Housing the Homeless: A Critical Step in Health Promotion


by Dr Rachel Manning


Rachel obtained a BA in Psychology and Sociology at University of Limerick (UL) in 2010. She then went on to complete a PhD in Psychology at UL in 2014. Rachel now works as a Research Fellow the University of Warwick. Her research interests include: – recovery experiences among vulnerable populations, particularly the homeless; – social and community approaches to health promotion and illness prevention; – and ecological approaches to health service research.

As a little girl I remember seeing an ornament in my grandfather’s house with Níl aon tinteán mar do thinteán féin’ printed on it. He explained it means ‘there’s no home like your own’. Perhaps this resonated with me. I have long thought home is a funny concept. Homes come in all shapes and sizes and exist in every corner of the globe. Homes are more than physical shelter; they are melting pots of human emotion and experience. Realising this, it is difficult not to wonder what it means to be without a home– that is, to be homeless.

yIn the last years I have been researching Ireland’s homeless. People ask ‘what causes homelessness?’ and I think of the young boy who ‘slipped into drugs’, the woman with depression, the girl abused at home, and the businessman who lost it all, among the many people I have met in my work. The only common thread through them is they are without homes and so that must be my answer.

In my work I also saw how unwell the homeless are. One of the few studies of health and homeless in Ireland [1] reported that 48% had psychiatric symptoms, while 76% had substance use problems. Physical illness was reported by up to 90% of participants, ranging across arthritis, back problems, pain, and tuberculosis. The human face of these numbers is that I was often unsure if someone I saw that day would survive to the end of the week.

It is easy to imagine how rough sleeping impacts health –  verbal and physical abuse are always possible. Many I met had been urinated on by drunken passers-by. The cold from city footpaths or country ditches causes sickness. Hygiene and medication management is almost impossible and access to healthcare is complicated without an address. But most of Ireland’s homeless reside in services, and often the ways in which these are provided limits health too.

Most homeless services operate a staircase model where ‘emergency’ time-limited (up to 2-years) shelter is offered first. This shelter is congregate ranging from 5- to 75-beds. Facilities (e.g. dining rooms, bedroom, bathrooms) are shared. The chaos of these spaces means rules on curfews, gender segregation, and set meal times are used. Most are also ‘treatment first’ so that shelter is leveraged against compliance with health advice (e.g. medication obedience, sobriety). If rules are obeyed, service users may move up a step toward independent housing.

Although intended to promote health and housing, the reality is that very few get past the ‘emergency’ step in these services – in 2013 around 37% had been in these services for longer than five years [2]. For some service users there is simply nowhere to go after services, but for others their inability or unwillingness to follow rules means they are evicted and circle between the streets, hospitals, and prisons, until they are taken back to homeless services to begin their staircase journey again.

The main problem of providing services in this way is that it undermines ‘self-determination’. Self-determination is an individual’s sense of choice and control over themselves. It has shown for positive behavioural change but if it is thwarted or restricted – as it is in services that enforce rules and operate treatment first philosphies –disengagement is likely. Self-determination has shown to promote better physical health [3] and health related to substance use [4] and psychiatic health [2].

An obvious way to enhance self-determination in homelessness is to provide homes. A home means individuals do not have to abide by rules. They are free to exercise the choice that you and I take for granted. I am xnot the first argue this point. Housing First is one example of homeless service provision where homes are provided from the offset. Support workers engage with the individual in their home 365 days a year for as long as necessary. Importantly, studies in America, Canada and Europe show better health outcomes among Housing First service users than those who receive care as usual. This type of care also costs less because individuals spend more time housed and less time in hospital, treatment facilities, and prison (See http://www.theguardian.com/cities/2014/oct/20/housing-first-the-counterintuitive-method-for-solving-urban-homelessness for an accessible summary). While in its early stages, there is also a pilot Housing first project in Dublin that is showing promise.

Slow but steady changes to homeless service provision shows that ‘tintean fein’ message is slowly infiltrating public and political will. The research shows that there really is no home like your own and it is possible that in the next years the potential of home to bolster health will be more fully realised. It is my view that aligning services with needs for self-determination is key to promoting health among Ireland’s most vulnerable people.


  1. Lawless, M. and C. Corr, Drug use among the homeless population in Ireland. A report for the National Advisory Committee on Drugs. Dublin: Merchants Quay Project, 2005.
  2. Manning, R.M., An ecological perspective on recovery in homelessness: the influence of key worker values on consumer self-determination. 2014.
  3. Williams, G.C., Z.R. Freedman, and E.L. Deci, Supporting autonomy to motivate patients with diabetes for glucose control. Diabetes care, 1998. 21(10): p. 1644-1651.
  4. Wormington, S.V., K.G. Anderson, and J.H. Corpus, The role of academic motivation in high school students’ current and lifetime alcohol consumption: adopting a self-determination theory perspective. Journal of studies on alcohol and drugs, 2011. 72(6): p. 965.


For more information on the NOVAS toiletries appeal contact Teresa Corbett (t.corbett2@nuigalway.ie)

Novas (http://www.novas.ie/about-us) are running a toiletries appeal for homeless people over Christmas. Personal hygiene is such a challenge in homelessness and having a ‘few new bits’ can make a huge difference to someone going through toughest of life circumstances.
There are two boxes in the postgrad tearoom  of the Psychology building at NUI,Galway as part of this appeal. If anyone would like to contribute please do. 
The boxes will be delivered to NOVAS before Christmas. All the things we gather will be made into packs and distributed around the country, so when people arrive at a shelter they will be given a pack that’s for them to keep. The aim is to provide people with things we often take for granted. When people have so little, keeping personal dignity intact becomes all the more important.
They are looking for:
• All types of toiletries and personal products;
• Underwear items of all sizes;
• Pyjamas and slippers;
• Small make-up sets.
Some things to note:
– They cannot give out any part used items.
– They are looking for donations for both males and females.
– Keep it simple, no need for fancy gift sets or expensive products. People need toothbrushes, toothpaste, shower gels, shampoo, tampons, underwear etc. Not gift sets that can be sold on.
– People need pjs and underwear. Often the women are quite petite so make sure to mix it up in terms of sizes. Slippers are wanted too.
– If you see shampoo marked 2 for 1, maybe even just buy the second… every little helps. You don’t have to give a lot!




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