The state of homelessness in Los Angeles County

SPA 4 PROFILE
THE STATE OF HOMELESSNESS
IN LOS ANGELES COUNTY:
The Need for a Multi-Dimensional Approach
Los Angeles County Department of Health Services • Public Health
June 2002
Metropolitan Service Planning Area Health Office (SPA 4)
SPA 4 BEST PRACTICE COLLECTIONRELIABLE INFORMATION FOR EFFECTIVE COMMUNITY HEALTH PLANS, PROGRAMS AND POLICIES
M. RICARDO CALDERÓN, SERIES EDITOR

The State of Homelessness in Los Angeles County: SPA 4 Profile June 2002
METROPOLITAN SERVICE PLANNING AREA HEALTH OFFICE (SPA 4)
241 North Figueroa Street, Room 312
Los Angeles, California 90012
(213) 240-8049
The Best Practice Collection is a publication of the
Metropolitan Service Planning Area (SPA 4). The
opinions expressed herein are those of the editor
and writer(s) and do not necessarily reflect the of-
ficial position or views of the Los Angeles County
Department of Health Services. Excerpts from this
document may be freely reproduced, quoted or
translated, in part or in full, acknowledging SPA 4
as the source.
Internet: http://www.lapublichealth.org/SPA 4
LOS ANGELES COUNTY
BOARD OF SUPERVISORS
Gloria Molina, First District
Yvonne Brathwaite Burke, Second District
Zev Yaroslavsky, Third District
Don Knabe, Fourth District
Michael D. Antonovich, Fifth District
DEPARTMENT OF HEALTH SERVICES
Thomas L. Garthwaite, MD.
Director and Chief Medical Officer, Department of Health Services
Jonathan E. Fielding, MD, MPH, MBA.
Director of Public Health and County Health Officer
James Haughton, MD, MPH.
Medical Director, Public Health
BEST PRACTICE COLLECTION TEAM
M. Ricardo Calderón, Series Editor
Manuscript Author & SPA 4 Area Health Officer
Angela Salazar, MPH.
Manuscript Author & Program Director, Health Education
Carina Lopez, MPH.
Project Manager, Information Dissemination Initiative
At a Glance
The SPA 4 Best Practice Collection fulfills the Los Angeles County Depart-
ment of Health Services (DHS) local level goal to restructure and improve
health services by“establishing and effectively disseminating to all con-
cerned stakeholders comprehensive data and information on the health
status, health risks, and health care utilization of Angelinos and definable
subpopulations”.1
It is a program activity of the SPA 4 Information Dis-
semination Initiative created with the following goals in mind:
To highlight lessons learned regarding the design, implementation,
management and evaluation of public health programs
To serve as a brief theoretical and practical reference for program
planners and managers, community leaders, government officials,
community based organizations, health care providers, policy mak-
ers and funding agencies regarding health promotion and disease
prevention and control
To share information and lessons learned in SPA 4 for community
health planning purposes including adaptation or replication in other
SPA’s, counties or states
To advocate a holistic and multidimensional approach to effectively
address gaps and disparities in order to improve the health and
well-being of populations
The SPA 4 Information Dissemination Initiative is an adaptation of the
Joint United Nations Program on HIV/AIDS (UNAIDS) Best Practice Collec-
tion concept. Topics will normally include the following:
1. SPA 4 Viewpoint: An advocacy document aimed primarily at policy and
decision-makers that outlines challenges and problems and proposes
options and solutions.
2. SPA 4 Profile: A technical overview of a topic that provides information
and data needed by public, private and personal health care providers
for program development, implementation and evaluation.
3. SPA 4 Case Study: A detailed real-life example of policies, strategies or
projects that provide important lessons learned in restructuring health
care delivery systems and/or improving the health and well being of
populations.
4. SPA 4 Key Materials: A range of materials designed for educational or
training purposes with up-to-date authoritative thinking and know-
how on a topic or an example of a best practice.
2

Table of Contents
THE STATE OF HOMELESSNESS IN LOS ANGELES COUNTY
I. INTRODUCTION 4
1. Definitions of Homelessness 5
2. How many people are Homeless? 6
The Numbers
3. Who is Homeless? 6
Families 55
Children 55
Adults
Veterans 7
4. Who is Homeless in Los Angeles County 7

II. REASONS FOR HOMELESSNESS 12
1. The Multi-Dimensional Framework for Homelessness
Indivdual
Environmental
Structural
Superstructural
III. HEALTH AND WELLBEING 13
1. Statistics 14
Mortality
Mental health and substance abuse
Physical health 15
Infectious dieseases
Barriers to care
IV. SERVICES FORTHE HOMELESS 17
1. Stewart B. Mckinney Homeless Assistance Act of 1987 17
2. Federal Assistance Programs 17
Food stamp Program
Public Housing and Section 8 Tenant-based Assistance 14
Employment and Training Services
Supplemental Security Income 19
Community Health Centers
Substance Abuse Prevention and Treatment Block Grant Program
Medicaid
3. State and County Assistance Programs 19
The Department of Health Services Programs
Alcohol and Drug Program Administration (ADPA)
Tuberculosis Control Program
Office of AIDS Policy and Programs (OAPP)
V. DISCUSSION: THE MULTI-DIMENSIONAL APPROACH TO ADDRESS HOMELESSNESS 21
VI. CONCLUSIONS 23

3

34
INTRODUCTION
I. INTRODUCTION
In the past decade, the United States has seen
enormous economic growth. While this growth
has substantially improved the financial well being
of many, there remains a bleak reality: the number
of persons in extreme poverty has risen along with
the number of homeless persons across the US.
Moreover, the economy’s success has driven up the
cost of living making housing more unaffordable.
Homelessness is clearly a national problem.
However, homeless persons across the US are not
homogenous. Homelessness varies across geo-
graphical areas and it is becoming more apparent
that there is no single face of homelessness. Home-
lessness is occurring in various ethnic minority
groups, females, and children at increasing rates. It
is important that each community understand its
etiology of homelessness in efforts to better serve
the unique needs of local homeless people.
This document is one in a series of articles to be
published by the SPA 4 Area Health Office in The
Best Practice Collection. The primary purpose of
this document is to provide extensive information
regarding the state of homelessness in Los Ange-
les County, with special attention to SPA 4 health
issues and services available to the homeless popu-
lation; but, the information provided goes beyond
simply the numbers. This document introduces
and advocates the use of The Multi-Dimensional
Framework for Homelessness, a model intended to
Goals of The State of Homelessness in
Los Angeles County:
Describe characteristics of the homeless
population and who utilizes homeless
services in Los Angeles County and SPA 4
Understand the reasons for homelessness
using the Multi-Dimensional Framework
for Homelessness
Describe health problems and issues
relating to health care in the homeless
population
Outline major services available to the
homeless population
Explain the role ofThe Multi-Dimensional
Framework for Homelessness in developing
comprehensive strategies for homelessness
Advocate the use ofThe Multi-Dimensional
Framework for Homelessness
describe the multifaceted etiologies of homelessness and to
provide the backbone for developing a comprehensive strat-
egy to end homelessness. Adopting The Multi-Dimensional
Framework for Homelessness is integral in creating a system
that advocates for multi-sectoral coordination and action to
create more effective community programming and planning
in the area of homelessness in our communities.
Skid Row,officially known as
Central City East,1
is an area of
Downtown Los Angeles between
3rd and 7th streets and Alameda
and Main Streets.As of the 2000
census,there were 17,740 people
and 2,410 households residing in
the neighborhood.

DEFINITION OF HOMELESSNESS
5
There is debate over where the
definition of homelessness lies
along this continuum. Currently,
definitions almost always leave out
the precariously housed, primarily
because identifying persons who are
living in doubled-up or shared hous-
ing situations is difficult in practical
terms. Furthermore, grouping those
who are in shared housing situa-
tions with those who are without
a home may obfuscate the specific
needs and concerns of these distinct
populations. Hence, researchers
most often use an operational defini-
tion of homeless limited to persons
in shelters, on the streets and those
using services such as soup kitchens
and mobile clinics.1
Unless otherwise
noted in this document, the num-
bers/figures come from research that
has used such operational definitions
in obtaining the data.
1. DEFINITION OF HOMELESSNESS
By the early 1980’s, there was a crisis
in the United States: thousands of
Americans found themselves without
a home or without shelter due
to a variety of reasons that will be
later discussed. The public reacted
because it was not since the Great
Depression that the US had seen
so many families living in shelters,
on the streets, or with family and
friends.1
The term homeless was created
around this time, intending it to be
an inoffensive way of referring to
persons living on the streets and in
shelters.2
Although the adoption of
this term brought public awareness
to an otherwise indistinct group
of people and circumstances, the
term still remains multifaceted and
can take on a variety of meanings.
Homelessness can mean anything
on a continuum that ranges from the
lack of basic shelter to being precari-
ously housed (Table 1).1,2
A largely accepted formal defini-
tion of homelessness comes from
the Stewart B. McKinney Homeless
Assistance Act of 1987, a Federal leg-
islation which created a series of tar-
geted homeless assistance programs.3
In the Act, a homeless person is:
(1) an individual who lacks
fixed, regular and adequate night-
time residence
(2) an individual whose primary
residence is one of the following:
i. a temporary place for people
about to be institutionalized
ii. any place not meant for hu-
man habitation
iii. a supervised shelter.
Table 1. Definition of Homelessness on a Continuum based on Housing Arrangements
On any given night in America,
anywhere from 700,000 to 2
million people are homeless,
according to estimates of the
National Law Center on
Homelessness and Poverty.
Researchers most often use an
operational definition of homeless
limited to persons in shelters,on
the streets and those using services
such as soup kitchens and mobile
clinics.1

2. HOW MANY PEOPLE ARE
HOMELESS?
Not surprisingly, putting a figure to
the number of homeless persons in
the US has been a challenging task
for researchers. Estimates have varied
from less than half a million to more
than two million each year.1
The
differences in estimates are due to
various definitions of homelessness,
different counting techniques and
the use of different time periods.
Homeless persons are counted using
either direct or indirect methods.
Direct counts are made by obtaining
numbers from the streets, shelters,
and service programs. Indirect
counts include telephone surveys and
interviews of a portion of the popula-
tion, which are used as representa-
tive samples that approximate the
entire population.4
Similarly, homeless
counts can occur at either one point
in time (point prevalence, i.e. each
night) or over a period of time (period
prevalence, i.e. in the past 5 years).1,4
These estimates can vary substan-
tially. For instance, when some people
experience homelessness only briefly
causing the period prevalence to be
many times greater than the point
prevalence. Because homelessness
most often occurs in short episodes,
using a period prevalence measure is
more appropriate.1
The Numbers
It is estimated that 3.5 million people
are currently without a home in the
United States.5
Yet, this number is an
incomplete picture of a problem that
is more serious: it is estimated that
14% of the U.S. population (26 million
people) have been homeless at some
time in their lives and 5% (8.5 million
people) have been homeless within
the past five years.6
With an area that spans four thou-
sand square miles and accommo-
dates over nine million people, Los
Angeles County has a large homeless
population. Up to 84,000 people are
homeless each night in the country
amounting to close to 236,400 people
being homeless over the course of
the year.7
The city of Los Angeles is
home to approximately 41,500 home-
less people each night.
SPA 4, with one of the most dense
and diverse populations in the
county, encompasses areas with a
high degree of homelessness such
as downtown/Skid Row, Hollywood,
and parts of East Los Angeles. Ac-
cording to the Los Angeles County
Health Survey, SPA 4 had the great-
est percentage of adults who were
homeless within the past five years.
Interestingly, SPA 4’s three health
districts, Central, Hollywood/Wilshire
and Northeast, have homeless popu-
lations that are unique to each dis-
trict; that is, homeless persons tend
to differ substantially between the
SPA’s three districts. About 375,000
adults have experienced homeless-
ness in the past five years.8
3. WHO IS HOMELESS?
The face of homelessness is changing.
While homelessness has traditionally
been associated with single white
males, the trend is changing to the
extent that ethnic minorities make
up the greatest share of the nation’s
homeless population and there is in-
creasing prevalence of homelessness
in women, families, and youth.5,9
Families
Families represent approximately 34-
37% of the national homeless popula-
tion.4
With costs of living increasing
nationwide, it is becoming more
difficult to raise children with one
source of income and most homeless
families are single-parents. About
84% of homeless families are headed
by mothers and have an average of
2.2 children.4
Most families become
homeless due to a housing crisis,
making housing their primary need.10
Homeless persons are counted
using either direct or indirect
methods.
Direct counts are made by
obtaining numbers from the
streets,shelters,and service
programs.
Indirect counts include tele-
phone surveys and inter
views of a portion of the
population.
HOMELESSNESS: DEMOGRAPHICS
6
“There are many risk factors
for becoming homeless,such
as disputes and relationship
breakdown,physical or sexual
abuse,lack of qualifications,
unemployment,alcohol or drug
misuse,mental health problems,
contact with the criminal
justice system,debt,lack of a
social support network and
institutionalization or the death
of a parent during childhood”
World Health Organization

7
The increasing prevalence of home-
less families is primarily a concern
for SPA 4’s Northeast Health District.
Financial stress is causing many
families, often with young children,
to live in shared housing situations
(doubled-up), out of cars, in local
hotels and shelters, or even on the
streets. Often, women and children
are made homeless due to domestic
violence. It has been estimated that
about half of the nation’s homeless
women are fleeing from domestic
violence situations.11
Children
Most homeless children are part of
homeless family units. It is estimated
that 38% of those who experience
homelessness over the course of a
year are children.10
Unaccompanied
minors (i.e. runaway or displaced
children) amount to about 3-7% of all
homeless persons.12
These youngsters
have issues distinct to their adult
counterparts that need to be ad-
dressed. For instance, many homeless
minors are victims of abuse, may
have extensive drug problems, and
are at particularly high risk of sexually
transmitted diseases and HIV infec-
tions.1,11,12
For decades, runaway youth fleeing
from problems at home or in search
of glamour found themselves on the
sidewalks and abandoned buildings
of Hollywood. In 1997, the Children’s
Hospital estimated that as many as
8,000 youths lived on Hollywood
streets over the course of a year.13
A recent impetus to revitalize Holly-
wood by creating offices, apartments
and restaurants out of abandoned
buildings is displacing scores of
young people, many who lived in
Veterans
While 13% of the general population
are United States veterans, 23% of the
homeless are veterans.9
According
to the U.S. Department of Veterans
Affairs, a large proportion of home-
less veterans are single, from disad-
vantaged communities, suffer from
mental illness, and have substance
abuse problems. Close to half of
homeless veterans served during the
Vietnam Era.18
4. WHO IS HOMELESS IN
LOS ANGELES COUNTY?
The data presented in this section
come from three different research
studies conducted in Los Angeles
County: (1) The Los Angeles County
Health Survey, 1997, (2) The UCLA
Homeless Women’s Health Study,
1997 and (3) The RAND Course of
Homelessness Study, 1991.
vacant building squats. Not surpris-
ingly, more young people are sleep-
ing on sidewalks, in alleyways, and
under freeway overpasses.14
With so many young homeless
people without roofs over their
heads, the situation is bound to be-
come more severe. Many homeless
youth discover that exchanging sex
for basic needs such as food, clothing,
shelter, or protection can be their key
to survival. A study conducted on
Hollywood youth revealed that 26%
of runaways reported involvement in
survival sex compared to only 0.2%
among non-runaway youth. Further-
more, rates of depression, alcohol
and substance abuse, post-traumatic
stress disorder and attempted suicide
are major concerns for these youth.1,15
Adults
Approximately 66% of people who
experience homelessness over the
course of a year are single adults,
most entering and exiting the situa-
tion fairly rapidly. The remainder live
in the homeless assistance system or
in a combination of shelters, hospi-
tals, streets and jails. About 81% of
homeless single adults are between
25 and 54 years while 10% are be-
tween 17 and 24 years and another
9% are over 55 years.4
The homeless population in down-
town Los Angeles is largely made
up of single adult males of African
American descent.16
With close to
11,000 homeless on downtown’s
Skid Row, a 50-block area east of
downtown bordered by 3rd and
7th streets and Alameda and Main
streets, there is a considerable
amount of attention given to this
population.17
HOMELESSNESS: DEMOGRAPHICS
According to a December 2000
report of the US Conference of
Mayors:
• Single men comprise 44
percent of the homeless,single
women 13 percent,families
with children 36 percent,and
unaccompanied minors seven
percent.
• The homeless population is
about 50 percent African-
American,35 percent white,
12 percent Hispanic,2 percent
Native American and 1 percent
Asian.

8
The Los Angeles County Health Survey 8
In 1997, the Los Angeles County Health Survey
assessed homelessness within the county using a
telephone survey of households within the county.
Homelessness within the past 5 years was assessed
using a definition of homelessness that includes
the precariously housed (i.e. doubled-up or shared
housing situations with friends or family).
THE LOS ANGELES COUNTY HEALTH SURVEY
Figure 1. Percent of adults who were homeless within the last 5 years by
Service Planning Area (SPA)
Figure 2. Ethnicity of adults who were homeless
within the last five years in Los Angeles County
Figure 3. Employment status of adults who were homeless
within the last five years in Los Angeles County
Figure 4. Education level of adults who were
homeless within the last five years in Los
Angeles County

The UCLA Homeless Women’s Health Study 19
The UCLA HomelessWomen’s Health Study was conducted
to assess the health status of homeless women in Los
Angeles County using service-based sampling. Unlike the
Los Angeles County Health Survey, this study excluded
precariously housed individuals (persons doubled up
or in shared living arrangements with friends or family
members). As stated previously, this definition is most
commonlyusedinhomelessnessresearchandseparatesthe
precariously housed from the definition of homelessness.
The ethnic breakdown of the sample population of
homeless women from Los Angeles County (N=964) versus
ethnic breakdown of sample population of homeless
women from SPA 4 (N=505) can be found in figure 5.
UCLA HOMELESS WOMEN’S HEALTH STUDY
9
Figure 5. Ethnic Break down of the sample population of homeless
women from Los Angeles County
Figure 6. Age structure of the sample population of
homeless women from Los Angeles County (N= 960)
Figure 7. Number of years since being last stably housed
among sample population of homeless women from Los
Angeles County (N= 966)

The RAND Course of
Homelessness Study 20
The RAND Course of Homelessness
Study was a prospective study of
homeless persons in Los Angeles
Downtown and Westside. This survey
was conducted using both service-
based sampling and probability
sample of homeless persons. This
study excluded precariously housed
individuals (persons doubled up or
in shared living arrangements with
friends or family members).
THE RAND COURSE OF HOMELESSNESS STUDY
10
Figure 8. Ethnic breakdown of the sample population of homeless indivduals in Downtown and
Westside (N = 1563)
Figure 9. Ethnic Breakdown of the sample population of homelesss indivduals by
gender (N = 1563)

THE RAND COURSE OF HOMELESSNESS STUDY
11
Figure 10. Education level of the sample population of homeless indivduals in Downtown and Westside
( N = 1563)
Figure 11. Ethnic breaksown of the sample population of homeless indivduals by gender
(N = 1563)

12
II. REASONS FOR
HOMELESSNESS

1. THE MULTI-DIMENSIONAL
FRAMEWORK FOR HOMELESS-
NESS
There is not a simple answer to
the question of why there are
homeless persons. Like many
other social issues, homeless-
ness has a multitude of causes.
In order to better understand
the etiologies of homelessness,
the needs of homeless persons
and to provide effective services,
we must understand all factors
that influence homelessness on
a holistic level. This can be best
achieved using the Multi-Dimen-
sional Framework for Homeless-
ness. This model is adapted from
a framework for HIV in develop-
ing countries.21
It identifies four
levels of causation involved in
homelessness. Table 3 summa-
rizes each causal level.
Homelessness can be under-
stood using a framework that
uses these levels of causation
(Figure 12). Included in the figure
are issues to be further discussed
in this document. Lack of af-
fordable housing and poverty
are highlighted because they
have been identified as major
contributing factors to the rise in
homelessness over the past two
decades.22,23
REASONS FOR HOMELESSNESS
Table 2. Time of current episode of homelessness and total time of homelessness among
sampled indivduals (N=1563).
Table 3. Causal Level of the Multi-Dimensional Model
Figure 12. The Multi-Dimensional Framework for Homelessness
INDIVIDUAL – substance abuse, mental
illness, perception of the services system
ENVIRONMENTAL – lack of affordable housing,
low paying jobs, domestic violence
STRUCTURAL – changes to public assistance, lack of
comprehensive policies to prevent homelessness
SUPERSTRUCTURAL –poverty, racism, gender
issues

REASONS FOR HOMELESSNESS
II. REASONS FOR
HOMELESNESS CON’T
Individual
Homeless persons experience mental
illness and substance abuse
at levels higher than the general
public. Mental illness and substance
abuse may cause homelessness but
it is more probable that they contrib-
ute to the inability to be freed from
homelessness.1
Environmental
A lack of affordable housing is a
major contributor to the current
housing crisis and to homelessness.
Affordable housing has become
increasingly scarce and is beyond the
reach of many poor persons because
they are forced to contribute in-
creasingly larger proportions of their
income toward housing. Likewise,
once they are homeless it is increas-
ingly difficult to locate affordable
housing.1
Structural
There have been changes to the
public assistance system that has
resulted in more persons becom-
ing or remaining homeless. One of
the major changes occurred in 1996
with the federal welfare reform law
that replaced the Aid to Families
with Dependent Children (AFDC)
program with a block grant program
called Temporary Assistance to Needy
Families (TANF). This change has
significantly decreased the aid given
to poor persons.23
There is cause for
concern because in some communi-
ties families are no longer eligible
Poor health status not only causes
significant problems for those
already homeless but it can also
be a cause for homelessness due
to a variety of reasons including
physical, emotional and financial
strain. A survey conducted in the
1980s revealed that poor physical
health was a factor for becom-
ing homeless in 13% of homeless
patients.25,26
As the number of
persons without health coverage
continues to rise, the situation
remains grim. Homeless persons
experience high rates of both
chronic and acute health prob-
lems. Many homeless people lack
health insurance, do not have a
regular source of care, and are
under-treated for common medi-
cal problems; hence, amplifying
their poor health. In addition,
they are at high risk for injuries
and crowded living situations may
contribute to outbreaks of disease.
Conditions requiring regular,
continuous treatment, such as
tuberculosis, HIV/AIDS, diabetes,
hypertension, addictive disorders,
and mental disorders are difficult
to manage among those without
adequate housing.26
for aid and consequently have begun
experiencing homelessness in increas-
ing numbers.24
Superstructural
Poverty is an important superstructural
factor contributing to homelessness.
Poor persons must decide where to
allocate resources for even the most
basic needs including housing, food,
childcare, health care and education.
Because housing drains most of an
individual’s resources, it is often the
first thing that is relinquished.1
While the number of poor people
has not changed much in recent
years, the number of people living in
extreme poverty has increased. These
people are the most vulnerable to
becoming homeless.1
III. HEALTH AND
WELL-BEING
According to the World Health Organi-
zation (WHO), health is not merely the
absence of disease; rather, it encom-
passes physical, mental and social
well-being. Since the state of home-
lessness encroaches upon all three of
these areas of well-being, homeless
persons are especially vulnerable to
poor health status.
13
It is estimated that 20-25% of
the homeless population have
mental health conditions,such
as schizophrenia,depression and
bipolar disorder.30
“Homeless people constitute
a heterogeneous population
characterized by multiple
morbidity (primarily alcohol
and drug dependence,and
mental disorders) and
premature mortality.The
problems need to be addressed
by many measures,requiring
a focused primary health care
system and multi-agency
cooperation”.

14
Many homeless persons experience
multiple health problems. Often a
direct consequence of homelessness,
frostbite, skin conditions, leg ulcers
and upper respiratory infections
are common.11
Moreover, homeless
people are at greater risk of trauma
frequently resulting from rape, mug-
gings and other street violence.11,26
To
make matters worse, homelessness
precludes even basic care, such as nu-
trition, personal hygiene and first aid.
It is also becoming more apparent
that self-medication occurs among
some homeless people through the
use of prescription drugs, illicit drugs
and alcohol.26
Homeless children are especially at
risk of poor health due to low immu-
nization rates, inadequate nutrition,
unsuitable living conditions, and little
health care.11,26
In a study conducted
in a population of homeless children
in NewYork City, it was revealed that
61% of homeless children had not
received their proper immuniza-
tions; 38% of homeless children in
shelters have asthma (an asthma rate
four times that for all NewYork City
children and the highest prevalence
rate of any child population in the
United States); and that homeless
children suffer from middle ear infec-
tions double the national rate, which
can adversely impact their language
development.26,27
1. STATISTICS
The following statistics are derived
from various research studies. They
reflect the health issues facing the
nation’s homeless population.
Mortality
Homeless persons face substan-
tially higher mortality rates than the
general population. From studies
conducted in homeless populations,
it has been estimated that mortality
in adults is approximately three to
four times greater than the general
population and mortality in children
is two times greater.11,28,29
The most frequent cause of death
among homeless in the 19-24 years
age group is homicide, for the indi-
viduals ages 25-44 years it is AIDS,
and for the 45-64 years group it is
heart disease and cancer. Similarly,
the risk factors for death in the
homeless includes AIDS and renal
disease (including hypertension and
diabetes).11
Mental Health Substance Abuse
It is estimated that 20-25% of the
homeless population have mental
health conditions such as schizo-
phrenia, depression, and bipolar
disorder.30
Mental health disorders
cause disruption in even the most
basic aspects of daily life, such as
self-care, household chores and
socialization. Research has revealed
that homeless persons with mental
illness remain homeless for lon-
ger periods of time and have less
contact with family and friends.
Moreover, they are more likely to en-
counter barriers to employment, are
in poorer physical health, and have
more contact with the legal system
than homeless persons without
mental illness.31
Because mental disorders require
chronic management, people with
little access to mental health care
have considerably poor mental
well-being. Nevertheless, most
people with mental disorders do
not need hospitalization, and even
fewer require long-term institutional
care. It is estimated that only 5-7% of
homeless persons with mental illness
require institutionalization; most can
live in the community with proper
supportive housing.31
Despite the
critical need for supportive housing
for homeless persons with mental ill-
ness, there is a dearth of appropriate
community-based treatment services
or supportive housing services.1,31
Addictive disorders often lead to
severe alcohol or drug abuse in
homeless persons. Among home-
less adults, 31-50% use alcohol and/
or other drugs.4
Often, alcohol and
other drugs serve as a form of self-
medication for people with untreated
concurrent mental disorders.32
Unfor-
tunately, there are limited services for
people with addiction disorders who
are in need of affordable/supportive
housing and health care.
Homeless children are especially
at risk of poor health due to low
immunization rates,inadequate
nutrition,unsuitable living
conditions,and little health
care.11,26
The most frequent cause of death
among homeless in the 19-24
years age group is homicide,for
the individuals ages 25-44 years
it is AIDS,and for the 45-64
years group it is heart disease and
cancer.
STATISTICS OF HOMELESSNESS

15
Physical Health
Several studies have found that one-
third to one-half of homeless adults
have some form of physical illness.33
Although arthritis, rheumatism and
joint problems are some of the most
common self-reported problems,
it has been evaluated that upper
respiratory tract infections, trauma,
female genitourinary problems,
hypertension, skin and ear disorders,
gastrointestinal diseases, peripheral
vascular disease, musculoskeletal
problems, dental problems, and
vision problems are the most com-
mon conditions affecting homeless
persons.11,33,34
Homeless adults and children suf-
fer from a variety of dental health
problems. It is estimated that they
are twelve times more likely to have
dental problems than the general US
population; the conditions of high
incidence are considerably more
serious, such as periodontal disease
(gum disease), edentulism (complete
tooth loss) and oral cancers.35
A
variety of conditions associated with
homelessness contribute to poor
dental health, they include: lack of
access to dental care, nutritional de-
ficiencies, inability to practice good
dental hygiene, alcoholism and other
substance abuse.33,35
Similarly, vision problems contrib-
ute considerably to the poor health
status of homeless persons. Little
access to optometric care contributes
to a situation where many homeless
people live with poor eyesight and a
variety of eye disorders.33
Close to half of the homeless per-
sons surveyed by the Interagency
Council on the Homeless in 1997
reported at least one chronic health
problem. The most common chronic
conditions were arthritis and related
disorders, high blood pressure, and
some type of physical disability (i.e.
lost limb, trouble walking).5
The
high prevalence of chronic disorders
among homeless people is especially
important because of its relation to
long-term disability and inability to
work or engage in other activities.36
There remains a severe need to
address issues of homeless persons
with chronic disabilities through
accessible housing units, supportive
services, and proper health care.
Approximately two-thirds of the
problems homeless people have are
acute illnesses which most are the
direct result of being homeless.33
The
three most common acute illnesses
that affect homeless people are respi-
ratory infections (i.e. colds, influenza,
pneumonia), trauma (i.e. lacerations,
wounds, sprains, contusions, frac-
tures, burns), and minor skin ailments
(i.e. sunburn, contact dermatitis,
psoriasis, corns and calluses).11,33
Infectious Diseases
Both acute and chronic infectious
diseases cause significant morbid-
ity in the homeless. Nationally, 26%
of the homeless reported an acute
infection, specifically chest infections,
coughs or bronchitis.5
There is high
prevalence of chronic infections in
the nation’s homeless population,
posing great threat to them and oth-
ers around them (see Table 4).11,33
Barriers to Health Care
The City of Los Angeles has the low-
est health insurance coverage rate in
California with 2.8 million uninsured
people.37
Compared with California,
Los Angeles has fewer free com-
munity health systems per 100,000
people.38
Hence, the major sources
of health care for homeless people
come from public hospitals, hospital
emergency rooms, and free clinics.
The homeless experience high rates
of hospitalization and re-hospitaliza-
tion since they often delay seeking
medical attention for their condi-
tions.11
Homeless adults and children are
twelve times more likely to have
dental problems than the general
US population.The conditions
of high incidence are periodontal
disease (gum disease),complete
tooth loss and oral cancers.35
Table 4. Prevalence of infectious diseases in homeless people.

16
According to a recent study conducted
in Los Angeles,39
57% of homeless
persons reported a regular source of
health care. Homeless persons with a
regular source of care were asked to
reveal their source. They responded as
follows: 30% hospital outpatient de-
partment, 25% community or home-
less clinic, 23% hospital emergency
room, 14% government-run clinic, and
9% private physician.
The homeless face a number of bar-
riers to health care.11,38
These barriers
are diverse and can be illustrated using
the four Levels of Causation from The
Multi-Dimensional Framework for
Homelessness. Examples of barriers to
health care are illustrated below:
Individual: the low perceived need
of health care by homeless persons;
that is, health care is not a top priority
for homeless persons trying to fulfill
basic needs such as housing and food.
Homeless persons may also have little
trust in medical establishments.11,38
Environmental: financial constraints
and lack of transportation.
Structural: lack of medical facilities for
homeless persons. Few clinics have
walk-in services or have complicated
enrollment procedures. Regimens
requiring actions such as bed rest or
refrigeration of medications. 11,38
Superstructural: discrimination or
improper care from medical providers
due to lack of experience caring for
homeless persons, poor attitude about
caring for homeless, or lack of experi-
ence working for homeless persons. 11
The inadequate service of health care
for homeless persons creates a system
that does not have the capacity to
provide continuous, comprehensive
health care necessary for the multi-
faceted problems of homeless people.
To make matters more difficult, there is
a lack of recuperative services available
to homeless persons once they are
discharged from medical establish-
ments.11
The three most common
acute illnesses that affect
homeless people are:
respiratory infections (i.e.
colds,influenza,pneu-
monia),
trauma (i.e.lacerations,
wounds,sprains,contu-
sions,fractures,burns)
minor skin ailments (i.e.
sunburn,contact derma-
titis,psoriasis,corns and
calluses).11,33
HOMELESSNESS FACTS:INTERNATIONAL
“Homeslessness is a complex concept embracing states of
rooflessness,houselessness,living in insecure accommodation,or
living in inadequate accommodation
Roofless includes rough sleepers,newly arrived immigrants
and victims of fire,floods or severe harassment or violence.
Houseless includes those living in emergency or temporary
accommodation such as night shelters,hostels and refuges and
those released from long-term institutions such as psychiatric
hospitals,prisons,detention centers,community or foster homes
with nowhere to go upon release.
Living in insecure accommodation describes people who are
staying with friends or relatives on a temporary or involuntary
basis,tenants under notice to quit,those whose security is
threatened by violence of threats of violence,or squatters.
Living in inadequate accommodation includes overcrowded or
substandard accommodation”

IV. SERVICES
Most urban centers in the US have
had missions, flophouses and soup
kitchens serving the poor for over a
century. These institutions, along with
government and non-profit agen-
cies and private individuals, provide
integral services to homeless persons.
While this makes for a broad arena of
services, there is little coordination or
communication between service pro-
viders creating a fragmented system
of services. Resources for homeless
services largely come from private and
federal grants. The federal govern-
ment serves homeless people with
two types of programs:
(i) programs for the homeless autho-
rized under the McKinney Act, and
(ii) programs for all low income people.
In 1999, 50 federal programs provided
services to homeless people. Of these
50 programs, 16 were specifically
targeted to homeless persons and 34
were mainstream programs designed
for all low income people. The federal
government set aside $1.2 billion for
programs for the homeless. In com-
parison, $215 billion was set aside for
mainstream programs in 1997.40
1. STEWART B. MCKINNEY
HOMELESS ASSISTANCE ACT OF 1987
There has been relatively little action
taken by the Federal government in
establishing comprehensive legisla-
tion responding to homelessness.
The Stewart B. McKinney Homeless
Assistance Act of 1987 was the govern-
ment’s first attempt at such legislation
and it remains the only one. The Act
was created in response to the grow-
ing homeless problem in the 1980s
and was most recently amended in
1994 to further expand the scope of
the legislation. The McKinney Act con-
tains nine titles summarized in Table 5
(see page 18). This Act is responsible
for funding various homeless pro-
grams seen at the local level.
Even though the McKinney programs
have been successful for helping
homeless persons, resources granted
to the programs are not enough to
meet demand. Furthermore, critics
argue that the McKinney Act fails to
respond to the causes of homeless-
ness; that is, the Act is designed to help
only those who are already homeless
and does not reach out to those who
are on the verge of homelessness.41
2. FEDERAL ASSISTANCE
PROGRAMS
Federal assistance programs are
designed for all low income individu-
als, including homeless persons. They
provide a wide range of assistance
such as housing, food, health care,
transportation, and job training (see
Table 6, page 18).
There has been increasing concern
that these programs have not met the
needs of homeless persons. In a Re-
port to Congressional Requesters, the
United States General Accounting Of-
fice (GAO) assessed the barriers to fed-
eral assistance programs encountered
by homeless persons.40
The following
is a description of each program and
barriers reported by the GAO.
Food Stamp Program:
The Food Stamp Program, adminis-
tered by the U.S. Department of Agri-
culture, provides low income persons
with coupons that can be redeemed
for food items at authorized food
stores. In 1999 this state-administered
program provided 18.2 million people
with an average of $72 in food stamps
each month. Only 37% of homeless
people received these benefits in 1996.
Obstacles to obtaining food stamps
include: misinformation about the pro-
gram, administrative difficulties, and
lack of outreach. In addition, homeless
persons may not be able to use food
stamps effectively because they often
lack facilities for food refrigeration,
storage and preparation.
Public Housing and Section 8 Tenant-
Based Assistance:
The Department of Housing and Ur-
ban Development oversees and funds
public housing and Section 8 tenant-
based assistance. These programs
house more than 6 million people.
While public housing is owned and
operated by a local housing authority,
Section 8 assistance is federally subsi-
dized privately owned housing. Scar-
city of public housing and dearth of
private landlords who accept Section
8 vouchers are the most fundamental
problems to accessing these programs.
Similarly, applying for these programs
includes long waiting periods during
which homeless persons may be lost
to follow up due to lack of stable ad-
dress or telephone number.
Employment and Training Services:
The Workforce Investment act of 1998
provides the framework for the federal
government’s employment and train-
ing activities. This legislation requires
states to establish workforce install-
ment boards that develop employ-
ment and training systems in their
communities. Job training is provided
through vouchers, which are used
to obtain services from community
providers. There is concern that this
program limits a homeless person’s ac-
cess to training since: the dollar value
SERVICES FOR THE HOMELESS
17

18
Table 5. The Stewart B. Mckinney Homeless Asstistance Act
Table 6. Federal Assistance Programs

of the voucher may not be sufficient to
meet the training needs of homeless
persons who require intensive services
and community providers may not
be qualified to serve special needs of
homeless persons.
Supplemental Security Income:
The Social Security Administration ad-
ministers the Supplementary Security
Income program, which provides cash
benefits to blind, disabled (physical
and mental), and aged persons who
are below certain income levels. In
1999, 6.3 million people received a
monthly average of $341 in SSI ben-
efits. Only 11% of homeless persons
received SSI in 1996 despite the large
number of homeless persons who
qualify for these benefits. The low
participation may be attributed to
the complex application process that
requires extensive documentation re-
garding issues such as living arrange-
ments, income and medical history.
Obtaining medical documentation can
be especially difficult since homeless
persons often do not have a single
service provider.
Community Health Centers:
Administered by the Department
of Health and Human Services, the
Community Health Center program,
funds primary and preventative health
care services in medically underserved
areas. The Program funds community-
based public and private nonprofit
organizations. Homeless persons were
approximately 2 percent of centers’
patrons in 1996. The barriers to access-
ing the centers’services are essentially
the same as barriers to health care in
general, as previously discussed.
Substance Abuse Prevention and
Treatment Block Grant Program:
The Health and Human Services’
Substance Abuse and Mental Health
Services Administration (SAMHSA) is
responsible for the Substance Abuse
Prevention and Treatment Block Grant
Program, which funds substance
abuse programs directed by states and
territories. There is cause for concern
because these substance abuse treat-
ment programs often do not address
the special needs of homeless persons,
who are especially in need of such
services. Examples of barriers to these
programs include: long waiting lists
that result in lost to follow up of home-
less persons; strict requirements, such
as access to telephone; and, outpatient
treatment rather than residential treat-
ment.
Medicaid:
Medicaid, a joint federal-state pro-
gram, provides health care coverage to
low income individuals. In California,
Medi-Cal is available to persons who
meet income limits or fall into“medi-
cally indigent”groups. Although most
homeless persons are eligible for Medi-
Cal, few homeless people actually have
this insurance. A major obstacle in
obtaining Medi-Cal is the application
process, which requires an interview
at which documentation of income,
residency, and medical history must
be provided. Further, individuals on
Medi-Cal must recertify their eligibility
annually. Without assistance, obtain-
ing Medi-Cal can be extremely difficult
for a homeless person.
3. STATE AND COUNTY ASSISTANCE
PROGRAMS
Homeless persons may be eligible for
the state of California’s welfare pro-
gram, CalWorks, and the county Gen-
eral Relief program. These programs
provide cash assistance to families and
the very low income, respectively. Bar-
riers to these programs include similar
programmatic obstacles discussed
above.
Services for homeless persons in Los
Angeles County are mainly concen-
trated within the downtown area.
Services range from housing agencies
to substance abuse programs. There
has been criticism that the system is
fragmented, with little coordination
or communication between service
providers. There exists a major need
to identify all services in Los Angeles
County and evaluate the effective-
ness of the services system. Further-
more, a multi-disciplinary approach
to providing services to homeless
persons, namely health care services, is
long overdue. For instance, a home-
less person who comes into a health
facility should be assessed for housing
status so that proper housing arrange-
ments can be made upon discharge;
moreover, he/she can be enrolled in
adequate recuperative services and be
referred to other agencies.
According to a study conducted
by Shelter Partnership7
, 153 agen-
cies operate 331 short-term hous-
ing programs for homeless people,
providing a total of 13,632 beds in
Los Angeles County. These beds are
primarily located (62%) in the City of
Los Angeles. More than one-third of
the County’s beds are intended for
the single adult homeless population.
Beds for families amount to about
19

17% and beds for persons with sub-
stance abuse problems comprise 22%
of the County’s total beds.
The majority of homeless services
are offered by non-profit organiza-
tions, some of which are religiously
affiliated. Services may have require-
ments and rules or contingencies that
are strictly upheld. Such a system
often promotes negative attitude
toward the services system because it
encroaches upon a person’s freedom.
For instance, it is estimated that skid
row has about 200 shelter beds open
many nights. Many homeless persons
do not use such services because they
do not want restrictions or do not feel
that they are treated with respect.43
The Los Angeles Homeless Services
Authority (LAHSA) is an important
player in the arena of service delivery
for homeless persons in Los Angeles
County.44
The Los Angeles County
Board of Supervisors and the Mayor
and City Council of Los Angeles cre-
ated LAHSA in 1993 to provide funding
and guidance for local, non-profit
agencies working with homeless per-
sons in areas such as housing, case
management, counseling, advo-
cacy, and substance abuse programs.
LAHSA is governed by a politically
appointed, 10-member commission
of which five members are selected
by the County Board of Supervisors
and five are chosen by the Mayor
and City council. Through a competi-
tive application process (Request for
Proposal), LAHSA distributes between
$45 and $60 million of public funds to
approximately 80 agencies and over
120 programs throughout the City and
County of Los Angeles each year. In
addition to allocating funds, LAHSA
coordinates its own direct services
to homeless persons, such as the Los
Angeles Winter Shelter Program.
The Department of Health
Services programs
The County of Los Angeles Depart-
ment of Health Services’public health
units play an important role in provid-
ing services to homeless persons in
Los Angeles County by collaborating
with other County and non-County
agencies. The Alcohol and Drug
Program Administration, TB Control
Program, and Office of AIDS Policy
and Programs have been involved in
the area of homelessness through a
variety of programs.
Alcohol and Drug Program Admin-
istration (ADPA): ADPA provides
several residential and non-residential
alcohol/drug recovery and treatment
services through contracts with vari-
ous community organizations. ADPA
contractors provided services to over
35,000 people, 24% of whom were
homeless at the time of admission in
FY 1998-1999. ADPA is also involved in
a number of jointly funded programs
that serve homeless persons, such
as: (1) Services for General Relief and
CalWORKS participants – screening,
assessment and treatment for partici-
pants with drug and alcohol problems
(2) Community Assessment and Ser-
vice Centers – substance abuse clinical
assessments, mental health clinical as-
sessments, and referrals to treatment,
screening for contagious diseases
and linking to other services (3) Los
Angeles Men’s Program – residential
recovery program for dually diagnosed
homeless men in downtown Los An-
geles (4) Alcohol and drug prevention
program in Skid Row – community
alcohol and drug prevention program,
providing drug-free environments.
TB Control Program: The TB Control
Program provides and facilitates the
proper completion of therapeutic regi-
mens by homeless persons with tuber-
culosis. The Program administers the
TB Control Incentive/Enabler Project,
which provides a variety of amenities
such as housing vouchers, meal vouch-
ers, and transportation assistance to
homeless and other indigent persons
with tuberculosis.
Office of AIDS Policy and Programs
(OAPP): Through a combination of
Federal Ryan White CARE and County
funds, OAPP supports housing services
for persons with HIV. Furthermore,
CARE funds provide involvement
in programs that identify homeless
persons with HIV, offer psychosocial as-
sessment, counsel and enroll persons
in comprehensive care.
20
HOWTO END
HOMELESSNESS:
THETEN ESSENTIALS
1. Plan
2. Data
3. Emergency Prevention
4. Systems Prevention
5. Outreach
6. Shorten Homelessness
7. Rapid Re-housing
8. Services
9. Permanent Housing
10.Income

21
DISCUSSION: THE NEED FOR A MULTI-DIMENSIONAL APPROACH
V. DISCUSSION: THE NEED
FOR A MULTI-DIMENSIONAL
APPROACH
As discussed earlier, in order to
better understand the etiologies
of homelessness and the needs
of homeless people we must
understand all factors that cause
and influence homelessness.
Homelessness is an extremely
difficult socioeconomic problem
to resolve and there has been
no dramatic improvement in the
state of homelessness over the
past couple of decades. There is a
critical need for a comprehensive
planning strategy that approaches
the problem from all angles and
perspectives. Homelessness requires
a wide-ranging, integrated, systems
approach to address complex,
multiple and competing priorities
and needs. In Los Angeles County,
just as in the rest of the nation and
many countries around the world,
there are countless governmental
programs and non-governmental
organizations dealing with specific
homeless issues often times in
isolation of each other. In some
places, duplication of efforts and
redundancy of programs and
services is common. In other
places, interventions are scarce or
ineffective, do not address the real
causes of homelessness, are limited
to a few group of beneficiaries or
contribute directly or indirectly to
exacerbate the problem. In many
settings, an inordinate amount of
funding is available for homeless
services. Nevertheless, the homeless
situation continues to worsen
instead of improving. In addition,
this situation is compounded in
some places by the fact that many
social and health governmental and
non-governmental organizations owe
their existence and sustainability to
the maintenance of the homelessness
problem. If in fact, there are
bureaucracies that support large
infrastructures and staff maintaining
status quo interventions and lacking
cost-effective programs and services.
The state of homeless in any county,
state or country cannot be resolved
without a unified strategic plan in
which all sectors of society –public,
private and non-profit—actively
contribute, participate and, most
importantly, share the vision, values,
resources, programs, services and
responsibilities in a complementary
fashion. Therefore, a framework to
plan, manage, implement and evaluate
all efforts to end homelessness is of
utmost importance. Consequently,
the SPA 4 Area Health Office proposes
The Multidimensional Framework to
Address Homelessness as a tool to
plan, organize, manage, implement
and evaluate all efforts to end
homelessness. This framework is
an adaptation of the Four Levels
of Causation of Disease and the
Multidimensional Model to Prevent
and Control HIV/AIDS promoted by
the Regional Office for Latin America
and the Caribbean of Family Health
International during the period
1992 – 1997. As has been discussed,
homelessness is a complex problem
with many levels of causation ranging
from individual behaviors to social,
economic and political conditions (see
Figure 12).
The SPA 4 Area Health Office proposes
the same levels of causation of HIV/
AIDS as the levels of causation
of homelessness –individual,
environmental, structural and
superstructural. “Superstructural
factors include macrosocial and
macropolitical arrangements, physical
and resource characteristics and
other elements such as economic
underdevelopment, sexism, racism
that often evolve over the long
term. Mechanisms for change at
this level include social movements,
revolutions, land distribution and
war. Structural factors include laws,
policies and standard operating
procedures. Mechanisms for change
INDIVIDUAL ENVIRONMENTAL
STRUCTURAL SUPERSTRUCTURAL
Causation Levels of Homelessness*
* SPA 4 Area Health Office
Causation Levels of Homelessness*
*SPA 4 Area Health Office

to local efforts in Los Angeles County
to deal with the issue. For example,
on January 30, 2001, LAHSA called
upon homeless service providers
and homeless people to facilitate a
discussion regarding homelessness
and homeless services. Among
those involved in the discussion
were Los Angeles County and City
representatives, law enforcement
personnel, community members and
governmental and nongovernmental
employees. Los Angeles County Sheriff
Lee Baca led the group discussion
identifying areas of need. The issues
were extensive, representing political,
social and personal concerns. Some of
the issues identified can be placed into
the Multidimensional Framework for
Homelessness (see figure 13)
The core message of the Multi-
dimensional Framework for
Homelessness is that efforts to address
homelessness at any of its four levels
of causation are not a collection of
independent activities, but rather
a system of integrated planning,
implementation and evaluation
practices. Los Angeles County, as a
whole, must manage these practices
at the structural level include
constitutional and legal reform, civil
and human rights activism, legislative
lobbying and voting. Environmental
factors include living conditions,
resources, social pressures and
opportunities, examples of which
include forced relocation/migration
in pursuit of employment and
urbanization. Processes for change at
the environmental level range from
community organization and legal
action to the provision of services. The
individual level factors relate to how
the environment is experienced and
acted upon by individuals and may
include, amongst others, isolation,
boredom and low perception of risk.
Change at the individual level is most
often achieved through education,
counseling, reward and punishment,
and the provision of information”.29
Therefore, in order for homelessness
programs and services to be effective,
a holistic approach is required
encompassing all the levels of society
and the economy.
The Multidimensional Framework to
Address Homelessness can be applied
or components and oversee their
successful integration to better address
homelessness issues and achieve
outstanding performance. The four
levels of causation of homelessness
represents more than isolated
components and even more than
individual levels with each one leading
to the next. Rather, they symbolize a
cohesive model or framework in which
each level supports and is supported
by every other. The connected levels
reflect a framework for a system in
which: (a) all parts are integrated
and altering one will affect all the
rest, and (b) assessing an issue in any
level requires examining the linkages
with all the other functions and the
multidimensional framework as a
whole.
“Successful and sustained public
health interventions of the past
have relied on changes at each
of the causation levels described.
The massive effort in the United
States to reduce cigarette smoking
is an example of an intervention
that worked at many levels and
ultimately succeeded in lowering
cigarette consumption. Initial efforts
targeted the individual smoker
INDIVIDUAL – healthcare seeking behaviors: homeless people do
not seek services because of poor customer services provided by
the personal, public and mental health systems.
ENVIRONMENTAL – lack of adequate sanitation on Skid Row, lack
of areas of recreation or fitness centers for exercise, few affordable
housing untis.
STRUCTURAL – no policies or protocols for adequate discharge
from medical facilities, no comprehensive release plan from
prisions, financial assistance procedures making funding inacces-
sible, lack of a comprehensive local, state or national plan.
SUPERSTRUCTURAL – Homeless people have no social,
economic or political power; the media and the public at large are
insensitive to homeless people and their issues
Figure 13. How Areas of Concern fit into The Mutli-Dimensional Framework for Homelessness
22
DISCUSSION: THE NEED FOR A MULTI-DIMENSIONAL APPROACH

the homeless. Current underlying
assumptions to end homelessness
are guiding programs in a direction
that can be counter-productive
or not cost-effective. Therefore,
The Multidimensional Approach
to Address Homelessness offers a
model to shift current planning,
management, implementation and
evaluation efforts and perspectives to
end homelessness. It is a framework
to facilitate innovation and change,
better utilize available resources, and
launch concerted public, private and
non-profit sector actions to address
the root causes of homelessness. It is
also a strategy to plan comprehensive
programs and services, organize and
deploy services, support policymaking
and improve the health status and
wellbeing of homeless people in Los
Angeles County, the state and the
nation as a whole.
Unfortunately, a homelessness
approach in Los Angeles County
operating on the referenced
complementary levels are rare or do
not exist. However, reinforcing and
multilevel strategies can achieve
results beyond those attainable
through purely individualistic
governmental and non-governmental
approaches. Clearly, to end
homelessness in Los Angeles County,
as well as in any other place, a
strategic approach based on
individual, environmental, structural
and superstructural interventions is
needed to address the causes and
conditions that facilitate homelessness.
VI. CONCLUSION
Homelessness is a reality around the
world in developing and developed
countries even in a booming economy.
Homelessness in Los Angeles County
has been and continues to be a major
societal problem. There are thousands
of people who live in substandard
conditions each night placing them in
vulnerable and high risk conditions.
Homeless people face a variety of
social, economic, mental and health
problems including chronic diseases,
injures and violence.
While a number of federal, state and
local services exist, there are multiple
unmet needs due to the lack of a
single, comprehensive strategic plan
comprising all public, private and
non-profit stakeholders in Los Angeles
County. The State of Homelessness
in Los Angeles County must be
addressed at the broadest biological,
social, economic and political levels.
New perspectives must be embraced
to change current mental models to
develop programs and services for
CONCLUSION
23
and eventually evolved to include
structural changes, such as cigarette
taxes, banning smoking in public
places and designating special
sections in airplanes for smokers. On
the environmental level, smokers
have been stigmatized and labeled
as outcasts and forced out onto
sidewalks to smoke, further reinforcing
these messages. The combination
of structural and environmental
pressures intensified the response of
the individual and produced results
beyond what would have been
attained through purely and individual
approach”. Other examples include
the prevention of vehicle-related
morbidity and mortality through
mandated seat-belt usage programs
along with water fluoridation,
enriching foods with micronutrients,
increasing educational opportunities
for women resulting in lower fertility
rates, syphilis screening on all hospital
admissions of reproductive age
women, and motorcycle helmet laws.
An additional example of the effective
application of multidimensional
approaches is the 100% Condom
Brothel Program in Thailand which
reduced the level of unprotected
sex and the incidence of sexually
transmitted infections and HIV/
AIDS. More specifically, individual
interventions included information,
education and training of commercial
sex workers. Structural internvetions
included non-compliance fines and
closure of brothels. Environmental
interventions included mass media
campaigns, condom availability and
brothel owners’buy-in and support,
and superstructural interventions
included macro level societal efforts
on poverty reduction, socioeconomic
improvement, gender equity, women’s
empowerment, etc.

1. Department of Health Services/ Public
Health Goals, Los Angeles County, 2000.
2. World Health Organization. The World
Health Report 2000: Health Systems:
Improving Performance (WHO,
Geneva, Switzerland, 2000).
3. Office of the Director of Health
Services, Rathgar Retreat Minutes (Los
Angeles County Department of Health
Services, August 22-23, 2000).
4. World Health Organization.
The World Health Report 2000:
HealthSystems: Improving
Performance (WHO, Geneva,
Switzerland, 2000).
5. Idem.
6. Idem.
7. Idem.
8. SPA 4 Area Health Office. Community
Liaising Program: A DHS Restructuring
and Reinvigoration Initiative (Los
Angeles County Department of Health
Services, 2000).
9. Gilbert, Tom. Behavioral Engineering
Model.
10. Family Health International. The
AIDS Control and Prevention
[AIDSCAP] Project Evaluation
Tools: Introduction to AIDSCAP
Evaluation (USAID/FHI, Arlington,
Virginia,1993).
11. Labovitz, George Rosansky,
Victor. The Power of Alignment
(Organizational Dynamics, Inc. USA
1997).
12. W. Leebow and C.J. Ersoz. The Health
Care Manager’s Guide to Continuous
Quality Improvement (Chicago:
American Hospital Publishing, 1991),
pp. 3-4.
1997).
14. Dallabeta, Gina et al. Control of
Sexually Transmitted Diseases:
A Handbook for the Design and
Management of Programs (USAID/
Family Health International,
Arlington, VA, 1995), pp. 43-56.
15. Idem.
1997).
17. American Management Association.
The Management Course for
Presidents (AMA, Hilton Head
Island, South Carolina, 1998).
18. Wright, Kate et al. Competency
Development in Public Health
Leadership (American Journal of
Public Health, August 2000) Vol. 90,
No. 8, pp 1202-1207.
19. Schuller, Robert H., 365 Positive
Thoughts (Crystal Cathedral
Ministries, Garden Grove, CA,
1998).
20. Maxwell, John C. Leadership 101
(Honor Books, Tulsa, OK 1994).
21. Murdock, Mike, The Double Diamond
Principle (The Wisdom Center,
Denton, TX, 1995).
22. American Management Association.
The Management Course for
Presidents. (AMA, Coronado, San
Diego, CA, 2000).
23. Gilbert, Tom. Behavioral Engineering
Model.
24. EnTarga, Approaches to Planning
(EnTarga Business Planning).
25. Lawrence, Paul and Jay Lorshc.
Organization and Environment
(Homewood, Ill.: Richard D.
Irwin,1969), pp. 11.
(Organizational Dynamics, Inc., USA
1997).
27. Idem.
28. Idem.
29. Calderón, M. Ricardo. HIV/AIDS
Prevention and Control SYNOPSIS
Series: Capacity Building (Family
Health International, Arlington, VA,
1997), pp. 5-12.
30. Idem.
31. Foege, William H. The Scope of Public
Health: Challenges to Public Health
Leadership (Oxford University Press,
1997), vol. 1, pp. 402-417.
32. Dever, G.E.A. An Epidemiological
Model for Health Analysis (Soc. Ind.
Res. 1976), Vol. 2.
24
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32. National Coalition for the
Homeless. NCH Fact
Sheet: Addiction disorders
and homelessness (Internet
communication, 20 August 2001
at http://nationalhomeless.org/
addict.html).
33. McMurray-Avila M, Gelberg L,
Breakey W. Balancing Act:
Clinical Practices That Respond
to the Needs of Homeless
People. In: Fosburg, Dennis (eds).
Practical Lessons: The
1998 National Symposium
on Homelessness Research. The
U.S Department of Housing and
Urban Development and the U.S.
Department of Health and
Human Services, August 1999.
34. Usatine RP, Gelberg L, Smith MH,
et al. Health care for the
homeless: a family medicine
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35. The United States Department
of Health and Human Services,
Health Resources and Services
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36. Sommer H. Homelessness in
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Literature. Paper presented
at Urban Homelessness and
Public Policy Solutions: A One-
Day Conference, January 22,
2001 (Internet communication,
20 August 2001 at http://
urbanpolicy.berkeley.edu/pdf/
briefbook.pdf).
37. The Los Angeles County
Department of Health Services. Los
Angeles County Health Survey
(LACHS) 1999-2000.
38. Rubell E. Homeless Health Care
Los Angeles. Presentation: Health
and Homelessness, 2001.
39. Gallagher TC, Andersen RM, Koegel
P, et al. Determinants of regular
source of care among homeless
adults in Los Angeles. Medical Care
1997; 35: 814-830.
40. The United States General
Accounting Office. Homelessness:
Barriers to Using Mainstream
Programs, July 2000.
41. National Coalition for the
Homeless. NCH Fact Sheet:
The McKinney Act (Internet
communication, 20 August 2001
at http://www.nationalhomeless.
org/mckinneyfacts.html).
42. Foscarinas M. The Federal
Response: The Stewart B.
McKinney Homeless Assistance
Act. In: Homelessness in America,
Oryx Press 1996.
43. Casillas O, Hayasaki E. Skid Row
Exiles Create Sidewalk Village. The
Los Angeles Times. February 19,
2001.
44. The Los Angeles Homeless Services
Authority (Internet communication,
1 August 2001 at http://www.lahsa.
org).
25

Metropolitan Service Planning Area (SPA 4)
241 North Figueroa Street, Room 312
Los Angeles, California 90012
Tel: (213) 240-8049
Fax: (213) 202-6096
www.lapublichealth.org
© 2002 SPA 4

The state of homelessness in Los Angeles County

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