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Violence and
Victims
www.springerpub.com/vv
With the Compliments of Springer Publishing Company, LLC
Violence and Victims, Volume 29, Number 1, 2014
122 © 2014 Springer Publishing Company
http://dx.doi.org/10.1891/0886-6708.VV-D-12-00069
Exploring the Experiences of
Violence Among Individuals
Who Are Homeless Using a
Consumer-Led Approach
Molly Meinbresse, MPH
National Health Care for the Homeless Council, Nashville, Tennessee
Lauren Brinkley-Rubinstein, MA, MS
Vanderbilt University, Nashville, Tennessee
Amy Grassette
Family Health Center of Worcester, Massachusetts
Joseph Benson
Healthcare for the Homeless Houston, Texas
Carol Hall
North Broward Hospital District Health Care for the Homeless,
Ft. Lauderdale, Florida
Reginald Hamilton
Advantage Health Centers, Detroit, Michigan
Marianne Malott
Community Health Clinics of Lane County, Eugene, Oregon
Darlene Jenkins, DrPH, MPH, CHES
National Health Care for the Homeless Council, Nashville, Tennessee
Homelessness increases vulnerability to violence victimization; however, the precise
factors associated with victimization and injury are not clearly understood. Thus, this
study explores the prevalence of and characteristics associated with violence victimization
among homeless individuals by surveying approximately 500 individuals experiencing
homelessness in 5 cities across the United States. Our findings reveal that nearly one-half
of our sample reported experiencing violence and that prolonged duration of homelessness
(greater than 2 years) and being older increased the risk of experiencing a violent attack.
In addition, increased length of homelessness and female gender predicted experiencing
rape. Women were also significantly more likely to know one’s perpetrator and experience
continued suffering after a violent attack. We conclude that certain subpopulations within
the homeless population are at an increased risk for victimization and, subsequently,
Copyright © Springer Publishing Company, LLC
Experiences of Violence Among Homeless Individuals 123
require added protective services; implications for health care and policy recommenda-
tions are also discussed.
Keywords: homeless; homelessness; violence; victimization; rape
Individuals who are homeless have an increased risk of experiencing myriad social prob-
lems including victimization and violence (Centers for Disease Control and Prevention,
2010; D’Ercole & Struening, 1990; Fazel, Khosl, Doll, & Geddes, 2008; Fitzpatrick,
LaGory, & Ritchey, 1999; Kerker et al., 2011; Kushel, Evans, Perry, Robertson, & Moss,
2003; Lee & Schreck, 2005; Raoult, Foucault, & Brouqui, 2001; Simons, Whitbeck, &
Bales, 1989; Tsai & Rosenheck, 2012; Welsh et al., 2012; Wright, 1990). The prevalence
of violence victimization in the homeless population has been estimated to range from
14% to 21% and approximately one-third report having witnessed a physical attack on
another person who was homeless (Fitzpatrick, LaGory, & Ritchey, 1999; Lee & Schreck,
2005). This rate of violence is highly disparate when compared to the general population in
which only 2% report experiencing a violent crime (Truman, 2011). In addition, research
has demonstrated that some subpopulations of homeless individuals are at even increased
risk of experiencing violence. For instance, those who experience longer bouts of home-
lessness have increased risk of victimization (Kipke, Montgomery, Simon, & Palmer,
1997; Lee & Schreck, 2005; Simons & Whitbeck, 1991). Those who have been previ-
ously turned away from a shelter or reported committing a crime since becoming home-
less are also significantly more likely to experience victimization (Garland, Richards, &
Clooney, 2010).
Research has also shown that experiencing violence can have serious prolonged
effects (Lindhorst & Beadnell, 2011; Sousa, Herrenkohl, & Moylan, 2011). Physical
assault on individuals experiencing homelessness has the potential to cause physical
and psychological injuries, extend homelessness, and may require considerable medical
treatment that most homeless individuals are unable to afford. The aftereffects of vio-
lence also include lower levels of perceived safety and an exacerbation of preexisting
mental health issues (Kilpatrick & Acierno, 2003; Perron, Alexander-Eitzman, Gillespie,
& Pollio, 2008; Sorenson & Golding, 1990).
Given these increased risks of experiencing violence and the understanding that
violence can have long-term prolonged consequences, this study specifically aims
to (a) describe the experiences of violence among individuals who are homeless,
(b) create a sociodemographic profile of individuals who have experienced violence,
(c) identify the factors that predict increased risk of experiencing violence and suf-
fering consequences after an attack, and (d) to craft health practice and policy recom-
mendations that illuminate solutions to addressing and stemming the increased rate
of violence experienced and the related negative effects both at the macro and micro
individual level.
In contrast to previous research, this study takes a consumer-led approach in which cur-
rently or formerly homeless individuals were integrally involved in each stage of research
(design, administration of the survey, and data analysis and interpretation). This sets our
study apart in that the critical perspectives of individuals who have experienced homeless-
ness helped to illuminate not only the issues that are of importance but what the results of
this study mean and how they can be incorporated into applied practice and affect relevant
policy change.
Copyright © Springer Publishing Company, LLC
124 Meinbresse et al.
METHODS
The data used in this study draw on a survey regarding experiences of violence by individuals
who were homeless in five cities across the United States (Detroit, Fort Lauderdale,
Nashville, Houston, and Worcester). This study was originally conceptualized, designed,
and administered by the National Consumer Advisory Board (NCAB) of the National
Health Care for the Homeless Council. NCAB comprises individuals who are currently
and formerly homeless, many of whom participate in the governance of their local
Healthcare for the Homeless (HCH) projects. HCH projects are grantees or subcontractors
of the federally funded community health center program. Some are stand-alone sites,
whereas others are housed within community health centers, public health departments,
or hospitals. Many HCH projects have multiple sites in one community and mobile units
or outreach workers travelling to different parts of a community to provide health care
services. For example, the HCH project in Nashville is part of a network of primary care
clinics with community, school, and mobile clinics. This project provides medical, dental,
and behavioral health services to men, women, and children who are homeless through
their Downtown Clinic (a brick and mortar clinic located in an impoverished neighbor-
hood), a mobile medical van, evening clinics at a local shelter, and other community
health center facilities. NCAB exists to voice the needs of the people who are homeless
on a national level, assist new projects in developing local consumer advisory boards, and
provide support to individuals who are currently homeless (National Health Care for the
Homeless Council, 2009).
Data Collection
The interviewers associated with NCAB recruited individuals at their local HCH projects
and sites where health care services relevant to homeless populations are provided.
Eligibility to participate in the study was met if individuals were currently homeless,
older than the age of 18 years, and self-reported that they were an enrolled patient of the
specified HCH project. If an individual met all three eligibility criteria, the interviewer
read the informed consent aloud, answered any questions or concerns about the study, and
asked for verbal consent from the potential participant. Research interviewers informed
individuals that participation in the study was voluntary and that they could discontinue
participation at any time.
The institutional review board of the Metro Public Health Department of Nashville and
Davidson County approved this study and allowed use of a verbal consent because of the
sensitive nature of the survey content and the vulnerable population being surveyed. If
an individual did not understand the informed consent for any reason, then interviewers
did not continue with the survey and documented the event. If an individual did not wish
to participate, interviewers recorded the refusal on a tracking form, including specific
reasons why. If a participant knew the interviewer or felt uncomfortable with a specific
interviewer, given the sensitivity of the survey questions, attempts were made to find a
different individual to administer the survey. All participants were offered a copy of the
consent form for future reference. Most surveys were administered in English. However,
when non-English, Spanish-speaking individuals were eligible to participate, attempts
were made to find a Spanish-speaking interviewer to administer the survey.
Because of the possibility that participants could become emotionally distressed and
retraumatized recalling violent experiences, research interviewers provided a list of local
Copyright © Springer Publishing Company, LLC
Experiences of Violence Among Homeless Individuals 125
resources after participants completed their surveys. Each site developed a list of resources
tailored to the specific services offered by the local community and HCH project (e.g.,
domestic violence shelters, legal assistance, and mental health services). Interviewers
received research training from the National Health Care for the Homeless Council, which
included topics such as research with human subjects, informed consent, data collection,
and confidentiality. One of the NCAB interviewers was principal investigator of the study
and received Collaborative Institutional Training Initiative (CITI) certification as well.
Personally identifiable information was not collected through the survey and all responses
were anonymous.
The total number of participants in the final sample was 516. This number represents roughly
100 participants from each city. Fifty-eight percent of participants required the assistance of the
survey administrator to complete the survey and 89% completed the survey in English.
Analytic Plan
Descriptive statistics were computed on all study variables. Three dependent variables were
used: experience of violence, experience of rape, and suffering after an attack. Bivariate
analysis was conducted to evaluate the associations between the three dependent variables
and myriad sociodemographic characteristics. Because the three dependent variables were
dichotomous indicators, four multivariate logistic regressions were conducted to evaluate
whether certain characteristics increased the odds of violence, knowing one’s perpetrator,
and suffering after an attack. A series of logistic regression analyses were then performed
using groups of conceptually related independent variables (e.g., regressing experience
of violence on gender and race). These exploratory models were used to guide selection
of variables for inclusion into the final regression models. The following variables were
selected as independent variables: race, sex, length of homelessness, place of attack, and
knowing the perpetrator. Evidence of significant predictors (p values) was derived using
chi-square. All data analysis was conducted using SPSS 19.0.
RESULTS
Of the total sample, 64% of participants were male, 35% female, and 1% transgender.
Nearly one-half (49%) of the participants self-reported as African American, 36% as
White, 12% as Hispanic/Latin American, and 3% reported they fell into the category of
Other. The median age of participants was 43 years old, with a range of 18–87 years. The
median length of homelessness reported by participants was 1.75 years, with a range of
1 day to 47 years.
Witnessing Violence
Participants were asked if they had ever witnessed a violent attack on another homeless
individual. For the purpose of this survey, a violent attack was defined as an event in which
one individual uses force to intentionally harm another individual physically, sexually,
or psychologically. Sixty-two percent of respondents reported witnessing an attack. Of
those, 32% witnessed an attack in the 30 days prior to the survey and 81% witnessed an
attack within the past year. More than half (56%), who responded that they had witnessed
a violent attack, reported witnessing an attack on another homeless individual 1–3 times.
Copyright © Springer Publishing Company, LLC
126 Meinbresse et al.
Personal Experience of Violent Attack
Participants were also asked if they had ever been the victim of a violent attack while home-
less. Forty-nine percent of respondents reported being the victim of an attack. When victims
were asked about the most recent time they were attacked, 30% reported being attacked
within 30 days of the survey and 73% within the past year (this percentage is cumulative
and includes those who reported being attacked with 30 days of the survey). Seventy-two
percent of victims reported being attacked 1–3 times while homeless (see Table 1).
Males and females experienced violence at virtually the same rate (49% and 48%,
respectively), whereas African American participants experienced violence more (51%)
than White participants (46%). However, White participants reported experiencing
more violence than Hispanic/Latino participants (46% and 44%, respectively). When
experience of violence was stratified by age and length of homelessness, the aver-
age age for victims was 4 years higher than that for nonvictims (44 vs. 40 years old,
respectively) and the average length of homelessness for victims was 1.6 times greater
than for nonvictims (4.5 vs. 2.9 years, respectively). In addition, there was a statisti-
cally significant difference in median age and length of homelessness between those
participants who reported experiencing violence while homeless and those who did not
(see Table 2).
Characteristics of Violent Attacks
More than half of victims (58%) reported that they were attacked in a street or alley,
whereas 16% reported being attacked in a public park and 13% reported being attacked in
a homeless shelter. Victims were also asked to provide the types of injuries they incurred
as a result of their most recent attack from a predetermined list of injuries. Although
TABLE 1. Time Elapsed Since Most Recent Attack and Number of
Times Victimized
Frequency Percentage (Cumulative)a
Most recent attack
Within past 30 days 71 30%
Within past 6 months 65 27% (56%)
Within past year 39 16% (73%)
More than 1 year ago 60 25% (98%)
Number of times victimized
1–3 times 179 72%
4–6 times 26 11%
7–9 times 7 3%
10 or more times 14 6%
aPercentages do not add up to 100 because response categories were created based on
open-ended responses. Responses that could not be categorized are not presented.
Copyright © Springer Publishing Company, LLC
Experiences of Violence Among Homeless Individuals 127
TABLE 2. Demographic Characteristics of Those Who Have and Have Not
Experienced Violence
Experienced
Violence (n 5 253) Never Experienced
Violence (n 5 287) x2
Race 3.70
African American 127 (51%) 124 (49%)
Latino 27 (44%) 34 (56%)
White 85 (46%) 101 (54%)
Gender 2.67
Male 161 (49%) 167 (51%)
Female 87 (48%) 94 (52%)
Age (years) Median age: 43 11.09**
$43 Years 144 (56%) 115 (44%)
,43 Years 103 (41%) 149 (59%)
Number of years homeless Median length of homelessness: 2 years 11.63**
$2 Years 139 (57%) 107 (43%)
,2 Years 103 (41%) 147 (59%)
**p , .01.
16% of victims were not injured, more than half of respondents (56%) reported bruising.
Approximately 30% were mentally traumatized, 15% were raped or sexually assaulted,
and 13% incurred a head or brain injury. Victims also reported broken bones, broken
teeth, being stabbed, and being shot (see Table 3). In addition, victims were asked if they
were robbed during their most recent attack and, if so, what specific items were stolen.
Forty-nine percent of victims reported that they were, in fact, robbed during the attack.
Commonly reported items stolen were money (75%), personal identification documents
(28%), medication (21%), and clothing (21%).
Victims were also asked to list reasons why they thought they were attacked. Again, the
responses came from a predetermined list, which included space for participants to report
additional reasons. The top four reasons victims thought they were attacked included the
following: robbery (32%), attacker was under the influence of alcohol or drugs (28%), hate
crime (15%), attacker had a mental illness (12%), and competition for space (5%). The
following explanations were additional qualitative responses provided by victims and each
reported by less than 5% of the sample: sexual assault, because of an argument, racially
motivated, and to prevent victim from helping another person. Almost a quarter of the
victims (24%) were not sure why they were attacked.
In addition, 31% of victims reported that they knew their attackers. Of those, a sub-
stantial minority (40%) identified the attacker as a friend; a small minority reported their
attacker was an intimate partner; and a very small minority reported that their attacker was
a family member (see Table 4). Victims were also asked about the housing status of their
Copyright © Springer Publishing Company, LLC
128 Meinbresse et al.
TABLE 3. Locations Where Violent Attacks Occurred and Injuries Incurred as a
Result of Attacks
Frequency Percentagea
Location of attacks
Street or alley 141 58%
Public park 38 16%
Shelter 32 13%
Abandoned building 18 7%
Houseb 10 4%
Jail 7 3%
Parking lotb 6 2%
Bus stationb 4 2%
Clinic 3 1%
Other 13 5%
Injuries from attacks
Bruises 137 56%
Mental trauma 76 31%
Raped/sexually assaulted 36 15%
Concussion/head injury 32 13%
Broken bones 32 13%
Tooth/teeth broken 22 9%
Stabbed 20 8%
Scraped or cutb 8 3%
Shotb 2 1%
Other 12 5%
Not injured 38 16%
aPercentages do not add up to 100 because participants could choose more than one response.
bThese responses arose from themes found in the qualitative data.
TABLE 4. Relationships of Attackers to Victims—Out of Those Who Reported
Knowing Their Attackers (n 5 72)
Frequency Percentage
Friend 29 40%
Intimate partner 11 15%
Family member 4 6%
Other 4 6%
No formal relationshipa24 33%
aThis response arose from a theme found in the qualitative data.
Copyright © Springer Publishing Company, LLC
Experiences of Violence Among Homeless Individuals 129
attackers. Thirty-two percent reported that the attacker was also homeless and 30%
reported the attacker was housed, a quarter of whom were reported to be police officers.
Assistance After the Attack
Forty-six percent of victims sought help after their most recently reported attack. More
than half of victims (60%) who sought assistance used the emergency room, more than
30% went to the police, and 30% went to a friend/family member or clinic (see Table 5).
Eighty-two percent of those individuals who reported seeking assistance stated that they
were successful in receiving assistance.
Sixty-eight percent of those who sought and received help were unable to pay the asso-
ciated medical bills. We asked victims if they were currently (at the time of the survey)
suffering consequences from a violent attack. Half of the victims (49%) reported that they
were still suffering. Choosing from a predetermined list, 73% of those reported suffering
from psychological trauma, 32% from resultant physical disability, and 28% from burden-
some financial debt.
Finally, we asked victims if they were familiar with the Crime Victims Fund, which
is a federal program to assist victims of violent crime (and sometimes family members
of victims) with resulting medical bills, mental health services, and lost wages. However,
only 14% of victims were aware of the Crime Victims Fund—9% of which had actually
attempted to receive funds. None were successful.
Multivariate Modeling
Four multivariate logistic regressions were conducted on the study sample to estimate the
risk factors for experiencing violence, experiencing rape, knowing the perpetrator, and
suffering after an attack. Table 6 shows the results of these multivariate logistic regres-
sions. The results demonstrate that being homeless for a long time (more than 2 years) and
older age led to an increased risk of experiencing violence. Moreover, increased length
of homelessness and female gender predicted experiencing rape specifically. Finally, only
female gender was a significant predictor of knowing one’s perpetrator and suffering con-
sequences after an attack.
TABLE 5. Where Victims Sought Assistance Sought After Attacks (n 5 105)
Frequency Percentagea
Emergency room 63 60%
Police 35 33%
Community clinic 11 11%
Friend/family member 10 10%
Health care for the homeless clinic 9 9%
Shelterb 3 3%
Other 12 11%
aPercentages do not add up to 100 because participants could choose more than one response.
bThis response arose from themes found in the qualitative data.
Copyright © Springer Publishing Company, LLC
130 Meinbresse et al.
TABLE 6. Multivariate Logistic Regression Models for Predicting Violence,
Experiencing Rape, Knowing the Perpetrator, and Experiencing Suffering
After an Attack
Characteristic
Violent
Victimization
Experiencing
Rape
Knowing the
Perpetrator
Suffering After
Attack
Regression
Coefficient SE
Regression
Coefficient SE
Regression
Coefficient SE
Regression
Coefficient SE
African
American
(n 5 127)
.994 0.188 .549 0.488 0.870 0.306 1.424 0.287
Female
(n 5 87)
1.131 0.197 89.770*** 0.814 2.122* 0.313 2.138* 0.309
$43 years
(n 5 144)
1.650** 0.194 1.374 0.503 0.841 0.275 1.680 0.317
Homeless
$2 years
(n 5 139)
1.676** 0.189 3.308* 0.517 1.740 0.325 1.087 0.303
Knowing the
attacker
(n 5 75)
0.166** 0.586 21.796 0.586
Sheltered
during attack
(n 5 55)
0.618 0.596 0.370 0.108 1.521 0.354
*p , .05. **p , .01. ***p , .001.
DISCUSSION
The results from this study provide a national picture of the prevalence of violence among
individuals who are homeless and the particular characteristics that predict increased risk
of experiencing a violent attack, experiencing rape, knowing one’s attacker, and suffering
consequences after an attack. Half of the participants in this study reported being the vic-
tim of a violent attack while homeless. This corroborates findings from previous research
demonstrating that homeless individuals may be at increased risk of experiencing violence
(Hwang, Orav, O’Connell, Lebow, & Brennan, 1997; National Coalition for the Homeless,
2012). Our results also demonstrate that specific populations within the homeless com-
munity are at increased risk to experience violence. Those who have been homeless for a
longer time and are older in age were most likely to experience violence. This highlights
the importance of targeted outreach and violence prevention efforts for specific popula-
tions such as those experiencing chronic homelessness. Thus, our findings indicate that
homeless health care providers may need to increase screening for experiences of violence
during primary care visits. Screening tools have been developed that can be used during
intake assessments by providers or social service agencies that ask about various experi-
ences, health, or social conditions that may be plaguing individuals or families (Helfrich
& Beer, 2007; Martinez, Hosek, & Carleton, 2009). The development of a screener that
Copyright © Springer Publishing Company, LLC
Experiences of Violence Among Homeless Individuals 131
specifically asks about the incidence of violence and associated characteristics would aid
health care practitioners in identifying those who are at increased risk.
Relatedly, research has found that social support is associated with a lower likelihood
of victimization (Hwang et al., 2009; McCarthy, Hagan, & Martin, 2002; Wenzel, Tucker,
Elliott, Marshall, & Williamson, 2004). This may indicate a need to provide victimization
prevention programs and interventions that focus on developing and harnessing social or
familial support to aid in a reduction in the rate of violence among individuals who are
experiencing homelessness. Social support based interventions have been successful in
increasing physical activity, improving diabetes self-management, and bettering health
outcomes for domestic violence shelter residents (Constantino, Kim, & Crane, 2005;
Kahn et al., 2002; McEwen, Pasvogel, Gallegos, & Barrera, 2010). These interventions
can take the form of support groups, risk-factor screening counseling, and group education
sessions at community events (Kahn et al., 2002). Based on our results, these types of pre-
ventative programs should be aimed at those who have been homeless for a considerable
amount of time, those who are older, and women who are at increased risk of experiencing
rape, knowing one’s attacker, and to suffer consequences after an attack.
Individuals who are chronically homeless are less likely to engage in primary care and
mental health services; therefore, clinic directors should ensure dedicated staff time to
conduct outreach to identify those individuals who are chronically homeless (Caton,
Wilkins, & Anderson, 2007). These outreach workers should be aware of the high like-
lihood for victimization and use trauma-informed approaches to assess and refer indi-
viduals to treatment. Trauma-informed care is a valuable health care delivery technique
that can be used to create a safe environment and avoid retraumatization for patients
who have been victims to adverse events. This might include first screening for trauma
among those who are known to be at increased risk and then providing educational
materials, a sense of safety, and support to aid in mobilization and realization of their
own strength and resources. In addition, providers can provide guidance to aid in devel-
opment of positive coping mechanisms for those who report violence victimization.
A large portion of the chronically homeless population has mental health issues and
previous research has found that persons with severe mental illnesses are more likely
to be victimized than the general population (Caton et al., 2007, Teplin, McClelland,
Abram, & Weiner, 2005). Although we did not ask about mental health diagnoses,
this could explain the higher rate of victimization in our study among those who were
chronically homeless.
Our findings also revealed that homeless women should also be targeted by preventive
and treatment interventions. The results of this study demonstrate that women are more
likely to experience rape. Relatedly, to our knowledge, this is the first study to examine
whether rape within homeless populations is related to knowing your attacker. Seventy-
nine percent of women who reported a rape in the United States in 2009 indicated that
they knew their attacker and only 21% of all rapes and sexual assaults were committed by
strangers (Rand & Truman, 2010). This is strikingly different from our findings that 21% of
the female victims reported knowing their attacker and 78% of all rapes were committed by
strangers, indicating that rape committed by strangers is much more prevalent in homeless
populations (Catalano, Smith, Snyder, & Rand, 2009). This difference could be explained
by the fact that women who are homeless are unsheltered and lacking a private residence to
protect them from perpetrators who otherwise would not have access to them. Thus, man-
agement personnel of shelters and clinical providers serving females and families should
look for signs that their residents have been victims of sexual assault and be prepared to
Copyright © Springer Publishing Company, LLC
132 Meinbresse et al.
connect victims to medical care and mental health services. Mental health consequences of
violence victimization include posttraumatic stress disorder (PTSD), depression, anxiety,
substance abuse, and panic disorders, with females at a much higher risk for PTSD and
depression than males (Kilpatrick & Acierno, 2003). In addition, health care providers
should increase access to STD and pregnancy screening for victims of sexual assault and
rape. Cross-sector collaboration between public health agencies, homeless service provid-
ers, and women and family service entities is needed to address and stem the prevalence of
rape against individuals experiencing homelessness. Interdisciplinary partnerships of this
kind have been demonstrated to promote health on various levels ( individual and commu-
nity) long term (Gillies, 1998). Accordingly, agencies that serve homeless women should
provide wraparound, comprehensive services that can help prevent and, if necessary, iden-
tify and treat sexual assault and the long-term suffering associated (e.g., resultant mental
health issues) with victimization.
Finally, providers and clinics frequented by individuals who are homeless may need to
increase support for victims of violence who are seeking medical and wage reimbursement
from state victim compensation programs (Office of Justice Programs, Office for Victims
of Crime, 2004). This study found that almost 70% of victims who received medical help
were unable to pay their medical bills and only 14% were aware of the victim compensa-
tion fund and none were successful in receiving funds from it. This indicates a need for
education-related outreach that brings awareness to the existence of programs that are
available to assist individuals who have experienced violence. The Office for Victims of
Crime provides educational materials for providers regarding the Crime Victims Fund and
may be a possible resource for providers to increase awareness of violence and victim-
related programs and outreach. In addition, many police departments have crime victim
advocates whose sole mission is to provide support to victims of crime. Partnerships
between homeless service providers may aid in increased awareness of victim financial
assistance.
Macro Level Implications
It has long been recognized that providing health insurance and access to health services
to individuals in need would aid in the treatment of physical and psychological injuries
(Andrulis, 1998; Berstein, Chollet, & Peterson, 2010). Ongoing treatment, appropriate
referrals, and appropriate use of medical services without fear of large medical bills
would improve access to health care and, subsequently, the health outcomes for victims
of violence. The 2014 Medicaid expansion provided for in the Affordable Care Act will
result in health insurance eligibility for persons experiencing homelessness, but adequate
outreach, education, and benefit design will be required to address the extensive health
care needs of victims of violence (Kaiser Commission on Medicaid and the Underinsured,
2011). Treatment for psychological disorders associated with violence, physical therapy,
recuperative care, and other services are needed to eliminate extended suffering of those
who have experienced violence and should be more widely available for vulnerable and
at-risk populations to access.
In the last several decades, laws have been passed that criminalize homelessness. This
trend may have led to decreased use of public spaces, forced homeless individuals to the
edges of society where they may be more likely to be victimized, and created a more
antagonistic relationship between homeless populations and law enforcement. Moreover,
previous research reports that individuals who are homeless may be less likely to report
Copyright © Springer Publishing Company, LLC
Experiences of Violence Among Homeless Individuals 133
acts of violence because of strained law enforcement relationships or fear of imprisonment
(Murray, 1996; Zakrison, Hamel, & Hwang, 2004). Our findings corroborate these find-
ings in that only 33% of victims who sought help after their attacks went to the police, and
30% of those who were attacked by a nonhomeless individual reported being attacked by
a police officer. This implies that efforts are needed to strengthen relationships between
local law enforcement officers and individuals who are homeless. This could take the
shape of organizing around initiatives that attempt to decriminalize homelessness and
sensitize law enforcement officers. For instance, Maine and California have implemented
police training protocols specifically geared toward ameliorating the strained relationship
between law enforcement officials and homeless populations, and Los Angeles has imple-
mented the tracking and reporting of crimes that are specifically aimed toward individuals
who are homeless (National Coalition for the Homeless, 2012). More organizing of this
kind is needed.
Limitations of the Current Study and Future Research Needed
There are various limitations to this study. All data was self-reported by participants,
meaning injuries and suffering could not be verified by clinical diagnosis. Also, we
limited eligibility to individuals who were enrolled patients within local Health Care
for the Homeless projects. Therefore, we did not get an accurate rate of victimization
within the homeless population for each community sampled. Surveying outside of this
patient population would provide a better understanding of the experiences of violence
of individuals who are homeless and not currently engaged in care. In addition, the sur-
vey did not include a follow-up question on why those who reported being victimized
did not seek treatment if they reported not doing so. This information could have helped
us to better understand the barriers that individuals who are homeless face in trying to
seek care when victimized. The biggest strength of this study was that its design and
data collection were led by individuals who have experienced homelessness. The NCAB
members initiated this project, developed the survey questions, recruited participants,
and administered surveys. NCAB strives to provide a voice to those who are margin-
alized because of their housing status. Leading a study to explore the experiences of
violence among those who are homeless has enabled NCAB to teach others about the
vulnerability of this population and potentially make an impact on the health care and
policy practices that affect it.
Future research is needed to better understand the root causes of violence against
individuals who are homeless and to investigate the circumstances and motivators of
perpetrators. In addition, the implementation of programs that are targeted toward those
who are at increased risk is needed and program efficacy evaluation must be carried out to
understand what specific prevention strategies are most effective.
CONCLUSION
In combination, the findings from this study identify that certain individuals are at an
increased risk of experiencing violence, knowing one’s attacker, and experiencing conse-
quences after an attack. Results from this study should be used to develop health practice
and policy recommendations to reduce the incidence of violence against people who are
homeless and to promote just and humane recourse for victims of violence. The potential
Copyright © Springer Publishing Company, LLC
134 Meinbresse et al.
programmatic, policy, and intervention implications for this study include the need for the
following: development of screening tools to aid in the identification of those most at risk
of experiencing violence; increased awareness of crime victim funding; creation and main-
tenance of cross-sector relationships to aid in the prevention of violence; and, finally, ame-
lioration of the relationship between law enforcement agencies and homeless populations.
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Correspondence regarding this article should be directed to Molly Meinbresse, MPH, National Health
Care for the Homeless Council, PO Box 60427, Nashville, TN 37206. E-mail: mmeinbresse@nhchc.
org or mollymein@gmail.com
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