For the homelessness prevention practice, we aimed to discover the sources of homelessness; defined as the factual pathway that leads to an (official) forced or voluntary displacement from ones home or facility. Therefore, we explored the pathways people took into homelessness and compared the characteristics, problems and service use per pathway taken. In our approach, we focus on the detection of underlying problems, that services should respond to, rather than exploring the reasons why the underlying problems exist. Knowledge of the characteristics and problems of people who follow different pathways into homelessness should contribute to timely detection of vulnerable people who might step into homelessness.
We identified 120 recently homeless people in Amsterdam to explore their pathways into homelessness, problems and service use, before and after becoming homeless. The main pathways into homelessness reported were evictions from ones home (38%), relationship problems that lead to leaving a home or being sent away by household members (35%), leaving prison (6%) and various other reasons (22%). These pathways into homelessness are consistent with those known in the literature [4–10, 15, 16]. However, the figures in this sample can not be compared with those found by others due to varying settings, definitions and methodology. For comparison, the factual pathways into homelessness, the key causes, underlying contextual factors and triggers need to be disentangled [4, 5, 9].
Not surprisingly, the characteristics of the recently homeless people in our study show more similarities than differences with those found among the majority of households at risk of eviction (due to rent arrears and nuisance), rough sleepers, shelter users and homeless adults visiting outreach medical care facilities in Amsterdam [6, 11, 17–19]. The profile of the majority of the homeless in Amsterdam is comparable with those in cities abroad [10, 20–22].
In all pathway groups almost two thirds reported a combination of social and medical problems. Those who were homeless after eviction did belong to a major migrant group more often, were slightly older, were more often living single, had more financial problems and more alcohol problems, than the other groups. Those who were homeless due to relationship problems were slightly younger, had more domestic conflicts and tended to report more drug (cocaine use) problems, than the others groups.
Gambling, as a known source of debts and financial difficulties, was reported by 24% among those evicted and 13% among those who had lived with others. In Melbourne, Australia, before homelessness, among 93 older homeless men, gambling was reported by 46% among those who were living alone and 28% among those living with others [4, 16]. In Amsterdam, gambling was hardly mentioned by employees of housing associations handling rent arrears and by employees in nuisance control care networks handling nuisance, when asked to report problems among households at risk of eviction . Service providers should be alert for gambling problems among mostly single men at the brink of homelessness due to financial difficulties.
Furthermore, regarding medical support before homelessness, for all pathways, the general practitioner, as a gatekeeper for addiction, mental and physical health problems, played a marginal role in providing care, which was also found among households at risk of eviction in Amsterdam . For those at risk of homelessness with silent and/or non-self perceived health needs, 39 out of 86 who reported a medical problem, a sharp decrease of home visits carried out by general practitioners might be unfavourable [8, 23]. Specifically, if no alternative social medical care at home is provided, and lessons how to integrate care for those in highest need have to be learned in the streets . Therefore, rent arrears and nuisance can serve as signals to explore underlying problems by outreach support [6, 7].
After becoming homeless, most problems identified before homelessness were also reported to exist afterwards, except for substance use and gambling, which had decreased significantly. The fact that many recently homeless had sought social care and were willing and capable of placing their addiction more in the background, is an indication of the motivation within this group to turn their situation around. The addiction decrease could be an indication that in the first homeless period the scarce financial means are being used mainly for subsistence. This moment should be an entry point for service providers to actively guide the recently homeless towards rehabilitation. Although validated diagnostic mental health tools were not used, by often reporting mental health problems many respondents did not seem satisfied with their mental health condition and/or situation. For recently homeless people staying in the same shelters and day centres together with the long-term homeless might have a numbing effect on a positive attitude towards rehabilitation [26, 27].
The strength of this study is that we had good access to key informants and the locations where recently homeless people tend to gather. We obtained a high response rate among the recently homeless people who were approached for an interview. This study involved two principal limitations. First, our data regarding medical problems were based on self-reported information. Specifically for psychiatric problems diagnostic or clinical instruments were not used, therefore data can not be compared with other studies. Furthermore, some respondents mentioned having trouble remembering the number of services they had used over time. Second, a random sample of the recently homeless could not be drawn since the duration of homelessness is not registered at day centres and shelters, and not for those not using these facilities. Following our experience with homeless care, we believe that the data are valid and can be generalised for the total recently homeless population in Amsterdam.
Homelessness prevention strategies
Scholars in Australia, England and the US have described multiple obstacles for homelessness prevention strategies and the evaluation of prevention programs [3–5]. Regarding causes of homelessness, most cases involved personal problems and incapacities, policy gaps and service delivery defects. Crane et al. found that vulnerable people were being excluded because health and welfare services did not have the responsibility or resources to search for people with unmet treatment or support needs [4, 5]. Furthermore, evaluation of homelessness prevention programs are hampered e.g. by fragmented and provision driven data registration .
In Amsterdam, several strategies to prevent and reduce homelessness have been implemented, since our study was executed in 2004. The Amsterdam Welfare and Care department promotes an integrated approach by housing, social and medical services to take responsibility in actively assisting vulnerable citizens with unmet support needs. This strategy is in concordance with the wishes and dreams of the majority of the recently homeless in our study. Since 2007 service providers are being trained for this approach to learn how to explore problems and pathways towards shared assistance. Furthermore, with substantial national and local financial support, services are able to expand their activities. More guided living options in the social housing sector (75% of the total housing stock in Amsterdam) are being offered, more integrated one stop social medical service units will be build, and the number of beds in shelters, addiction and mental health care facilities are being increased .
Regarding the three pathways into homelessness of the recently homeless people in our study, we reflect and comment on the existing strategies in Amsterdam.
1) Eviction from ones home was the main source of homelessness. Per year more than 1,400 households are being evicted in Amsterdam . To decrease the number of evictions, the existing outreach networks respond to persistent rent arrears and nuisance, as signals to be picked up by housing associations and landlords, to be shared with social services. In response, during a house visit underlying problems, such as gambling and medical problems, and unmet support needs are being explored [6, 7, 28]. Based on our previous studies on evictions and current findings, we suggest that assistance should explicitly be applied to low income single men, with underlying financial problems, addiction and/or mental and/or physical health problems. As among these high risk men a mix of social and medical problems is to be expected, social and medical workers should be trained to systematically approach and guide the underlying problems to keep these men at home [6, 7, 25].
2) Relationship problems that lead to leaving a house was the second source of homelessness. Prevention strategies might be difficult to design. However, underlying problems and service use are also prevalent among this high-risk group. Alertness of social and medical services could be the way to identify this high risk group for preventive actions. Services should know their clients and should (be trained to) be sensitive for signals of vulnerability. These signals should be detected with a few additional questions related to how a person is coping with daily living, household management, income and debts (alcohol, cocaine and gambling), and should actively be shared among disciplines [4, 5, 21]. In health care settings medical professionals, and the general practitioner in particular, do have the opportunity and responsibility to diagnose social disease (such as poverty and imminent homelessness), that intrinsically interacts with medical disease, and actively ask for social assistance in response [5, 29].
3) Leaving prison was the third source of homelessness, among various other reasons. In the Netherlands, when people stay in prison for a certain period of time welfare benefits are being terminated. Data on the number of people that did pay rent off welfare benefits before they went to prison are not being collected. Nor data on the number of people that lost their house during time in prison because nobody assisted in paying the rent at home, and, as a consequence, became homeless after leaving prison. However, in Amsterdam, vulnerable inmates and multiple offenders are actively being followed up and assisted to anticipate housing, income and care after prison .
Furthermore, to prevent long term homelessness, new arrivals in the homeless circuit, at places the homeless tend to gather, are actively being identified and fast tracked along social and medical services, as the motivation to turn their situation around is expected to be a crucial entry point towards rehabilitation. For this strategy, social and shelter services aim to converge their intake procedures in a central shelter unit, where (recently) homeless people can undergo a social medical assessment and be guided towards problem oriented housing and care. Among the services for the poor and underserved, the GGD Municipal Public Health Service is operating as the central field director to monitor strategies to further prevent and reduce homelessness in Amsterdam . New evaluations should demonstrate whether the present situation has improved compared to our findings in 2004.