smallest communities have resources to care for the needy among them. Unfortunately, health care and social service providers who live there often are unaware of many of them. Figure II includes a range of formal and informal resources that are available to health and social service providers even in very small communities to assist the homeless (Bushy, 2000).

Professional roles
In addition to formal and informal resources, health professionals have a range of roles available to intervene with clients. (Figure III.) For example, the roles of advocate, activist, educator, counselor, partner, collaborator, expert clinician and case manager. Examples of associated actions and interventions for some of these roles are highlighted in the remaining paragraphs (Bolla, 2000; Bushy, 2000; Clark, 1996; Gladden, 1991).

Unlike urban homeless, the rural homeless are invisible and not featured on the national news reports. In fact, many rural residents are not aware of the homeless in their town. As activist and advocates, health professionals can promote public awareness among rural residents of the prevalence, issues and needs surrounding homelessness in the area. In the role of educator and counselor, elected officials and informal leaders can be informed about the needs of the homeless, such as housing and other types of human services. A presentation to the commissioners or an editorial in the local newspaper is one way to inform various audiences of federal, state and philanthropic groups that provide support for programs that target vulnerable; perhaps, preventing homelessness among some.

Oftentimes, administrators in rural agencies are not aware of these options either, because they are over-extended with heavy case loads. In other instances an agency may be a one- or two-person operation. These individuals have multiple responsibilities along with the expectation to provide outreach services. Consequently, they may not be able to effectively counsel and refer the homeless who come to their agency. In the clinical expert and consultant role, one could assist community leaders and agency’ staff to write competitive grant proposals to seek outside funds.

As mentioned earlier, even the smallest community has some resources to care for the needy among them. Care givers especially if they are recruited from outside the local community, often are not aware of them.

Technology holds potential for addressing the information gap. For example, in the roles of partner or collaborator, one could work with a civic organization or graduate student to compile a database of local, regional, state and federal agencies along with local informal resources. Placed on the world wide web (internet), the data base would be an invaluable tool for local as well as regional health and social service professionals IF the information was kept current. For the information to be used, the availability and how to access the data base must be widely disseminated among health care providers of all types.

Community-focused partnerships hold promise to develop initiatives to prevent and respond to the rural homeless. With the trend to ‘right-size’ the federal government, greater responsibility is placed on state and local governments. Health and social service professionals along with other community members currently are developing innovative programs that fit those in need within their region; for example, partners responding to families who are in financial distress and facing a farm or business foreclosure. In this model, the faith community could have a role in earlier recognition of congregation members who are facing financial problems and at-risk for becoming homeless. Once identified, these individuals could be referred to a financial advisor who provides counsel on income management and debt restructuring. Earlier recognition and intervention might help some farmers and small business owners to stave off bankruptcy, eviction, breakup of the family unit and eventual homelessness. Needless-to-say, many questions remain unanswered regarding the prevention and resolution of rural homelessness but partnership models hold some promise (Bushy, 2000; Wagenfeld, 2000).

The evaluator and researcher roles also are important to deal more effectively with rural homelessness. Specifically, studies are needed that examine the interaction effects of rural economic infrastructures, the housing situation and other family-related factors on dislocation and homelessness. Data are need on the short and long term outcomes of welfare reform for the homeless family in a rural community with its fragile economic infrastructures.

Evaluation and outcome studies are needed of programs that were designed for the rural homeless such as the example in the previous paragraph. What worked? What did not? Why? What is the cost of delivering a particular service to a rural client? For a family? Does an existing urban-based, or suburban-based, or another rural-based program for the homeless fit the needs of another small community with a different population mix? If so, are modifications needed? What incentives motivate the private sector to participate infederal, state and locally-sponsored initiatives that target the rural homeless? Finally, how well are current efforts addressing homelessness in a given community? To be useful, the findings must be disseminated to policy developers and program planners. In turn, health professionals, in the advocate, activist and educator roles can help to implement the findings to fit the needs of targeted rural groups.

Other issues
There are many other issues surrounding homelessness in general, and the rural phenomenon in particular (APHA, 1997; NRHA, 1996). Most center on risks that threaten the public, personal safety of the homeless, and equitably dispersing scarce resources. Safety issues include how and where to house persons who are chronic mentally ill and those with highly infectious disease such as hepatitis, HIV/AIDS or tuberculosis. In rural areas, the availability of housing, much less affordable housing tends to be limited.

Child safety and neglect is another major issue associated with homelessness. Who determines when children should be taken from parents and placed in foster care? There also are complex issues surrounding domestic violence and abuse, and motivating adults to leave these often life-threatening situations. In rural areas, this issue becomes more complex
associated with tight knit informal social structures coupled with threats to confidentiality and the scarcity if adequately prepared health professionals in mental health and social service disciplines.

Profound issues exist regarding the allocation of scarce health care resources and biotechnology. This concern is particularly relevant in rural areas where there tend to be fewer of both coupled with a small tax base to support community health and social service infrastructures. What resources are essential? Who should provide these services –the federal, state or local governments, the private sector or volunteers? How can the provision of services be justified in a small community when it can be offered at a much lower cost in a metro area (Wagenfeld, 2000)? Are partnership models a better option? If so, what are the characteristics of successful rural models?

In conclusion, there is no quick or easy solution to the prevailing
problems surrounding homelessness in our nation. This article discussed their health-related issues and highlighted resources that can be found in many small communities to deal with the needy among them. Data are needed to determine if the rural
population is similar or different from the urban homeless. Perhaps the greatest need is to identify and locate the rural homeless, who often remain invisible within their community and to health professionals who work there.

REFERENCES

American Public Health Association. (APHA). (1997). Featuring homelessness. American Journal of Public Health, 87(2), entire issue.

Bolla, C. (2000). Poverty and homelessness. In M. Stanhope & J. Lancaster’s (Eds.), Community Health Nursing, Promoting Health of Aggregates, Families and Individuals. St. Louis, MO: Mosby. (pp. 666-683).

Bushy, A. (2000). America’s lost population: The rural homeless. Orientation to nursing in the rural community. Thousand Oaks, CA: Sage Pub.
Clark, M. (1996). Care of homeless clients. Nursing in the community. Stanford, CT: Appleton & Lang. Chapter 22, 55-573.

Gladden, J. (1991). Homelessness. A rural perspective. In A. Bushy (ed.), Rural Nursing VOL I. Newberry Park, CA: Sage Publications, pp. 375-393.

Jencks, C. (1994). The homeless. Cambridge, MA: Harvard University Press.

Lemal, C. (1998). Access to prenatal care for immigrant women in Georgia: A study of the effect of welfare reform on eligibility for prenatal care services. (A report to the State Office of Rural Health and Primary Care & The Georgia Mutual Assistance Association Consortium.). Augusta, GA: National Council for State Legislatures (Pub. # 9377). Phone # (303)820-2200.

Loy, M. (1997). Rural veterans-outreach and treatment. Vet Center, 18(2), 2-6.

Mooneyhan, R. (1997). Homeless veterans case study review. Vet Center, 18(1), 2-7.

National Rural Health Association. (NRHA). (1996). The rural homeless: America’s lost population. Kansas City, MO: Author.

Wagenfeld, M. (2000). Delivering mental health services to persistently and seriously


	Health and Service Needs & Resources of the Rural Homeless Angeline Bushy PhD, RN, CS* Professor, Bert Fish Endowed Chair University of Central Florida School of Nursing @ Daytona Beach Campus 1200 International Speedway Blvd. Daytona Beach, Florida 32114 Background Rural and urban alike, the health-related and human service needs of the homeless are numerous. Individually, and as a group, the health status of the homeless is influenced by genetic, demographic, behavioral, and environmental factors. Some are healthier than others, and there are wide variations in the health status of the homeless population from community-to-community. For example, strep throat may be more prevalent in children living in the rocky mountain area, scabies in other regions, poorly managed hypertension in elderly people of color in southern states, and uncontrolled diabetes with its associated complication in homeless Native Americans in the midwest. In general, compared to the general population, health professionals can expect to encounter a high prevalence of infections, chronic illness, substance abuse, tuberculosis, HIV/AIDS, hepatitis and chronic mental illness among the homeless (APHA, 1997; Bolla, 2000; Clark, 1996; Jencks, 1994). Figure I highlights some of the more commonly encountered health problems in the homeless population. Access and availability of resources A continuum of services for homeless persons is recommended ranging from emergency shelters, extending to rehabilitation services, and ultimately, permanent housing. Once immediate shelter is provided, attention must be devoted to issues associated with joblessness and work/life-skill deficits that keep people homeless and in chronic dependency. People who are homeless in rural areas encounter some other unusual obstacles when seeking social services and public assistance (Bushy, 2000; Gladden, 1999). For example, inherent in traditional rural culture is an unstated admonishment that an adult should be able to deal with his or her own problems. For those unable to care for themselves and their family, there is the fear of being perceived as being lazy, weak and immoral. A cultural-based expectation of self sufficiency deters an unknown number of needy families from reaching out for help even when services are available in the community. Sometimes, children suffer the consequences for parents reluctance to seek available services that are publicly funded even when these are available in their home community (Lamel, 1998; Wagner, Menke, Cicone, 1994). Threats to anonymity and confidentiality, associated with personally knowing the employees in an agency is another deterrent that may not exist in a more populated setting. A few rural people distrust anyone who works for the government. In brief, a distrust of ‘outsiders’ coupled with a work ethic contributes to the stigma associated with accepting charity or public assistance among some rural people who are on the verge of homelessness (Loy, 1997; Mooneyhan, 1997; Wagenfeld, 2000). In rural areas health care and social service delivery systems often are organized in a somewhat unusual manner. For example, a social service or mental health agency may have its ‘main office’ located in a nearby city. Providers from these facilities may provide outreach services - on certain days, at specific times, in a particular community. Or, a social service agency in the community houses a number of publicly funded services, and the providers who work there wear several hats. Hence, a homeless person may not know where an agency is located, or how to access services that could be of benefit. There are other more subtle deterrents for services not being available in rural communities. For example, local elected officials may be unaware of state and federal monies that could be available to assist rural communities. Sometimes, writing a competitive grant or completing required paper work may be the only obstacle in developing or enhancing services for the vulnerable. Additionally, formal leaders in small communities tend to be of higher socioeconomic status; hence, may be unaware of the needs of poor people among them. The client-base for health and human services tends to be low in rural areas compared to urban. Often renewed federal and state funding, which may be an agency’s principle source of revenue, is tied to ‘numbers’ of people who use its services. Turf-guarding by staff often is an outcome of capitate funding models. The loss of even a few clients can result in decreased funding to a small agency; which can eventually lead to the elimination of staff positions. In turn, this could mean that a local resident may lose his or her job. Such an outcome is a serious concern for residents of a rural community that has few employment opportunities! Consequently, associated with economic and employment factors, there is a duplication of some social services accompanied by deficits in others. Still, in spite of seemingly sparse resources, even the smallest communities have resources to care for the needy among them. Unfortunately, health care and social service providers who live there often are unaware of many of them. Figure II includes a range of formal and informal resources that are available to health and social service providers even in very small communities to assist the homeless (Bushy, 2000). Professional roles In addition to formal and informal resources, health professionals have a range of roles available to intervene with clients. (Figure III.) For example, the roles of advocate, activist, educator, counselor, partner, collaborator, expert clinician and case manager. Examples of associated actions and interventions for some of these roles are highlighted in the remaining paragraphs (Bolla, 2000; Bushy, 2000; Clark, 1996; Gladden, 1991). Unlike urban homeless, the rural homeless are invisible and not featured on the national news reports. In fact, many rural residents are not aware of the homeless in their town. As activist and advocates, health professionals can promote public awareness among rural residents of the prevalence, issues and needs surrounding homelessness in the area. In the role of educator and counselor, elected officials and informal leaders can be informed about the needs of the homeless, such as housing and other types of human services. A presentation to the commissioners or an editorial in the local newspaper is one way to inform various audiences of federal, state and philanthropic groups that provide support for programs that target vulnerable; perhaps, preventing homelessness among some. Oftentimes, administrators in rural agencies are not aware of these options either, because they are over-extended with heavy case loads. In other instances an agency may be a one- or two-person operation. These individuals have multiple responsibilities along with the expectation to provide outreach services. Consequently, they may not be able to effectively counsel and refer the homeless who come to their agency. In the clinical expert and consultant role, one could assist community leaders and agency’ staff to write competitive grant proposals to seek outside funds. As mentioned earlier, even the smallest community has some resources to care for the needy among them. Care givers especially if they are recruited from outside the local community, often are not aware of them. Technology holds potential for addressing the information gap. For example, in the roles of partner or collaborator, one could work with a civic organization or graduate student to compile a database of local, regional, state and federal agencies along with local informal resources. Placed on the world wide web (internet), the data base would be an invaluable tool for local as well as regional health and social service professionals IF the information was kept current. For the information to be used, the availability and how to access the data base must be widely disseminated among health care providers of all types. Community-focused partnerships hold promise to develop initiatives to prevent and respond to the rural homeless. With the trend to ‘right-size’ the federal government, greater responsibility is placed on state and local governments. Health and social service professionals along with other community members currently are developing innovative programs that fit those in need within their region; for example, partners responding to families who are in financial distress and facing a farm or business foreclosure. In this model, the faith community could have a role in earlier recognition of congregation members who are facing financial problems and at-risk for becoming homeless. Once identified, these individuals could be referred to a financial advisor who provides counsel on income management and debt restructuring. Earlier recognition and intervention might help some farmers and small business owners to stave off bankruptcy, eviction, breakup of the family unit and eventual homelessness. Needless-to-say, many questions remain unanswered regarding the prevention and resolution of rural homelessness but partnership models hold some promise (Bushy, 2000; Wagenfeld, 2000). The evaluator and researcher roles also are important to deal more effectively with rural homelessness. Specifically, studies are needed that examine the interaction effects of rural economic infrastructures, the housing situation and other family-related factors on dislocation and homelessness. Data are need on the short and long term outcomes of welfare reform for the homeless family in a rural community with its fragile economic infrastructures. Evaluation and outcome studies are needed of programs that were designed for the rural homeless such as the example in the previous paragraph. What worked? What did not? Why? What is the cost of delivering a particular service to a rural client? For a family? Does an existing urban-based, or suburban-based, or another rural-based program for the homeless fit the needs of another small community with a different population mix? If so, are modifications needed? What incentives motivate the private sector to participate infederal, state and locally-sponsored initiatives that target the rural homeless? Finally, how well are current efforts addressing homelessness in a given community? To be useful, the findings must be disseminated to policy developers and program planners. In turn, health professionals, in the advocate, activist and educator roles can help to implement the findings to fit the needs of targeted rural groups. Other issues There are many other issues surrounding homelessness in general, and the rural phenomenon in particular (APHA, 1997; NRHA, 1996). Most center on risks that threaten the public, personal safety of the homeless, and equitably dispersing scarce resources. Safety issues include how and where to house persons who are chronic mentally ill and those with highly infectious disease such as hepatitis, HIV/AIDS or tuberculosis. In rural areas, the availability of housing, much less affordable housing tends to be limited. Child safety and neglect is another major issue associated with homelessness. Who determines when children should be taken from parents and placed in foster care? There also are complex issues surrounding domestic violence and abuse, and motivating adults to leave these often life-threatening situations. In rural areas, this issue becomes more complex associated with tight knit informal social structures coupled with threats to confidentiality and the scarcity if adequately prepared health professionals in mental health and social service disciplines. Profound issues exist regarding the allocation of scarce health care resources and biotechnology. This concern is particularly relevant in rural areas where there tend to be fewer of both coupled with a small tax base to support community health and social service infrastructures. What resources are essential? Who should provide these services –the federal, state or local governments, the private sector or volunteers? How can the provision of services be justified in a small community when it can be offered at a much lower cost in a metro area (Wagenfeld, 2000)? Are partnership models a better option? If so, what are the characteristics of successful rural models? In conclusion, there is no quick or easy solution to the prevailing problems surrounding homelessness in our nation. This article discussed their health-related issues and highlighted resources that can be found in many small communities to deal with the needy among them. Data are needed to determine if the rural population is similar or different from the urban homeless. Perhaps the greatest need is to identify and locate the rural homeless, who often remain invisible within their community and to health professionals who work there. REFERENCES American Public Health Association. (APHA). (1997). Featuring homelessness. American Journal of Public Health, 87(2), entire issue. Bolla, C. (2000). Poverty and homelessness. In M. Stanhope & J. Lancaster’s (Eds.), Community Health Nursing, Promoting Health of Aggregates, Families and Individuals. St. Louis, MO: Mosby. (pp. 666-683). Bushy, A. (2000). America’s lost population: The rural homeless. Orientation to nursing in the rural community. Thousand Oaks, CA: Sage Pub. Clark, M. (1996). Care of homeless clients. Nursing in the community. Stanford, CT: Appleton & Lang. Chapter 22, 55-573. Gladden, J. (1991). Homelessness. A rural perspective. In A. Bushy (ed.), Rural Nursing VOL I. Newberry Park, CA: Sage Publications, pp. 375-393. Jencks, C. (1994). The homeless. Cambridge, MA: Harvard University Press. Lemal, C. (1998). Access to prenatal care for immigrant women in Georgia: A study of the effect of welfare reform on eligibility for prenatal care services. (A report to the State Office of Rural Health and Primary Care & The Georgia Mutual Assistance Association Consortium.). Augusta, GA: National Council for State Legislatures (Pub. # 9377). Phone # (303)820-2200. Loy, M. (1997). Rural veterans-outreach and treatment. Vet Center, 18(2), 2-6. Mooneyhan, R. (1997). Homeless veterans case study review. Vet Center, 18(1), 2-7. National Rural Health Association. (NRHA). (1996). The rural homeless: America’s lost population. Kansas City, MO: Author. Wagenfeld, M. (2000). Delivering mental health services to persistently and seriously