Academy of Healing Arts Risk Factors for Homelessness Among US Veterans Paper Select a human/social service organization, which can be where you are curren

Academy of Healing Arts Risk Factors for Homelessness Among US Veterans Paper Select a human/social service organization, which can be where you are currently employed, or where you would have an interest in gaining future employment. You will use this organization and research problem as the basis of your final project.

Then, identify a social problem that is targeted by your selected organization. Examples of final projects are: program/service delivery design, program evaluation, quantitative or qualitative research on an issue in human service delivery, or other appropriate areas.

It is important to select your research problem carefully. The following considerations should be addressed in the assignment:

How do you know when you have a legitimate research problem?
How would you delineate the subparts of the social problem for your research project?

Based on your research problem, write a two- pages paper using a minimum of two scholarly sources. In your paper, describe the process of how you made these determinations, providing specific details of this process and how you would plan for such a research project.

References

Evans, W. N., Kroeger, S., Palmer, C., & Pohl, E. (2019). Housing and Urban Development–Veterans Affairs Supportive Housing Vouchers and Veterans’ Homelessness, 2007–2017. American Journal of Public Health, 109(10), 1440–1445. https://doi-org.proxy-library.ashford.edu/10.2105/AJPH.2019.305231

Tsai, J., & Rosenheck, R. A. (2015). Risk factors for homelessness among US veterans. Epidemiologic Reviews, 37(1), 177–195. https://doi-org.proxy-library.ashford.edu/10.1093/… Epidemiologic Reviews
Published by Oxford University Press on behalf of the Johns Hopkins Bloomberg School of Public Health 2015. This work is written
by (a) US Government employee(s) and is in the public domain in the US.
Vol. 37, 2015
DOI: 10.1093/epirev/mxu004
Advance Access publication:
January 16, 2015
Risk Factors for Homelessness Among US Veterans
Jack Tsai* and Robert A. Rosenheck
Accepted for publication August 29, 2014.
Homelessness among US veterans has been a focus of research for over 3 decades. Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, this is the first systematic review to
summarize research on risk factors for homelessness among US veterans and to evaluate the evidence for these
risk factors. Thirty-one studies published from 1987 to 2014 were divided into 3 categories: more rigorous studies,
less rigorous studies, and studies comparing homeless veterans with homeless nonveterans. The strongest and
most consistent risk factors were substance use disorders and mental illness, followed by low income and other
income-related factors. There was some evidence that social isolation, adverse childhood experiences, and past
incarceration were also important risk factors. Veterans, especially those who served since the advent of the allvolunteer force, were at greater risk for homelessness than other adults. Homeless veterans were generally
older, better educated, and more likely to be male, married/have been married, and to have health insurance coverage than other homeless adults. More studies simultaneously addressing premilitary, military, and postmilitary
risk factors for veteran homelessness are needed. This review identifies substance use disorders, mental illness,
and low income as targets for policies and programs in efforts to end homelessness among veterans.
clinical characteristics; homelessness; low income; mental illness; risk factors; substance abuse; veterans
Abbreviations: HUD, Department of Housing and Urban Development; OEF, Operation Enduring Freedom; OIF, Operation Iraqi
Freedom; PTSD, post-traumatic stress disorder; VA, Department of Veterans Affairs; VASH, Veterans Affairs Supportive Housing.
consider homelessness a violation of a basic human right—
the right to have access to safe and secure housing (11, 12).
Homelessness is also a concern because it is associated with
a host of other negative outcomes, including a wide range of
serious medical problems (13, 14), mental health and substance abuse problems (10, 15), premature mortality (16,
17), frequent hospitalizations, greater than average costs per
hospital stay (18, 19), and incarceration (20, 21).
Veterans constitute a unique segment of the US population
because of their service to the nation and, as reflected in their
increased access in the years since World War II (22), to special benefits such as VA health care, disability and education
benefits, and home-loan guarantees. Veterans may also be
more vulnerable to certain health and psychosocial problems
than other adults because of their higher exposure to combatrelated trauma and geographic dislocation for military deployment (23). The presence of veterans within the general
US homeless population is regarded as a point of public
shame by many, and public concern for their health and wellbeing is strong (24, 25). In 2009, Secretary Eric Shinseki of
the Department of Veterans Affairs (VA) pledged to end
INTRODUCTION
Homelessness among veterans has been of major public
concern for over 3 decades. Homelessness among substantial
numbers of veterans was first documented after the Civil War
(1), but it was not until the early 1980s, a period characterized
by high inflation and 2 economic recessions, that veteran
homelessness began to be recognized as an important public
health problem (2–4). Most recent estimates report that veterans are slightly overrepresented in the US homeless population with veterans constituting 12.3% of all homeless
adults in the United States (5) but only 9.7% of the total
US population (6).
Homelessness has been defined as not having a “fixed, regular, and adequate nighttime residence” (7, p. 1), and it
includes moving frequently between different types of accommodations and staying in homeless shelters and places not
meant for human habitation (e.g., vehicles, abandoned buildings). Among the general population, homelessness has been
a social, economic, and public health concern in the United
States and internationally since the early 1980s (8–10). Some
177
Epidemiol Rev 2015;37:177–195
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* Correspondence to Dr. Jack Tsai, 950 Campbell Avenue, 151D, West Haven, CT 06516 (e-mail: jack.tsai@yale.edu).
178 Tsai and Rosenheck
METHODS
A systematic and exhaustive computerized literature search
of PubMed, PsycINFO, Google Scholar, Academic Search
Premier, and Web of Science databases was performed by
both authors of studies published in English from 1900 to
July 2014. Different combinations and iterations of the following key words and medical subject headings were used
to search titles and abstracts in each database: homelessness,
homeless, veterans, military, risk, risk factors, characteristics,
and causes. Boolean operators (e.g., AND, OR) and wildcard
symbols (e.g., *) were used (e.g., search string: “homeless
veteran*” AND “risk factor*” OR “homeless veteran*”
AND “characteristic*”).
Only studies that met the following criteria were included
in the review: 1) sampled US veterans; 2) assessed homelessness in the United States; 3) included homelessness as an outcome or dependent variable; and 4) examined variables in
relation to homelessness as a main study aim with the intent
to identify risk factors or characteristics associated with homelessness. A broad definition of homelessness was used to be
inclusive of studies, which included the US Housing and
Urban Development’s (HUD’s) definition (35), use of any
specialized VA homeless services, or a documented V60.0
clinical code suggesting homelessness according to the International Classification of Diseases, Ninth Revision, Clinical
Modification (ICD-9-CM). Veteran status was defined as
having ever served in the US military regardless of discharge
status.
Studies were excluded if they reported only the effects of a
specific intervention (e.g., supported housing) or if they reported only qualitative data. Case reports, published commentaries, and letters to the editor that did not report any
quantitative data were also excluded. References from all relevant literature were hand searched and used to identify additional relevant studies. Several experts in the field were
contacted to inquire about additional studies or reports that
may not have been found in the literature search.
As Figure 1 shows, our search initially yielded a total of
153 individual records, which were screened generally for
topic relevance and reporting of quantitative data, resulting
in the exclusion of 30 of those records. The remaining 123
records were carefully examined, of which 81 were excluded
because they failed to meet inclusion/exclusion criteria, resulting in a total of 32 studies that met criteria. All 32 studies
included were peer-reviewed journal articles, except for 4
book chapters and 2 published governmental reports. One report (36) and one study (37) used the same data and reported
similar results so they were considered one study, resulting in
a total of 31 separate studies included in this review.
Our systematic review followed the guidelines from the
Preferred Reporting Items for Systematic Reviews and MetaAnalyses (PRISMA) Statement (38). We did not conduct a
meta-analysis because a varying array of measures, variables,
research designs, and statistical tests were used in these studies that precluded an accurate, balanced, quantitative synthesis of this literature. However, we reported odds ratios or
adjusted odds ratios (both denoted as “ORs” for simplicity)
and other effect size statistics (e.g., hazard ratios, risk ratios,
percentages) when available to provide readers with a sense
of the magnitude of the risk factors identified. However, we
do caution that these statistics must be understood in the context of each individual study and may not be directly comparable as different research designs, covariates, and measures
were used in each study.
For our review, we categorized studies on the basis of the
rigor of their research design and provided a narrative synthesis of their findings. We divided the 31 included studies into 3
categories: more rigorously designed studies, less rigorously
Epidemiol Rev 2015;37:177–195
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homelessness among veterans in the next 5 years, and since
then millions of dollars have been used to fund the creation
and expansion of VA services for homeless veterans (26). A
growing component of those efforts is a focus on the prevention of homelessness, which involves addressing key risk factors before they result in an episode of homelessness.
Veterans have been overrepresented in the homeless population since at least the late 1980s. Although this disparity
has attenuated over time (5), it remains puzzling because
homeless veterans are consistently found to be older, better
educated, more likely to have married, and more likely to
have health coverage than other homeless adults (22). By virtue of their military service, all homeless veterans also have
had some employment and a work history. These advantages
should put veterans at lower risk for homelessness than other
homeless adults, although they appear to be at higher risk
among some veteran cohorts, especially those who were recruited after the advent of the all-volunteer force in 1975 (22,
27). No comprehensive models of veteran homelessness have
been formulated, but it has been recognized that premilitary,
military, and postmilitary factors need to be considered in
identifying risk factors for veteran homelessness (28–30).
Several reviews of studies on risk factors for homelessness
in the general population have been conducted (31–33), and a
broad literature review on homelessness among veterans was
recently conducted by the VA’s Evidence-Based Synthesis
Program (34). However, to our knowledge, there has been
no systematic review of risk factors for homelessness specifically among veterans in the published literature. Such a review is important as efforts to address veteran homelessness
continue, government funds are directed at prevention efforts,
more veterans return from recent conflicts in Iraq and
Afghanistan, and the scientific community seeks to understand the body of knowledge amassed from research on the
causes of homelessness among veterans.
In this systematic review, we provide a comprehensive
examination of the published literature on risk factors of
homelessness among US veterans. First, we compiled and
categorized existing studies into 3 categories on the basis
of the nature and rigor of their research designs: 1) large cohort, case-control, or other more rigorous studies based on
recognized designs; 2) less rigorous, cross-sectional, descriptive, specific focus, or other uncontrolled studies; and 3) studies comparing homeless veterans with homeless nonveterans.
Second, we summarized the findings of studies in each category and provide a synthesis of distinctively consistent findings
across studies. Third, we describe current gaps in knowledge
and recommend future areas for research. Fourth, we conclude with a discussion of the implications of these findings
for policy and practice.
Risk Factors for Homelessness Among US Veterans 179
417 Records Identified Through
Database Searching
10 Additional Records Identified Through
Other Sources
153 Records After Duplicates Removed
153 Records Screened
30 Records Excluded
31 Separate Studies
Included in Review
Figure 1. Different phases of the search for risk factors for homelessness among US veterans in studies published from 1900 to 2014.
designed studies, and comparative studies of homeless veterans and homeless nonveterans. One book chapter (39) contained 2 separate analyses so it was divided into 2 categories.
More rigorous studies consisted of studies that used a cohort, case-control, or clearly formulated research design that
provided support for causal factors for homelessness (e.g.,
structural equation modeling estimates of causal relations)
(40); used relatively large samples; and evaluated a broad
range of sociodemographic, psychosocial, and health measures. These studies were judged to have lower risk for bias
because methodologies were clearly described, more representative samples were used, and confounding variables
were taken into account.
Less rigorously designed studies consisted of studies that
were cross-sectional (i.e., descriptive) or had weaker research
designs (e.g., case-control design with no historical controls);
had relatively small sample sizes or focused descriptively on
particular subgroups of homeless veterans; and utilized a limited number of psychosocial and health measures or focused
on a particular domain (e.g., neurological deficits).
Comparative studies consisted entirely of studies that compared veterans with nonveterans on risk factors and characteristics associated with homelessness. These studies mostly
used a cross-sectional research design, with a few exceptions
(e.g., one longitudinal and one case-control design study).
RESULTS
More rigorous studies
A total of 7 studies were identified that were based on data
collected between 1986 and 2011 (arranged by date of data in
Table 1). Of these 7 studies, 3 were case-control studies,
Epidemiol Rev 2015;37:177–195
3 were cohort studies, and 1 was a study that used a structural
equation modeling analysis of cross-sectional data. These
studies differed in their sample frames, partly based on when
the studies were conducted. For example, one study sampled
Vietnam era veterans (28), while 3 studies exclusively sampled
Iraq and Afghanistan era veterans (36, 41, 42). It is notable
that all of the studies exclusively or predominantly sampled
male veterans given the predominance of males in the veteran
population, except for one study that exclusively sampled female veterans (43). All of the studies used large populationbased samples, except the study focused on female veterans
and another study that examined subsequent homelessness
among veterans who had obtained supported housing (44).
Of the 7 studies, the most consistent risk factors for homelessness identified by all studies were substance abuse and
mental health problems. This was found in all 3 cohort studies (36, 41, 44), which provide support that these problems
preceded homelessness. Substance abuse problems appeared
to be the risk factor with the greatest magnitude of effect.
Three of the 4 studies that included assessment of psychotic
disorders (i.e., schizophrenia) also particularly identified psychotic disorders as a major risk factor (36, 42, 45). Posttraumatic stress disorder (PTSD) was a risk factor, but it was
found to be of the same magnitude as other mental health disorders. One study did find that PTSD specifically increased
a veteran’s risk for returning to homelessness, but only
after supported housing had led to an initial exit from being
homeless (44).
Another consistent finding was that 6 of the 7 studies
identified low income/poverty and income-related variables,
such as military pay grade and unemployment, as risk factors for homelessness. Presumably all of the homeless veterans
in these studies were poor and lacked financial resources for
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123 Full-Text Articles
Assessed for Eligibility
Design
Data Source
Total No.
Epidemiol Rev 2015;37:177–195
Rosenheck, 1994 (28)
Cross-sectional study
using structural
equation modeling
National Vietnam Veterans
Readjustment Study
1,460
O’Connell, 2008 (44)
Retrospective cohort
study
Randomized controlled trial
of the HUD–VASH
Program
Washington, 2010 (43)
Matched case-control
study
Local survey data
VA Office of Inspector
General, 2012 (36);
Metraux, 2013 (37)
Population-based
retrospective cohort
study
Administrative data from VA
and DoD maintained by
the Office of Inspector
General
No. of Homeless
Sampling Frame
Study Period
Identified Risk Factors
123
Male Vietnam
veterans
1986–1987
Four premilitary factors
included year of birth (total
effect = 0.10), childhood
physical or sexual abuse
(total effect = 0.10), other
childhood trauma (total
effect = 0.07), and foster
care (total effect = 0.06).
Four postmilitary factors
included psychiatric
disorders (total effect =
0.08), substance abuse
(total effect = 0.06), being
unmarried (total
effect = 0.14), and low
levels of social support
1 year after military
discharge (total
effect = 0.30).
392
172 subsequently
homeless
Formerly
homeless
veterans in
supported
housing
1992–1995
Drug use upon entry into
housing (RR = 12.33) and
a diagnosis of PTSD
(RR = 1.85) were
predictive of subsequent
homelessness.
198
33
Female veterans
2005–2006
Being unemployed
(OR = 13.1), disabled
(OR = 12.5), in fair or poor
health (OR = 3.2),
unmarried (OR = 0.1),
having less than a college
education (OR = 0.2), and
screening positive for
post-traumatic stress
disorder (OR = 4.9).
5,574
Iraq and
Afghanistan era
veterans
2005–2006
Lower military pay grade
(HR = 0.13–0.43),
diagnosed mental illness
in the military, especially
psychotic disorders
(HR = 1.57–4.22) and
substance use disorders
(HR = 1.85–2.72),
traumatic brain injury
(HR = 1.20–1.64),
problematic military
discharges (HR = 1.79–
8.18), service in OEF/OIF
(HR = 1.34), and active
duty vs. reserves
(HR = 0.74–1.34).
310,685
Table continues
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First Author, Year
(Reference No.)
180 Tsai and Rosenheck
Table 1. More Rigorous Published Studies on Risk Factors for Veteran Homelessness, 1994–2013
First Author, Year
(Reference No.)
Design
Data Source
Total No.
Blackstock, 2012 (42)
Population-based
case-control study
Administrative data from VA
445,319
Edens, 2011 (45)
Population-based
case-control study
Administrative data from VA
1,120,424
No. of Homeless
Sampling Frame
Study Period
Identified Risk Factors
OEF/OIF VA
service users
2001–2009
Age, 18–35 years
(HR = 1.51–1.66), black
(HR = 2.53), unmarried
(HR = 1.32), high school
education or lower
(HR = 1.76), urban
location (HR = 0.77),
enlisted vs. military officer
(HR = 2.66), VA service
connection (HR = 1.45–
2.35), and nearly all mental
health diagnoses,
especially substance use
disorders and
schizophrenia (HR = 1.17–
3.38).
109,056
VA mental health
service users
2008–2009
Diagnoses of alcohol and
drug use disorders
(OR = 2.0–3.3),
schizophrenia (OR = 1.1),
bipolar disorder
(OR = 1.0), pathological
gambling (OR = 2.4),
personality disorders
(OR = 1.6), male,
urban-dwelling (OR = 0.3–
0.5), lower income
(OR = 0.3–0.8), age, 40–
49 years (OR = 1.7), and
being black (OR = 1.4).
Protective characteristics
were VA service
connection (OR = 0.3),
age, ≥65 years (OR = 0.2–
0.6), and service in OEF/
OIF (OR = 0.4).
Elbogen, 2013 (41)
Retrospective cohort
study
National Postdeployment
Adjustment Baseline and
Follow-up Survey
1,090
39
Iraq and
Afghanistan era
veterans
2009–2011
Criminal history (OR = 2.65),
mental health diagnosis
(OR = 2.59), income level
(OR = 0.30), and money
mismanagement
(OR = 4.09).
Abbreviations: DoD, Department of Defense; HR, ha…
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