Sleep Disturbance in the Homeless Population: The Relationship between Homelessness, Sleep and Health

Little is known about how sleep disruption impacts physical health among the homeless. The association between homelessness, quality of sleep and physical health were investigated in the current study. Convenience sampling was used to select participants from a pool of people attending the programs of Ecclesia Ministries. Interviews were conducted with 32 persons from the Boston metropolitan area, of whom 23 were currently homeless. The researcher assessed level of sleep disturbance, number of health problems and degree of homelessness using a standard demographic questionnaire, the General Health Questionnaire-12 (GHQ-12) and the Pittsburgh Sleep Quality Index (PSQI). Our results found evidence of significant sleep disturbance as well as significant mental and physical health problems in the sample. Correlational analyses provided partial support for the hypothesis that degree of homelessness impacts both sleep quality and physical health. Future work should investigate whether change in homelessness status alters sleep quality and physical health and also whether interventions may be utilized in this understudied and vulnerable population. SLEEP DISTURBANCE IN THE HOMELESS POPULATION 3 Introduction Homelessness emerged as a significant issue in the United States in the late 1970s and has since become an increasingly prevalent feature of the American socioeconomic landscape, affecting an estimated 2.3 to 3.5 million Americans in a given year (Poverty, 2007). As the rates of homelessness have increased, the aspects of homelessness that have received the most attention from researchers are the physical and mental health problems commonly suffered by this population (Davis & Shuler, 2000; Muñoz, Crespo, & Pérez-Santos, 2005). While a confluence of poverty-related factors affect the lives of the homeless, it is clear that the condition of homelessness itself (i.e. lack of consistent shelter) is a driving force in determining physical health. Even when compared to a low income, at-risk-for-homelessness group of people, the health status of homeless persons was significantly poorer (Muñoz et al., 2005). In fact, the mortality rate for the homeless population is two to four times higher and their life expectancy is 20 years less than those with a home (Muñoz et al., 2005). Among the potential factors contributing to this increased mortality rate are unstable living conditions and constant exposure to the elements (Davis & Shuler, 2000). Examples of these include overcrowding in shelters, lack of nutritional food, lack of hygiene and exposure to inclement weather (Vazquez, Muñoz, Crespo, Guisado, & Dennis, 2005). Violent acts targeting the homeless also pose a substantial risk. From 1999 through 2007, there have been 774 acts of violence by housed people, resulting in 217 murders of homeless people and 557 victims of nonlethal violence in 235 cities from 45 states (National Coalition for the Homeless, 2008). Complicating matters, the lack of housing can make treatment of health problems—whether in sanitary care, medication or follow-up—extremely difficult (Vazquez et al., 2005). SLEEP DISTURBANCE IN THE HOMELESS POPULATION 4 Apart from the risk of traumatic injury, various acute and chronic physical health problems plague the homeless population. Bronchitis, asthma, vision impairment, skin and bone problems, positive tuberculosis skin tests and joint complaints are common. Rates of arthritis, high blood pressure, diabetes and sexually transmitted diseases are also elevated within the population (Vazquez et al., 2005). Further research on homeless persons has found that their living conditions contribute significantly to mental health problems. Neurotic disorders in the homeless population are twice the rate of that in the general population (Sims & Victor, 1999). This increased incidence is associated with stressful life events such as long-term illness and lack of social support. Furthermore, mental health typically worsens as homelessness continues (Sims & Victor, 1999). The potential causes of this phenomenon are indicated throughout the scientific literature. In a study on the mental health consequences of exposure to violence, homeless persons who had witnessed various forms of violence tended to exhibit more symptoms of anxiety and paranoia (Fitzpatrick, LaGory, & Ritchey, 1999). Additionally, depression, schizophrenia, anxiety and chronic stress have all been linked to homelessness (DeForge, Belcher, O'Rourke, & Lindsey, 2008). The actual prevalence of mental illness within the homeless population varies, but data indicates that it generally hovers around 20 to 30% (Mowbray, Cohen, Harris, Trosch, Johnson, & Duncan, 1992). Interestingly, affective disorders and schizophrenia are known to be associated with sleep disorders (Davis & Shuler, 2000), another aspect of homelessness that is often overlooked. The primary element of interest in the current study is sleep disturbance and its connection to physical and mental health in homeless populations. Included in sleep disturbance are those disorders of initiating and maintaining sleep (insomnias), disorders of excessive SLEEP DISTURBANCE IN THE HOMELESS POPULATION 5 somnolence (hypersomnias), and disorders of the sleep-wake cycle and dysfunctions related to sleep, sleep stages or partial arousals (parasomnias) (Cormier, 1990). Insomnia, defined as difficulty falling asleep, difficulty staying asleep or difficulty waking up too early (Meisler, 1998), is a consistent predictor and risk factor for depression, anxiety disorders, other psychological disorders, alcohol abuse or dependence, drug abuse or dependence, and suicide. Furthermore, insomnia is related to decreased immune functioning, and may also be a risk factor for cardiovascular disease (Taylor, Lichstein, & Durrence, 2003). However, little research has examined insomnia in the context of homelessness. This is a large gap in the scientific literature, given that the many potential sources of insomnia—environmental disturbances, pain, stress, hunger, consumption of alcohol, sleeping during the day and physical activity just prior to bedtime—are common conditions of the homeless experience (Davis & Shuler, 2000). Only one study to date has specifically examined the effects of sleep disturbance on homeless persons. Davis & Shuler (2000) examined altered sleep-wake patterns in 50 homeless women from the Los Angeles area. Compared to the general population, atypical sleep patterns, namely a day/night sleep pattern and sleeping six or less hours a day, were present in over half the participants. Restless sleep was also a common complaint. The authors attributed this sleep disturbance to a number of causes, including inadequate sleeping arrangements, substance abuse, mental illness, anxiety and concerns about safety. Similar to the aforementioned study, the focus of the current study is to investigate the connections between homelessness, quality of sleep and health conditions through interviews with homeless persons. Unlike the study noted above, homelessness will be assessed in terms of its severity. Conceptualizing homelessness by severity is not in itself new, as it has been previously thought of in terms of levels, distinguishing living with friends and relatives, living in SLEEP DISTURBANCE IN THE HOMELESS POPULATION 6 shelters and living on the streets (DeForge et al., 2008). A similar distinction is made in the current study, with severity of homelessness starting low and increasing from sleeping in one’s own house or apartment, someone else’s house/apartment, a hotel, a shelter and outside. Designating sleep and health conditions as dependent variables and degree of homelessness as the independent variable, it is hypothesized that these three factors will be inter-related. It is expected that as the degree of homelessness increases, the number of health problems and the level of sleep disturbance will also increase. If there is such an association between sleep quality, homelessness and health, this research will shed light on the import with which homelessness should be treated, and where national priorities should be in terms of solving a problem that affects 2.3 – 3.5 million Americans each year.