An Overview of Homeless Clients Service Needs, Stresses, and Vulnerabilities Service Needs as Seen by Clients. Clients were asked to name the three things they needed most "right now," and also to identify the single most important thing keeping them in a homeless condition. Help finding a job was the most frequently cited need (42 percent), followed by help finding affordable housing (38 percent), and assistance with paying rent, mortgage, or utilities in relation to securing permanent housing (30 percent). Other needs cited by more than 10 percent of clients were assistance with transportation (19 percent), clothing (18 percent), food (17 percent), job training and medical care (13 percent each), and a GED and dental care (11 percent each). Insufficient income was cited most frequently as "the single most important thing" keeping the client homeless, at 30 percent of all homeless clients (figure 2.8). An additional 24 percent cited lack of a job or employment. Lack of suitable housing was mentioned by 11 percent of homeless clients, and addiction to alcohol and/or drugs by 9 percent. No other categories except "other" (14 percent) were reported by many clients. Food Consumption and Hunger NSHAPC clients were asked a basic question about the sufficiency of the food they eat. Twenty-eight percent of homeless clients report that they sometimes or often do not get enough to eat. Only 39 percent get enough of the kinds of food they want to eat. This contrasts with 60 percent of poor U.S. households and 80 percent of all U.S. households who say they get enough of what they want to eat.15 Other food problems experienced by homeless clients include usually eating one meal a day or less (20 percent); being hungry in the past 30 days but not eating because one could not afford enough food (39 percent); and going a whole day without eating anything at all in the last 30 days (40 percent) (figure 2.9). Data for some of these problems from poor U.S. households indicate that homeless clients have much higher levels of food problems than poor people generally. Thirty-nine percent of homeless clients versus 5 percent of poor households reported that in the last 30 days they were hungry but didn't eat because they couldn't afford to buy food, and 40 versus 3 percent said they didn't eat for one whole day or more because they couldn't afford to buy food. An index of food problems based on clients' reported hunger and difficulties obtaining adequate food was also calculated. This five-level index reports the percentage of homeless clients reporting none, one, two, three, or four food problems. On this index, 42 percent of homeless clients report no food problems. By contrast, 37 percent have two or more food problems. Victimization while Homeless In addition to the stresses of finding enough food to eat, being homeless removes the safety of a permanent residence and leaves one's person and possessions vulnerable to attack. Robbery and theft are common threats experienced by two in five homeless clients (figure 2.10). Thirty-eight percent of homeless clients report having money or things stolen directly from them while they were present (robbery), and a similar proportion (41 percent) report having money or things stolen from their bags, locker, or other location while they were gone (theft). In addition, 22 percent report being physically assaulted or beaten up at least once while homeless, and 7 percent report being sexually assaulted or raped. Physical Health Status and Insurance Survey clients were given a list of 17 medical conditions and asked if they had any of them. These include conditions classified as acute infectious conditions (chest infection/cold/ cough/bronchitis, pneumonia, tuberculosis, STDs other than AIDS); acute noninfectious conditions (skin diseases, lice/ scabies); or chronic health conditions (diabetes, anemia, high blood pressure, heart disease/stroke, liver problems, arthritis/rheumatism, cancer, problems walking/lost limb/other handicap, HIV/AIDS), as well as "other" conditions. Reported rates of these conditions may be underestimates because they rely on client self-reports. These self-reports may be low due to lack of knowledge or diagnosis of medical conditions, or reluctance to admit to having some of them. It is also possible that if the interview had inquired about other conditions, reported rates would be higher. Twenty-six percent of clients report one or more acute infectious conditions, 8 percent report one or more acute noninfectious conditions, and 45 percent report one or more chronic health conditions. Three of the four most commonly reported medical conditions are chronic health conditions: arthritis, rheumatism, or joint problems (24 percent); high blood pressure (15 percent); and problems walking, a lost limb, or other handicap (14 percent). Chest infection, cold, cough, or bronchitis (acute infectious conditions) are also among the most highly reported, at 22 percent. Twenty-four percent of homeless clients report that they needed medical attention in the past year but were not able to get it. Forty-six percent could not get access to a dentist when one was needed. This lack of access may be due in part to their general lack of insurance coverage. Fifty-five percent report that they have no medical insurance of any kind; the comparable figure for all American adults is 16 percent. By contrast, 30 percent say they are covered by Medicaid, 7 percent by medical care through the Department of Veterans Affairs, 4 percent by private insurance, and 10 percent by insurance of other types. A few clients mentioned more than one type of insurance. Among homeless clients in family households, 10 percent report that their children needed to see a doctor or nurse in the past year but were not able to do so. Homeless children are much less likely than homeless clients to be without insurance coverage. Only 20 percent of homeless family households have no insurance for their children. Seventy-three percent16 report Medicaid coverage for their children, while 6 percent have private insurance coverage and 6 percent have some other type of medical insurance coverage for their children (some clients in family households mentioned more than one type of insurance).  Alcohol, Drug, and Mental Health (ADM) Problems among Homeless Clients ADM Combinations Past Month Past Year Lifetime Any ADM Problema 66(%)b 74(%) 86(%) Alcohol Problem 38 46 62 Drug Problem 26 38 58 Mental Health Problem 39 45 57 Specific Combinations: Alcohol problem only 13 12 9 Drug problem only 7 7 6 Mental health problem only 17 15 10 Alcohol and drug problems 7 10 15 Alcohol and mental health problems 10 10 9 Drug and mental health problems 5 7 8 Alcohol, drug, and mental health problems 8 14 30 No ADM problems 34 26 14 Source: Urban Institute analysis of weighted 1996 NSHAPC Client data. Note: Percentages do not sum to 100% due to rounding. * Denotes values that are less than .5 percent but greater than 0. aThese ADM measures include a small number of cases (21 for the past month, 3 for the past year, and 5 for lifetime) who answered questions suggesting they had a substance use problem  but did not satisfy any other specific criteria for alcohol or drug problems. Because the precise nature of the problem cannot be determined from these measures, they are not included in the problem-specific measures. bThis is the measure used throughout this report as the ADM standard break. Alcohol, Drug, and Mental Health Problems Clients were asked about experiences considered to be indicators of alcohol, drug, and mental health (ADM) problems, and about treatment experiences related to these problems. Responses to questions were combined to categorize clients as having or not having particular problems during the past month, past year, and/or their lifetime (see chapter 1 for details on how alcohol, drug, and mental health problems were defined). When looking at the results, it is important to remember that NSHAPC information is not based on clinical diagnoses. Past Month. Homeless clients report a variety of problems with mental or emotional conditions, alcohol use, or use of illegal drugs within the past 30 days ). During this period 38 percent report problems with alcohol use; 26 percent report problems with drug use, and 39 percent report mental health problems. Sixty-six percent of homeless clients report one or more of these problems during the past month . Thirteen percent report only alcohol problems, 7 percent report only drug problems, 17 percent report only mental health problems, 22 percent report combinations of two problems, and 8 percent report all three problems during the past month. Past Year. The longer time period of the past year (including the past month) captures a larger proportion of homeless clients who report one or more problems with mental or emotional conditions, alcohol use, or use of illegal drugs. During this period, 46 percent report problems with alcohol use; 38 percent report problems with drug use, and 45 percent report mental health problems. Seventy-four percent of homeless clients report one or more of these problems during the past year (figure 2.11). Twelve percent report only alcohol problems, 7 percent report only drug problems, 15 percent report only mental health problems, 27 percent report combinations of two problems, and 14 percent report all three problems during the past year. Lifetime. As the longest time period being considered, it is not surprising that lifetime histories reveal the highest level of problems. During their lifetime, 62 percent of homeless clients report problems with alcohol use; 58 percent report problems with drug use, and 57 percent report mental health problems. Eighty-six percent of homeless clients report one or more of these problems during their lifetime (figure 2.11). Nine percent report only alcohol problems, 6 percent report only drug problems, 10 percent report only mental health problems, 32 percent report combinations of two problems, and 30 percent report all three problems during their lifetime. Overall Patterns. Looking over the three time periods examined, it is clear that as the time period lengthens more clients report problems in each area. Second, as the time period lengthens the proportion of clients who report a single problem decreases and the proportion who report combinations of two or three problems increases. Third, in each succeeding time period the difference decreases in the proportion reporting problems with alcohol compared to the proportion reporting drug problems, until for lifetime problems the difference is no longer statistically significant. Fourth, the proportion reporting combinations involving mental health problems plus alcohol and/or drug problems increases from 23 percent during the past month to 31 percent during the past year up to 47 percent over clients' lifetimes,17 with the most dramatic increase occurring in the proportion reporting all three. History of Incarceration About half (49 percent) of homeless clients have spent five or more days in a city or county jail in their lifetime. Some of these jail experiences may have been a direct result of their homelessness (i.e., the charges might be for behaviors that are difficult to avoid if one is homeless, such as loitering). Eighteen percent of clients have been in a state or federal prison, and 16 percent were held in juvenile detention at least once before reaching their 18th birthday. Altogether, 54 percent have some experience of incarceration. Adverse Childhood Experiences Ever since a Minneapolis study (Piliavin, Sosin, and Westerfelt 1993) identified childhood out-of-home placement in foster care as a common experience of homeless people, interest has been focused on these early separations from family and the ways that lack of family support after age 18 (when one has to leave foster care) might increase a young person's risk of homelessness. Homeless clients in the present study reveal that 27 percent were placed in foster care, a group home, or other institutional setting before their 18th birthday (figure 2.12). Many experienced multiple placements, as 12 percent were in foster care, 10 percent had been in a group home, and 16 percent had been in residential institutions. Twenty-nine percent of homeless clients also report abuse or neglect in childhood from someone in their household (12 percent neglect, 22 percent physical abuse, and 13 percent sexual abuse). Thirty-three percent ran away from home and 22 percent were forced to leave home for at least 24 hours before they reached age 18. In addition, 21 percent report that their first period of homelessness predated their 18th birthday (this homelessness might have been with their family or on their own). 15Information in this and the following paragraphs about food problems for all and poor U.S. households comes from the Current Population Survey Food Security Supplement, April 1995 (Food and Consumer Service, 1999). 1690% C.I. = ±12 percentage points. 17People who report regular use of marijuana (three or more times a week) but do not report any other drug use are included in estimates of people reporting problems with drug use. Were they to be excluded, the proportion with any drug problem would drop for the past month by about 6 percentage points, for the past year by about 8 percentage points, and for lifetime by about 10 percentage points. However, the proportion with any ADM would drop only by about 2 percentage points each for past month, past year, and lifetime ADM problem. 18 Most of this 6 percent reporting temporary housing with no overlap to shelters or streets actually indicated in other ways that they are currently homeless, including having been found in an emergency or transitional shelter; saying they got food at the shelter where they lived; or saying in answer to the basic screener question that the last time they had a permanent place to live was more than 90 days ago.