Homeless population : characterization and contextualization by census research

Rev Bras Enferm. 2020;73(5): e20190236 http://dx.doi.org/10.1590/0034-7167-2019-0236 8 of ABSTRACT Objectives: to analyze characteristics of homeless people and factors associated with living on the streets. Methods: a census-type sectional survey carried out between 2015 and 2018, in the municipality of Maringá-Paraná. A total of 701 homeless answered a structured questionnaire with sociodemographic data, living conditions, and drug use. We used Pearson’s correlation test for the association analysis of the variables at a 95% confidence level. Results: men (90.7%) the average age of 37.7 years had been homeless for an average of 5.39 years. Most had little education (54.2%), and homelessness was due to drug use (47.2%) and family disagreements (38.9%). Conclusions: drug use and family disagreements were the main reasons for homelessness. Time on the street, gender, and drugs were associated with a negative correlation to be homeless; and age, mean daily income, the number of daily meals, having been in prison, and having an income source were associated with positive correlation. Descriptors: Homeless Persons; Censuses; Vulnerable Populations; Street Drugs; Public Health Nursing.


INTRODUCTION
In the context of social phenomena, being homeless is among those that expose a person to social exclusion (1)(2) . Homeless, commonly called beggars, wanderers, bummers, and junkies, compose a group characterized by social invisibility, referring to marginality, crime, and drug use (3)(4)(5) .
Brazil does not have official data on the amount of the homeless population. The decennial demographic census and the periodic population counts do not include the investigation of the homeless populations since the census data are collected from the home base. Without housing and a conventional family arrangement, the group remains invisible to the State (6)(7) .
A survey published based on data collected in 2015, estimated that Brazil had over 100,000 homeless people -on sidewalks, squares, highways, parks, under bridges, gas stations, beaches, boats, tunnels, warehouses and abandoned buildings, alleyways, garbage dumps, junkyards or staying over in shelters (7)(8) .
The homeless population constitute a heterogeneous group, characterized by extreme poverty, interrupted or fragile family bonds and without regular conventional housing, using public places and ruined areas as a living space and to make living, temporarily or permanently, as well as shelter for a temporary living (9)(10) . The absence of official data on homeless justifies conducting municipal censuses, to implement public policies aimed at reducing their social invisibility.

OBJECTIVES
To analyze characteristics of homeless people in a medium-sized municipality in the Northern region of Paraná from 2015 -2018 and factors associated with living on the streets.

Ethical aspects
We submitted the research project to the Human Research Ethics Committee from the Universidade Estadual de Maringá (State University of Maringá), CAAE (Certificate of Presentation for Ethical Consideration) 02126916800000104. Participants signed the Informed Consent Form -ICF, and the ones unable to sign it, either because of being illiterate or due to physical impairments to sign, using a fingerprint.

Study design
Census-type sectional research, using intensive diary (11) , repeated in the years 2015 to 2018, performed in a single night of fieldwork in the streets of Maringá -PR with notes on data collection, and in different environments with homeless -social entities, health care units, therapeutic communities, non-governmental organizations and police stations during seven days (11) .
The Census is an example of descriptive nature research, through the direct observation of a certain planned number of individuals in a single opportunity, applied to society to obtain information about the demographic characteristics of this population (12) .

Study period and site
We conducted the study in the city of Maringá-PR, from 2015 to 2018, in the urban scenario of the homeless population. The city had an estimated population of 417,010 in 2018, a total territorial area of 487.052 km², and the Municipal Human Development Index of 0.808 (13) .
The routes and places to access homeless people were established according to the movement of these people and indicated by the Centro de Referência Especializado em Atendimento à População de Rua -Centro Pop (Reference Center Specialized in Attendance to Population Street), which resulted in 12 routes to the investigated population and ten host institutions and shelters.

Population under study
The study participants were homeless people in Maringá-PR, in the period of the annual censuses, who lived on the streets or were housed in shelters or host institutions, with over 18 years. We excluded the indigenous people, who were on the streets during the daytime and at nighttime were housed in shelters or host institutions, and also people who used the street for an overnight stay.

Study Protocol
Once we defined the population at a given moment and along the lines of census research, we collected relevant information on characteristics of the homeless people and factors associated with their living in a medium-sized municipality in the Northern region of Paraná in the years 2015 -2018.
A structured questionnaire was used, with questions related to sociodemographic profile and means for survival on the streets, and questions about living conditions, health and drug use -type, the average age of experimentation and current use.
For a non-domiciled population, we established some procedures distinct from traditional surveys. The interviews were done mostly in the nighttime, previously organized, prioritizing the times with the highest contact with them, when the population was settled to stay overnight in the 12 established routes, to guarantee the approach and interviews without duplicity. The shelters or host institutions were visited along one week, with the permission of the management, at times with the highest stay of users.
A total of fifty researchers -nursing and social sciences professionals, undergraduate and graduate students in psychology, nursing, and social sciences -have been divided annually between the different sites of the city and institutions.

Analysis of results and statistics
We compiled the data from the Database of the Research Project "Homeless People of Maringá: Deconstructing Invisibility", developed by the Observatório das Metrópoles -Nucleus of the State University of Maringá, using the IBM SPPS® Software. We performed descriptive statistics, using relative and absolute frequencies, as well as measures of dispersion and central tendency and used Pearson's correlation test for the association analysis of the variables, at a confidence level of 95%.
Regarding the time living on the streets, the time mean was 5.39 years (SD ± 7.48), the median of 2 years and mode of one year, with a minimum time of less than one year and a maximum time of 49 years. The time living on the streets was arranged in 5-year groups, observing that 72.2% (n:506) lived in the street from zero to 5 years; 14.8% (n:104) lived on the streets from 6 to 10 years in the research years ( Table 1).
The average age of the homeless was 37.7 years (SD ± 11.43), with a median of 36, mode of 28 years, and minimum and maximum ages were 18 and 77, respectively. The distribution in age groups showed that 59,6% (n:418) were in the age group of 25 to 44 years, and 6 participants (0,9%) were elderly (Table 1).
The reasons that led these people to live on the streets were drug use, 47.2% (n:331), family disagreements, 38.9% (n:273), and unemployment for 25.5% (n:179). The main reasons for coming to the city of Maringá were job search (29.7%), family disagreement in the city of origin (16.3%), or the easiness of living in the city (9.0%) ( Table 2).
The sources of income were: begging -28.7% (n: 201), watching cars in public spaces -24.4% (n:171), collecting recyclables -15.3% (n:107), working in construction 14.4% (n:101) and being a sex worker was pointed out by 10.3% (n:72), and the daily income was from one to 10 Reais -6.6% (n: 46) up to 50 Reais 30.4% (n: 213). As for food and daily meals, 28% (n: 196) reported four meals a day, but 13.6% (n: 95) had less than one meal a day.  had been in Prison, and 7.6% (n:53) had been hospitalized in Socio-educational Units for under-age offender children. Use of tobacco and alcohol was more prevalent in life, representing 84.6% and 84.7%, respectively, and a higher prevalence of current use, with 68.4% and 61.6%. The age mean of experimentation of the two drugs was on average, below 14 years.
The most prevalent illicit drug use in life was marijuana, with 67.9%, crack, 63.9%, cocaine powder, with 44.1% and inhalants, 40.1%. These four drugs had average experimentation ages of 14 to 15 years, and prevalence of current use was, respectively, in descending order: crack, marijuana, inhaled cocaine, and inhalants (Table 3).
Club or recreational drugs had the following prevalence of use in life: amphetamine 25.4%, sedative drugs 13.5%, hallucinogenic drugs 13.5%, opioids/opiates 3.2%. The prevalence of current consumption was 4.7% for amphetamines, 3.2% for sedative drugs, 1.7% for hallucinogens, and 0.8 for opioids/opiates. These drugs had averages ages of experimentation between 15 and 19 years (Table 3). Table 4 presents the frequencies of the type of drug used in the studied years. Tobacco and alcohol were the most commonly used licit drugs, and among the illicit drugs were marijuana and crack, respectively ( Table 4).
The Pearson's Correlation Test (Pearson's R) aiming to evaluate the statistically significant association, at the 95% confidence level, between being homeless and socioeconomic variables of the 701 homeless outcomes, pointed out that the variables time living on the streets and gender were statistically associated with the outcome variable in negative correlation; and the variables age, average daily income, number of daily meals and being in prison were significantly associated, at the 99% confidence level to the outcome variable, being homeless, with positive correlation. The variable drug use was statistically associated, at the 95% confidence level, with the outcome variable, in negative correlation and, to have a profession, in the sense of positive correlation (Table 5).

DISCUSSION
The experience of annual censuses presents the characteristics of the urbanization and the socioeconomic development of a municipality of 400,000 inhabitants of the North of Paraná, and we can consider for the findings the improvement in the data collection and a more effective recognition of the places and routes.
The gradual increase in the number of people approached and interviewed in the studied years might indicate the effective increase of homeless people living in the municipality, since   intermunicipal mobility was mainly for job search and for the easiness of living in the city in this decade of crisis and social inequalities (2,(14)(15) . Another aspect to be considered regards the time they live on the streets, which was significantly higher between 0 to 5 years, and the average of 5.39 years, might indicate the growth of the homeless population in the municipality. A survey carried out by the Ministério do Desenvolvimento Social (Brazil's Social Development Department) at the end of the 2010s, which considered only Brazilian cities with more than 300,000 inhabitants -71 municipalities except for the cities of São Paulo, Belo Horizonte, Porto Alegre, and Recife -found 31,722 homeless in these cities (9) . We presume that the total homeless living in Brazil was higher in that year since they did not count the homeless in cities with a population of less than 300,000.
Among countries conducting periodic national census research, in the year 2012, there were over 600,000 homeless people in the United States and the European Union over 400,000, with an increase in each census, and only Finland and the Netherlands reported reductions (16) . In 2018 there were 2,181 homeless people in Vancouver, Canada, with a 2% increase over the previous census, however, this is the highest number since the first regional homeless count in 2005 (17) .
In Brazil, it is estimated 100,000 homeless, being over 75% in cities with more than 100,000 inhabitants, a high concentration in larger cities, and regional distribution strongly influenced by big cities, where stands out the Southeast region (6)(7) . In the central countries, the origin and increase of the phenomenon seem to be associated mainly with migratory processes and with the emergence of wars, and in the Latin American countries with poverty and social inequality (2,14) .
Being homeless in Brazil easily changes from temporary to permanent, and 30% of them live under this condition for more than five years (7) . It is as a social situation that presents little in terms of overcoming. The process of becoming homeless comes from multiple conditioning factors, the reason why the intervention with those who have been living on the streets for less time seems to be central to achieve greater effectiveness in terms of public policy (2,10,15) .
The profile of homeless living in the streets of Maringá follows the trend of national and international studies (9,15,(17)(18)(19)(20) . Most homeless are men, and in Maringá, it rates above 90% young people -the predominant age group is 26 to 35 years -, with low schooling, brown and black color/race, and they have some source of income activity.
In the IBGE census -which gathers black and brown color/ race -the Brazilian population accounts for 53% of blacks and 46% of whites (9) . Considering the homeless population, if we use the same method, the black in our study is 65.8% -higher than in the Brazilian population.
Contrary to common sense, a large proportion of homeless carry out some source of income activity and claim to have a profession, even though it is part of the so-called informal economy, in which there is no formal job, official hiring and contract. The activities most carried out by them are those of collectors of recyclable materials, car watchers, construction workers. Many of the homeless do not beg to survive, in most cases there is work, but there is no hiring, which contradicts the popular logic that this would be a population that does not work, which justifies studies and interventions on the "work" them with these population (9,21) .
Regarding work and special populations, it is noteworthy that not everyone is qualified and capable enough for the formal labor market, in the sense of entering and staying in it, which makes a large contingent of workers vulnerable, including those affected by unemployment and lack of occupation. In this context, without work stability and guaranteed rights, the situation is seen as a dead-end, since it is a permanent threat, being left outlaw activities, side jobs, and small occupations as an alternative for survival (22) .
One of the human needs added to income is food. There is no time to eat, but most of them know the points that provide food and the times in which this happens (23) , and in Maringá, 25% of those surveyed reported they ate four meals a day.
The health of homeless people is among the worst of any vulnerable group, and national and international studies address several issues that go through the health of homeless people, especially the difficulties in accessing health services, meanings and health/disease practices, drug use, and psychiatric disorders (24)(25)(26) .
However, important milestones for the homeless were established in the National Policy for Homeless, to assert the rights of this population, as well as stipulate conditions of equality and equity for the homeless (9) . Homeless is entitled to all the services available in the Unified Health System, such as the Basic Health Units, Emergency Care Units, Psychosocial Care Centers, the Mobile Emergency Care, and the health strategy of the Consultório na Rua (Clinic on the Street) (27) .
The Consultório na Rua (Clinic on the Street is an action instituted based on the National Primary Care Policy, and its objective is to expand the access of the homeless to health services, in a more accessible way, and it has team composed of several health professionals, such as a medical doctor, nurse, psychologist, and social worker (28) .
There are multiple factors for becoming homeless; hardly a single factor will lead to this situation (20) . The main reasons why these people started living in the streets refer to problems with drugs; unemployment and family disagreements (9,14) . They report family disagreements and drug use as reasons for going to the streets, but we can question whether the permanence in the streets may be related to these findings. Caution is needed when stating that people are homeless because of the drug use, as it is difficult to measure whether drug use is a "cause" for homelessness or "consequence", in which drugs led them to be homeless, or was it the opposite, living on the streets that were central for drug use in their subsistence? (20,29) .
They have to deal with unfavorable living conditions on the street such as violence -many of them have already been in prison -lack of basic sanitation and hygiene, lack of food, lack of beds in public shelters and host homes (a problem in most cities), and being constantly away from family. In the study, many reported having children and not living with them, which leads to a highly stressful condition. Homeless can develop psychiatric disorders and drug use in response to difficult living conditions, being threatened by violence, hunger, and lack of shelter and care. The conditions in which they live not only relate to their characteristics but also to their context and other programmatic issues, which influence the vulnerability situation of an individual or social group (30) .
Other national and international researches have also studied drug abuse, especially alcohol, in the homeless population, factor 8 of
mentioned repeatedly in the speeches of several interviewees in Maringá (9,(17)(18)(19)(20) . The authors of these studies are emphatic in pointing out the need for integration between social policies to face situations of becoming homeless, stressing the importance of ensuring that this population has access to treatment in mental health in an articulated way to other policies. Socially excluded populations, such as homeless, prisoners, sex workers, and drug users, have mortality rates about eight times higher for men and 12 times higher for women, associated with moderate or extreme inequalities (31) . Globally, between 41 and 84% of adult homeless use drugs (32) ; in Brazil, an average of 80% of the homeless use drugs (18) , and this index is approximately 79% in the city of Maringá -PR (33) . In many cases, drug abuse is concomitant with mental disorders, and risk to violence or victimization (32) .
According to research by the Substance Abuse and Mental Health Services Administration (34) , drug abuse is more common among homeless people than among the general population. The results of the survey point that drug abuse was 26% among the homeless, and use is predominant among younger people, and 38% of this population drinks alcohol, which is predominant among the older population (34)(35) .
A qualitative study with the purpose of knowing aspects of the living, health, and illness of the homeless population in Maringá -PR, found drugs as part of the lives of six out of eight interviewees, when asked "what is it like to be healthy being a homeless?", they pointed to difficulties in health care, because they did not find health care services for their needs, did not have financial resources or family support, and faced denial of their life condition by other people and by themselves (36) .
Although alcohol and tobacco are statistically the most used drugs by this population, crack represents a serious problem due to individual consequences, aggravating the street environment and it is a challenge for public health policies, especially for primary health care policies, because of an observed increase in the prevalence of this use (37) .

Study limitations
The drug use, social vulnerability, and mental health of the study population can influence the information gathered about the homeless. However, the group of researchers has been trained in methodologies to approach vulnerable people and to formulate the questions to reduce this limitation.
The methodology of the census, by immersion in a week may not reach all homeless people, because it is a floating population -temporarily housed in relatives' homes or institutions, or temporarily displaced to other municipalities. This condition reinforces the need for a follow-up study with this population. Nevertheless, it is not possible to assert that a longer period for data collection would be better since it would be possible to count them more than once, or the homeless could have left the city since they are floating populations.

Contributions to the Field
Approaching this population, getting to know their way of living, the drug use and health in their environment would allow identifying peculiar aspects to propose alternatives that can contribute to their visibility and subsidize the creation and implementation of public policies for the impact of a hostile environment such as living on the streets. The study may also contribute to a less stigmatized and prejudiced view of the homeless so that health professionals can work to reduce the suffering of this population.
Nurses, and specifically Public Health nurses, are often the first health care providers to meet people who are homeless and are highly effective in involving this population in various educational and skills activities, to produce positive health outcomes and reduce risk behaviors (2) .

CONCLUSIONS
We consider as the differential of the study population the mental vulnerability, poor use of Consutório na Rua (Clinic on the Street) and frequent mention of social support homes, search for work and income beyond begging, and recognition of heterogeneity. They reported family disagreements and drug use as the main reasons for living on the streets, but we can question whether staying in the streets may be related to these findings.
Time living on the street, gender, and drug use was associated with a negative correlation to be homeless; and age, mean daily income, the number of daily meals, having been in prison, and having work was associated with positive correlation.
We suggest the creation of different strategies that contemplate the particularities of this group to allow the surpassing of the processes of becoming homeless, avoiding massive approaches, and it is emphasized the indispensable participation between state and society for the overcoming of stigmas and prejudices, from social research, inclusion of the theme in teaching, debate, use of the media and social networks, so that these subjects can be visible as subjects with rights.