Introduction
Embodied in the conventions of the United Nations, the right to housing is recognized by international law (Segal, 2020). Even though housing is viewed as a fundamental right and a necessity for achieving a society devoid of poverty, despair, and destitution, homelessness occurs around the world. Until the structural question of building adequate housing is solved, homelessness will exist. Although treating the health and mental health problems of homeless people will not solve the need for housing development and structural change, it is important to provide relief to those who are homeless around the world.
Attempts to provide relief to homeless persons in developing countries are constrained not only by the lack of a clear definition of homelessness but also by unreliable data about homeless people (Hwang, 2001). Persons with mental health and/or addiction problems are more likely to become homeless, and those who lack stable housing face mental and physical health threats (Grenier, Barken, Sussman, Rothwell, & Bourgeois-Guérin, 2016). Homeless people face poorer health conditions than the general population, as health difficulties encountered during a person’s life can be both a risk factor for and an effect of being homeless. In Ethiopia, there is limited literature addressing the health issues of homeless individuals from their own perspective. This study uses a mixed-methods design to look at the health problems of homeless people. Findings are triangulated from four data collection points: key informants, in-depth interviews, focus group discussions, and extensive observation to validate the voices, views, and living conditions of chronic homeless persons in Debre Berhan, Ethiopia.
The article begins with a brief review of the limited literature on homelessness in Ethiopia. Next, data analysis reveals three important themes—hygiene and sanitation practices, physical health problems, and mental health challenges. After reporting the results of each theme, there is a discussion of the findings with recommendations for intervention.
Homelessness in Ethiopia
Major reasons for homelessness in Ethiopia include poverty, unemployment and underemployment, war and armed conflict, natural disasters, disability, especially where disability services are poor performing, and chronic and weakening diseases (Ali, 2012). Preferable places of living are areas around hospitals, churches, colleges, and at the sides of rivers. In various ways, these locations help people who are homeless deal with food shortages, health problems, lack of security, stigma, and discrimination. Sources of income include begging, working as a house servant, and other types of day labor or secondary jobs (Ashenafi, 2006). Homeless people go through harsh experiences, such as harassment, mugging, and exposure to rape and diseases. The impact of homelessness has long-term consequences and often leads to deterioration of basic health, loss of self-confidence, dignity and self-respect, and drug and alcohol abuse.
Gebeyaw (2017) points out the intersection of multiple reasons such as unavailability of low-cost house rent, health problems, poverty, lack of social support, lack of legal protection, aging, divorce, and death of close relatives—all of which contribute to the homelessness of older people. According to Azilke (2016), lack of information, begging work and domestic duties, lack of money, the community’s negative attitudes, and insecurity are the main challenges to the utilization of hospital services by homeless mothers. An ethnographic study on homeless street females discovered that homeless street females have unique coping methods. Homeless females
…seemed to exemplify caregiving relationships in that they took care of each other when one of them was sick… . they sought out other females so they could become a part of that group… . as a way to protect themselves from the possibility of being raped… . shared food, clothing and shelter made of plastic… . and helped those homeless females just coming to the streets find a boyfriend. Having a boyfriend or husband is one way of reducing threats of physical and sexual abuse including rape (Edwards, Guy-Walls, Jacinto, & Franklin, 2015, p. 49).
Misganaw and Worku (2013) assess sexual violence among street females in Bahir-Dar town, northwest Ethiopia. Lifetime prevalence of rape was 24 percent and the prevalence of rape in 2012 was 11 percent. None of the victims were able to use condoms during the rape. Only 4 percent used emergency contraceptive methods following the rape. Out of the total of 96 victims, 19 percent experienced unwanted pregnancy and 13 percent had an abortion. Moreover, 41 percent claimed genital injury and 22 percent experienced unusual vaginal discharge. Victims reported psychological trauma (29 percent) and loss of interest in sexual activity (29 percent). Forty-two percent of those raped attributed victimization to sleeping in areas where there are many brothels.
According to Semunigus, Tessema, Eshetie, and Moges (2016), the prevalence of smear-positive among TB suspect homeless individuals was 2.6 percent. Among smear positives, the prevalence of HIV coinfection was 55 percent. Smoking cigarettes regularly for more than 5 years and HIV infection were factors associated with smear positives. Special outreach is needed to detect TB cases to limit the circulation of the disease in the community. A study of hardship on the street found that women suffer from a lack of food and are often starving. One woman with HIV infection had difficulty taking her medications because, though she had access to the pills, she frequently did not have food with which to take medicine (Nathan & Fratkin, 2018). Frankish, Hwang, and Quantz (2005) found that respiratory diseases are common and cardiac and pulmonary problems are also prevalent among homeless people. The rates of certain serious infectious diseases are significantly high including HIV and hepatitis C.
The street child population appears related to complex interactions among poverty, the death of parents and conflict in family, peer pressure, job search, and lack of alternative living conditions (Sebrato, 2016). The impact of migration, urbanization, and the significant rate of poverty were all factors which contributed to the high percentage of children who were homeless, along with factors of abuse, and escape from child marriages (Edwards et al., 2015). A major literature review of street children from 16 countries in Africa reports that physical injuries associated with living on the street are the leading reason for death. Physical injuries include lacerations and untreated cuts from street fights, burns, and accidents from moving vehicles. Other critical health issues are parasitic and infectious diseases, including worms, tuberculosis, pneumonia, and malaria (Cumber & Tsoka-Gwegweni, 2015).
Homeless pregnant teens fear the difficulties of their situations and worry about further complications such as early parenthood, and their children’s fate through impoverishment in a single-parent life. They also fear the burning of their plastic shelter by police, losing their job due to pregnancy—even getting pregnant from a very close family member—and the financial constraint of abortion. The trauma experienced during the developmental stages of their childhood challenges their decision-making process (Merga, Anteab, Sinayehu, & Bayu, 2015). Results of a survey conducted by Ayano et al. (2017) report a high level of mental, neurologic, and substance use disorders among street homeless people in Ethiopia.
Fekadu et al. (2014) assessed 217 street homeless adults which showed that 90 percent had experienced some form of mental or alcohol use disorder, with 41 percent having psychosis, 60 percent hazardous or dependent alcohol use, and 15 percent attempting suicide. Homeless people with psychosis have extensive unmet needs with 80 percent to 100 percent reporting unmet needs across 26 domains. Nearly 30 percent have physical disabilities, visual and sensory impairment, and impaired mobility. Only 10 percent of those with psychosis had ever received treatment for their illness. Most were homeless for over 2 years, and alcohol use disorder was positively associated with chronic homelessness. Consequently, although economic reasons seem to play a major role in the causation of homelessness, mental illness may be an important factor in the continuance of homelessness among homeless people with psychoses. In a study by Wakgari et al. (2021) of 423 homeless persons, more than half (53 percent) had taken a drink that contained alcohol in the yearlong study period. Out of 324 khat chewers, 190 (59 percent) had sex after chewing khat. More than one-third, 323 (38 percent) of respondents smoked cigarettes. In a qualitative study of homeless street women, the onset of substance abuse, alcohol, cigarettes, khat chewing, and glue sniffing was related to peer pressure. These addictions continued as a coping method for women to mentally escape the distressing situations they witnessed on the street (Haile, Umer, Ayano, Fejo, & Fanta, 2020). A community-based phenomenological qualitative study conducted with street women found that the likelihood of physical violence, sexual harassment, STDs, unprotected intercourse, and unintended pregnancy is high among women who live on the streets. Having an abortion increases the chance of developing health issues because most abortions are performed in dangerous and unlawful ways (Assegid, Abera, Girma, Hailu, & Tefera, 2022).
Research Methods
This research uses an exploratory qualitative design to describe homeless people’s health challenges among those residing around Holy Trinity Church in Debre Berhan, Ethiopia. Exploratory research allows for the investigation and understanding of complex issues, holistically and in-depth (Creswell, 2007). Data from the four research methods—key informant interviews, in-depth interviews, focus group discussions, and observation—are reported. In-depth interviews took one hour, and each focus group took two hours. Frequent observations in the study area were carried out at different times. Purposive sampling included homeless people with the knowledge and experience of health challenges that manifested explicitly due to homelessness. The inclusion criteria for in-depth interviews and focus groups were participants who were homeless for at least 1 year. Those selected for key informant interviews had worked with homeless persons for at least 6 months, and were self-selected on the principle that they had expert knowledge about homelessness and health conditions (Table 1).
Methods and data sources
Methods |
Participant number |
Description |
Data source |
|---|---|---|---|
In-depth interview |
11 |
In-depth interviews allowed participants to describe their experiences, how they perceive their world, and the meanings they assign to it. Researchers gathered information on the feelings, attitudes, beliefs, and experiences of homeless people. Data on the physical and mental health problems, consequences, and coping techniques used by homeless people were gathered. |
Homeless individuals with evident experience of health problem |
Key informant interview |
22 |
Key informant interviews provided evidence of health challenges for homeless individuals, hygiene and sanitation conditions, and so on from the perspective of experts dealing with homeless people and health care. |
Government Officials/experts: LSA, WCA, and Health Center |
FGD |
33 |
Twelve participants/homeless individuals who have been homeless for at least a year took part. FGDs investigate difficult problems concerning health challenges. Evidence was gathered on homeless hygiene and sanitation issues, as well as physical and mental health obstacles. |
Twelve homeless individuals with experience of health problems were categorized into two FGD groups |
Observation |
44 |
Observation was employed to document the situation on the ground and the living conditions. Observation focused on health symptoms associated with observable physical and mental issues. Hygiene and sanitation conditions in the natural setting were carefully monitored. Data were collected on the physical, mental, hygiene, and sanitation issues that homeless people face. |
Settings in which homeless people live at different times of the day. |
Data were recorded using Amharic/local language since it is the language of the study participants. The data were transcribed and translated into English, keeping the originality of the information through review by the researchers. Through member checking and interpretation, the researchers obtained approval from the study participants for the use of quotations. The transcribed data from each data source were organized and analyzed through the interpretation of meanings and crosschecking of associations between categories. Field observation notes were included as indicators of the broader socio-environmental context of the research. Coding techniques checked for patterns and frequencies across all data sources. This required keeping a lengthy data book with coded themes related to each data source. Popay, Rogers, and Williams (1998) note the use of member checks to improve the credibility of the research. The researchers worked diligently to disregard their views and accept the interpretations of respondents. Finally, themes were identified and merged when the data indicated similar ideas, relational concepts, and so on. Three major themes emerged: hygiene and sanitation conditions, physical health challenges, and mental health problems.
Hygiene and Sanitation
Homeless people experience a high prevalence of poor hygiene and sanitation conditions, which pose overall health challenges, including the ability to maintain personal and environmental hygiene. The lack of access to enough safe water and facilities for the sanitary disposal of excreta brings with it the high burden of disease. A lack of awareness of sanitary practices—hand washing, fingernail trimming, body hygiene, food consumption, and drinking water—contribute to making homeless people susceptible to health problems. Table 2 shows qualitative data collected across all four data sources. Additionally, sanitary practices before eating, after defecation/urination, and after cleaning their children are low. They do not wash their hands or trim their fingernails on a regular basis.
Personal hygiene and sanitation
Key informant |
In-depth interview |
Focus group discussion |
Observation |
|---|---|---|---|
Homelessness exposes people to poor hygiene and sanitation practices in our community. Despite the municipal administration’s efforts to provide awareness-raising training, they are unaware of proper hygiene and sanitation standards. Lack of access to water and sanitary facilities, combined with a lack of understanding, are major contributors. Because of this, homeless people are susceptible to a variety of hygiene-related ailments and infectious diseases. |
I became homeless six years ago. Since becoming homeless, I have neglected to maintain proper personal hygiene and developed a horrible habit of not washing my hands before eating, after defecation, and after urinating. As a result, I am frequently exposed to infectious diseases such as typhus, typhoid fever, eye infections, and diarrhea. |
We have had catastrophic hygiene and sanitation practices since we first became homeless. The government did not give us priority as homeless people like myself. We do not have access to water or sanitation facilities, which we freely use as homeless people without help. Above all, the major reason for our inadequate hygiene and sanitation practices is a lack of shelter where we can rest and conceal our secrets. |
For years, homeless people have been living outside without access to hygiene and sanitary amenities. They do not have the experience of changing their clothes for an extended length of time because they live outside, and as a result, kids are susceptible to a variety of infectious and waterborne diseases, as well as an increased risk of parasite infestation such as body lice, fleas, head lice, and scabies. |
Lack of hygiene is a serious health issue among the homeless, causing sickness and death. Cholera, a highly infectious excreta-related disease, continues to impact entire populations, particularly the homeless. Diarrhea spreads readily in a setting with low hygiene and inadequate sanitation facilities, and it can kill homeless people. |
My current living situation is unsafe due to its proximity to a church. I have felt unwell several times this month as a result of…leftover items I’ve consumed. This location appears to be in better shape now that it is still dry. You can’t image how cold it used to be during the rainy season; I used to suffer from respiratory health complications like asthma as a result of the cold weather… |
Homeless people live unpleasant lives because they sleep in an environment that causes various illnesses. Homeless persons also suffer from skin infections, which can progress to more serious skin problems. They are battling with body lice and nits in my hair. This is all due to a lack of safe housing and sleeping arrangements. |
Homeless people sleep in an unsafe setting. The musty smell of their sleeping quarters is terrible; because they defecate in the environment, where they spend the majority of their time both day and night. Most homeless people are unfamiliar with washing their hands before eating. The hygiene of the food they eat is not safe because they acquire it from various sources. |
The reasons for poor hand cleaning are a lack of access to water, self-neglect, and not prioritizing hand washing. Key informant interviews and observation show that living places expose the homeless to unhygienic conditions, infectious and waterborne diseases, pollution, unsafe water sources, and insufficient access to toilets and bathing facilities. Focus group discussions reveal different inter-connected causes for poor hygiene and sanitation, including a lack of awareness about the benefits of hygiene and sanitation, lack of access to water for drinking, showering and washing their clothes, hopelessness, and lack of access to sanitation services from development actors.
Key informant interviews indicate that the government and other development actors do not pay attention to multidimensional health and sanitation-related needs. The government does not build or otherwise provide public toilets and hand washing facilities for homeless people. Government housing policies also do not include a program for homeless persons to get housing. The housing deficit was explained as
Government administration in collaboration with other sector offices did not address homeless persons through building temporary shelter and providing water and sanitation facilities. Due to these homeless persons have an experience of defecating and urinating around the place they are sleeping and on the street. This in turn makes them vulnerable to other physical health challenges and infectious diseases (Key Informant 2).
In-depth interviews and focus group discussions indicate that there are various diseases which affect homeless people due to their poor hygiene and sanitation practices. Trachoma, scabies, elephantiasis, bad odor, dental caries, and health problems are the consequences of poor hygiene and sanitation practices. Accordingly, the impact of poor hygiene and sanitation practices was substantiated as follows:
I have no experience with keeping personal hygiene to protect myself from disease. I also do not have enough clothes to change and wash. Because of this, I am always plagued by eye infections caused by germs, insects, and parasites such as nit, body, and head flux (In-depth Interview 6).
Hygiene and sanitation: Discussion and intervention
Homeless people have low hygiene and sanitation such as limited access to safe drinking water and sanitary waste disposal services. This area is permeated by the smell of raw sewage, as the area acts as a defecation facility for homeless people living on congested streets. Most homeless individuals do not wash their hands before eating. They use food which is collected from different sources. Lack of awareness, lack of water access, self-neglect, and giving a very low priority for hand washing practice are reasons for poor personal hygiene.
Practitioners can develop feasible interventions to provide care and support services and thereby ensure the health and well-being of the street homeless. Interventions include providing shelter, food, and free health care. Recently, a national housing strategy and a health policy for homeless individuals was developed. As this materializes, homeless people will benefit from housing policies that also provide access to free health care. In the capital city of Addis Ababa, for example, the lack of low-cost housing is seen as the fundamental source of homelessness.
Underpinning all other drivers of homelessness is the lack of low-cost housing. Rapid urbanisation and unprecedented population growth have created enormous pressure on the housing market. Around 80 percent of the population live in sub-standard slum dwellings, the majority of which are government-owned ‘kebele’ houses built with mud and wood or straw several decades ago. Moreover, the capital’s innercity slums are being demolished to make way for the development of new housing schemes, triggering important socio-economic disruptions in the affected communities. The housing shortage is expected to worsen as the capital’s population size will nearly double to 8.9 million in 2035 (UNICEF, MOLSA and Development Pathways, 2019, p. 3).
Meanwhile, homeless people in Ethiopia who are suffering from health problems caused by poor hygiene and sanitation practices require special attention and treatment. In response to these problems, the local government has started to enlist the help of volunteers, the commercial sector, and other civic organizations to provide care and support. Substantial community-based services are required, as well as a campaign to raise awareness and influence the attitudes of the community about homeless people.
Most international and domestic non-governmental organizations (NGOs) working in Ethiopia are religious based and have active operations focused on relief, rehabilitation, and development with marginalized people at the grassroots level. For instance, Habitat for Humanity Ethiopia used to include homeless people in its vulnerable group housing programs in different parts of the country. In response to cultural and religious holidays, there are also some domestic NGOs and individuals who give food and non-food items to homeless people on an irregular basis. Some also offer clothing to homeless people. There are some rare cases in which NGOs and volunteers provide mobile health services.
Physical Health Challenges
From the in-depth interviews and focus group data, physical health problems—whether visible or not—are critical issues in homelessness. These include sight defects and blindness, partial hearing impairments, joint problems, difficulty walking, and occasional body shakes. Other reported problems include elephantiasis, hypertension, severe headaches, diabetes, heart problems, epilepsy, and asthma. Homeless individuals are vulnerable to foot trauma, dental caries, and other infectious diseases, including HIV/AIDS and sexually transmitted diseases. Skin ulcers, wounds, and infections are common among homeless people due to their poor hygiene and sanitation practices.
Data obtained from focus groups and interviews indicate that homelessness increases vulnerability to physical health problems due to unhealthy and irregular food consumption and the lack of access to health treatment (Table 3). Physical health problems are severe because of the challenges of living on the street and other places which are not conducive for human habitation. The data obtained from observation indicate that food poison often occurs as a result of leftover foods. Consequently, homeless people suffer from excessive gastric problems.
Physical health challenges
In-depth interview |
Focus group discussion |
|---|---|
A 28-year-old woman has been homeless for four years: I have spent four years as a homeless person with my two children in a difficult circumstance, particularly for them. I cannot afford the medication. I can’t access nutritious foods, which has resulted in a variety of physical health issues. I beseech the Almighty God to deliver me from such a poor life. |
Homeless persons are exposed to a variety of physical health issues, which can worsen over time because they spend the majority of their time on the streets. The majority of homeless people experience partial hearing loss and severe headaches as a result of exposure to cold and sunburn. Adult and youth homeless people are HIV positive, and they contracted the disease after becoming homeless. Some homeless people suffer from respiratory health concerns including asthma and influenza as a result of their poor lifestyle. |
A 49-year-old guy has been homeless for ten years: I live in a region that does not have access to contemporary medical care and is unclean. This problem puts me prone to a variety of ailments and infections. As you can see, I have a wound on my chest, which makes my life unpleasant. It is really painful, and I am unable to sleep comfortably as a result of the constant pain. I became afflicted with this sickness after becoming homeless. I couldn’t seek medical help. Other physical health difficulties, such as high blood pressure and stomach reflux, constantly bother me and make me want to give up on life. |
According to the focus group discussion, the majority of the people are in better health; before they became homeless, My health deteriorates over time, and I eventually get walking difficulties and joint problems. I am also living with HIV and taking medication that the government provides for free. I also have hypertension and diabetes, which are illnesses commonly associated with wealthier individuals. I am homeless and sleep on the street, dressed inadequately, which is why I have turned to begging due to my poor health. I shall struggle through life till I die. |
The data obtained from in-depth interviews indicate that homelessness is a causative factor in the deterioration of physical health. The poverty lifestyle exacerbates health problems because of the unsafe living conditions on the street. A 42-year-old man, who was homeless for one and half years, explained the causative relationship between homelessness and physical health.
The basic reason for my physical health challenges is the homeless poverty life on the street. I have multiple visible and invisible health problem such as diabetes, high blood pressure, dental caries, back pain, and joint problems which directly relate to my homeless life (Homeless Man 1).
Homelessness increases vulnerability to physical health challenges. Homeless people are not advised on ways to access health services. They sleep outside around the churches, and these congregate areas put them in a situation in which they are susceptible to increased health problems as well as exposure to infectious diseases. The lack of shelter and proper sleeping materials exacerbates physical health problems.
Physical health challenges: Discussion and intervention
Serious and chronic physical health conditions require and demand ongoing and consistent treatment. There is also a need for preventive care. For example, family planning for homeless women in Ethiopia is an unmet need (Terefe, Abebe, & Teka, 2022). The lack of adequate medical care is, in part, related to the fact that Ethiopia has long faced an extensive shortage of doctors, nurses, and other healthcare staff, particularly in rural areas where the majority of the population lives. For example, a qualitative study of the outmigration of medical doctors in Ethiopia reports that
In 2016, the physician-to-patient ratio in Ethiopia was 1:20,000, which is below the WHO recommended minimum density of 2.3 doctors per 1000 population needed to achieve the minimum levels of key health interventions (Sedeta, Abicho, & Jobre, 2022, p. 2).
Despite this limitation, local health sectors attempt to provide some assistance in delivering health services to the most vulnerable homeless people. Free medications for some chronic conditions and free checkups for diseases that require physician follow-up are packages offered by both the public and private health sectors to the most vulnerable people. Some of the homeless people’s medication costs are funded by indigenous and international NGOs. Some homeless people with HIV and other chronic conditions require a letter of support from the local administration in order to receive free medical services from public health institutions.
Some of the health challenges are addressed by NGOs, Private Limited Companies (PLCs), volunteers, and interested individuals. Individuals and some private firms have supported homeless persons by funding medication costs. Social media and some broadcast media are mostly used to promote the health needs of the most impoverished homeless individuals. As a result of this exposure, private institutions, volunteer groups, and individuals are assisting by covering medical expenditures and providing some healthcare costs.
Mental Health Problems
Homeless people are greatly affected by insomnia and sleeping disorders. Poor sleeping habits can contribute to stress, worry, and depression. In-depth interviews and focus groups report that insomnia is common, and in turn, aggravates poor mental health. The stress of experiencing homelessness may exacerbate previous mental illness and encourage anxiety, fear, depression, sleeplessness, and substance use. The study findings indicate that mental health issues are both a cause and a result of homelessness. People with mental health issues are more vulnerable to poverty, loneliness, and personality disorders, all of which can lead to homelessness as persons thus afflicted may lack the ability to sustain employment. Overthinking and extreme worries can cause people to escape from friends, family, and others and avoid dealing with problems and life challenges. Homelessness creates a situation whereby people are separated and sometimes disenfranchised from their families and communities.
Mental health problems
Insomnia (In-depth interview) |
Depression and Loneliness (In-depth interview) |
Personality Disorder (In-depth interview) |
Schizophrenia (Key informant interview) |
|---|---|---|---|
Since I became homeless, I cannot recall a night when I slept well unless I drank Areqe. Most nights, I fail to fall asleep. This situation has become a habit, and it is severely affecting my health. When I did not get enough sleep the night before, I was forced to walk down, exhausted, to collect leftover food and drink holy water. As a result, sleeping disorders have been a long-standing source of concern for my health. |
I forget the last time I slept well. Most nights, I cannot fall asleep. This condition becomes a habit and has a major impact on my health, leaving me gloomy and unable to discuss my feelings with my friends. When I fail to get enough sleep at night, I am fatigued the next morning and have trouble finding something to eat. As a result, I experience depression and loneliness, which may eventually lead to other mental health issues. |
Being homeless and asking for food and clothing is surprising for someone who has come from a different background. Sometimes I feel guilty when I see people I knew before becoming homeless, especially when I am begging and sitting on the street. I attempted to avoid their vision and to act normally. |
Homeless people are vulnerable to a variety of mental health issues. When they first become homeless, they appear to be in better condition. The disorder may occasionally worsen, leading to schizophrenia and other mental health issues. |
Homeless people are vulnerable to a variety of mental health issues. When they first become homeless, they appear to be in better condition. The disorder may occasionally worsen, leading to schizophrenia and other mental health issues. |
I have been homeless for seven years. My friends and neighbors who became homeless before me had no greeting for me now. Surprisingly, this refutation had never occurred in my life before I became homeless. |
When I meet people who know me before I became homeless, I feel humiliated because of my past living situation. I never considered asking for food to eat for just one day. However, when I became hungry or thirsty, I was compelled to do so. |
Homeless people exhibited a variety of schizophrenia symptoms, including diminished social involvement, reduced emotional expression, failure to understand reality, attempting to hear voices that others do not hear, and believing that something is wrong despite the fact that reality is not on the ground. |
This situation results in loneliness and situational depression due to strained and failing social networks with the housed family members, friends, and former acquaintances. Participants report that this kind of depression and loneliness was not a part of their previous lives. Homelessness created such complex problems that even close relatives and adult children no longer seem concerned about them. Causative factors of loneliness and depression were seen as the lack of affection from friends, children, and housed community members, their inability to cover the costs of living, and chronic physical health problems. Direct observation indicates that homeless people mainly sit around the church and the street. They are silent and seem not to share their thoughts and feelings even among themselves. They experience loneliness in the absence of love and affection from other people.
The community isolation of homeless persons contributes to personality disorders. Their psychological well-being is haunted by internalized stigmatization, which in turn weakens self-esteem, dashes hope, and creates its own type of psychological trauma. Key informant interviews revealed that homeless persons are denied access to employment due to stereotypes, trauma, and social isolation. In responding to such stigmatization, focus groups report that homeless persons do not want to create social bonds with other community members. They see this as the result of the personality disorder they have developed from being homeless.
Homeless persons with a personality disorder are known with their unpredictable behavior. From their mood and temper to their actions and reactions, nothing is constant or typical. They are more likely to indulge in impulse decisions and poorly judged choices, alongside being highly prone to oddities like always walking by a particular lane, eating food in a certain order (Focus Group A).
Key informant data indicate schizophrenic symptoms among homeless people when living outdoors and being homeless for years.
Homeless people showed different symptoms of schizophrenia such as reduced social engagement, reduced emotional expression, failure to understand reality, try to hear voices that others do not and their belief that there is something wrong though the reality is not on the ground. On the other side, we can also see that these mental health problems are the causes of homeless for some homeless persons (Key Informant 5).
Mental health problems: Discussion and intervention
Homeless people are more likely to develop mental diseases such as sleeplessness, personality disorders, depression, extreme isolation and loneliness, and schizophrenia. Mental health challenges are both cause and consequence of homelessness. Persons with mental illness are at greater risk of experiencing homelessness. They are susceptible to poverty life, loneliness, and personal disorder. They do not have the capacity to sustain employment. Their wrong perceptions may lead to withdrawal from friends and family and as a result, they are unable to cope with troubles and challenges.
These and other mental health challenges require special attention and treatment. The local government has sought the help of volunteers, companies, and other civic organizations to provide care and support for the homeless. A public awareness campaign was established in order to influence the community’s attitude toward homeless people’s mental health difficulties. Pathways in and out of homelessness in rural Ethiopia found that
The most important pathways into homelessness were reported to result from family conflict and the worsening of mental ill health, interplaying with substance use in many cases. Participants also mentioned escape and/or wanting a change in environment, financial problems, and discrimination from the community as contributing to them leaving the home. Pathways out of homelessness included contact with (mental and physical) health care as a catalyst to the mobilization of other supports, family and community intervention, and self-initiated return (Smartt et al., 2021, p.1).
According to key informants, Ethiopia has some rehabilitation clinics actively working on mental health issues. These include Agar Ethiopia, New Life Rehab Center, Gefersa Mental Health Rehabilitation Center (GMHF), and Sitota Center for Mental Health Care. These psychiatric rehabilitation centers assist homeless people in developing the emotional, social, and intellectual abilities re-quired to live, learn, and work in the community. In Ethiopia, there is only one hospital that focuses on mental health issues, although the country has been expanding mental health treatment through integration into primary health care and general medical services since 2012.
Most international and domestic NGOs rarely deal with mental health issues. According to this study, the organizations working with marginalized homeless individuals at the grassroots level gather them in one center to provide full services such as shelter, food, and clothing. For example, Mekedonia Home for the Elderly and Mentally Disabled is an organization dedicated to improving the lives of the elderly and those with mental impairments by offering all basic services which include food, clothing, shelter, hygienic facilities, medical, educational, and other services. Furthermore, the organization assists mentally disabled people in developing their physical and mental capacities via encouragement and rehabilitation.
Conclusions
The health challenges of homeless people are minimally understood in Ethiopia. Three major challenges emerge—hygiene and sanitation practices, physical health challenges, and mental health issues among homeless street people. Understanding the health challenges of homeless street people provides a basis for developing international and domestic NGO interventions to reduce the onset and severity of health problems among the street homeless in Ethiopia.
Ultimately, structural change to address the lack of adequate and affordable housing is needed. Development actors and governments alike should take low-income housing construction as a major effort in developing countries around the world. In the mean-time, relief efforts to address the physical and mental health issues of homeless people are important in two ways. Some health and mental health issues can be viewed as a downward spiral into street homelessness. Once homeless, health and mental health issues aggravate a person’s already destitute situation of being homeless and often lead to chronic homelessness.
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Yosen Melka Arerie, is a PhD Candidate, College of Center for Food Security and Development, Addis Ababa University, Ethiopia. He can be contacted at ymelka30@gmail.com.
Abiot Simeon, is a Assistant Professor, College of Social Science and Humanities, Debre Birhan University, Ethiopia. He can be contacted at abiotsimeon@gmail.com.
Alice K. Butterfield, is a Professor, Jane Addams College of Social Work, University of Illinois Chicago. She can be contacted at akj@uic.edu