Family transitions to homelessness: a qualitative approach

Rev Bras Enferm. 2020;73(5): e20190554 http://dx.doi.org/10.1590/0034-7167-2019-0554 6 of ABSTRACT Objectives: to characterize the homeless families who use a Public Shower Room; identify significant life events/phenomena for the family’s transition to homelessness; understand the relationship between significant life events; identify future expectations of respondents. Methods: an exploratory, descriptive study using the interview and thematic content analysis. Sample consisted of public shower room users. Results: mental illness, social, personal and family factors justify the transition of subjects to homelessness. The total absence of hopelessness alternates with expectations for the future based on resilience and hope. Final Considerations: we highlight in the study the self-determination expressed in small expressions of the narrative, on the one hand, as well as aspects related to the evolution of family relationships, on the other. Descriptors: Family; Homeless Persons; Qualitative Research; Self-Determination; Family Dynamics.


INTRODUCTION
International and national policies direct a path not always easy for nurses and other health professionals to operate. As nurses, and based on global thinking, we act locally in search of viable answers for the vulnerable population (1) and for local and territorial development (2) .
This study is part of a university extension project, concerning the health of Public Shower Rooms users of the city of Lisbon, a project that integrates the dimensions: research, service delivery, and education. Universidade Católica Portuguesa aims to investigate the problems of Portuguese society to promote cultural values. In this sense, and within the scope of university extension projects to the community, the study on the diagnosis of the health situation of Alcântara Public Shower Room users was developed (3) . Given the identified social vulnerability, the transcendence of the phenomenon and the available resources, a mental and community health nursing consultation was instituted.
This consultation aims to contribute to the promotion of healthy lifestyles; identify health problems and refer people where necessary to health system resources; identify psychosocial risk factors; identify interventionable mental health changes; contribute to minimize psychological distress; empower users to manage their health processes disease. Not replacing the recommendations of the national health service, this consultation can, however, speed up the search for better responses leading to health gains of vulnerable people and families.
According to the diagnosis of health situation of Alcântara Public Shower users, 30% live in homeless condition (3) .
The trend of homelessness in Portugal has been increasing. Between 2004 and 2005 there were 2,717 homeless people (4) . It is estimated that in Lisbon there are 3,000 homeless people (5) .
The Portuguese National Plan for the Integration of Homeless People (Plano Nacional para a Integração das Pessoas em Situação de Sem-Teto) (2017-2023) defines as one of the strategic axes of intervention the promotion of knowledge of the phenomenon, information, awareness and education, and as one of the strategic objectives to ensure the quality of answers and services provided (6) . According to this plan, a homeless person is a person who, regardless of nationality, age, gender, socioeconomic status and physical and mental health condition, is homeless, living in public space, housed in an emergency shelter or with whereabouts in a precarious place, or without a home, being in temporary accommodation (6) .
In the Health Profile document and its determinants of the ARLVT, it can be read that homeless people are all approaching the limit of social exclusion because, although most of them have homes and families, mostly because of break of family ties, do not live with family (5) . The bibliography lists a number of factors responsible for the transition to homelessness. Understanding the causes of being homeless should be viewed within a broad context as there are implications for the well-being of individuals.
We contextualized this theme in the context of transitions experienced by the person, situational type, usually associated with events or situations that require the definition or redefinition of the repertoire of roles of the person/family (1,7) .
The concept of family, specified by Figueiredo (2012) from a systemic perspective, integrates variables related to family self-determination, characterized mainly by affective bonds. The family system complexity also integrates evolutionary and contextual dimensions that give it an identity path that emerges from the reciprocity of the processes of mutual interaction with the environment and the characteristics of globality, equifinality, and self-organization as an eco-evolutionary autopoietic system (8) .
The factors that lead to homelessness point to issues of individual, family and social nature. Individual issues lead us to lack of skills, debts, physical and mental health problems such as drug dependence (9)(10) , and to disabilities and economic factors related to unemployment (11) . Mental illness and cognitive disability lead to stigma and greater difficulty in human relationships, particularly with the family (11)(12)(13) . Unemployment, poverty and inadequate public policies justify social causes (3,14) .
Given the importance of continuing to study vulnerable populations in the construction of nursing responses (1) (Meleis, 2010) and according to the data obtained, it was found that 30% of public shower room users are homeless (3) . A research project that aims to understand the causes of homelessness and the phenomena/ events of transition of the person/family to this condition arose.

OBJECTIVES
To characterize the homeless families who use a public shower room; identify significant life events/phenomena for the family's transition to homelessness; understand the relationship between significant life events; identify future expectations of respondents.

Ethical aspects
The project was approved by the Health Ethics Committee of the Regional Health Administration of Lisbon and Tagus Valley (Opinion 8030/CES/2018). The anonymity and confidentiality of the data and the destruction thereof were safeguarded in accordance with the legislation in force. Researchers expert in Mental and Psychiatric Health Nursing and Community Nursing dominate the complex specialized communication, which in no way weakened the participants in this research.

Type of study
This is an exploratory, descriptive study of qualitative nature.

Theoretical-methodological framework
The methodological framework fits into the qualitative, naturalistic paradigm that has as its basic characteristics the conduct of research in the natural environment and the researcher as the main instrument (15) .

Methodological procedures
The convenience sample consisted of users of a Public Shower Room in the city of Lisbon, according to the inclusion criteria, being over 18 years old, homeless and participating in the study. Data collection was performed between August and September 2018.
of Family transitions to homelessness: a qualitative approach Figueiredo AS, Ferrito C, Santos AS, Deodato S, Seabra P, Vidal T. et al.

Study setting
The study was carried out in the public shower rooms of Lisbon.

Data source
Data were collected through interviews, recorded in audio, transcribed by the researchers and subject to their own internal validation. In-depth semi-structured interview technique was used, according to a script previously prepared with questions that answer the proposed objectives.

Data analysis
Participants expressed their thoughts and experiences. A narrative corpus was obtained, which was later subjected to thematic content analysis and organized into main categories and subcategories, according to Bogdan & Bicklan (15) .

RESULTS
The dimensions of analysis were defined according to the objectives. From the successive readings of the interviews by the researchers, major categories and subcategories (15) were identified following the data reduction, which harmonize in an analysis matrix in Chart 1 and lead to the presentation of results.
In exploring the dimensions highlighted, five main categories emerged: personal/family factors, social factors, mental illness, future expectations and no future expectations. These main categories fall into subcategories (Chart 1).

Subject characterization
Of the 13 respondents 69% are male and 31% female. The average age is 44 years old, the minimum age is 26 years old and the maximum age 70 years old. With regard to schooling 40% have basic education, 30% have completed high school, 10% have a degree and 20% cannot read or write.
Of the same total, 70% are single, 15% married and 15% divorced. They are mostly Portuguese nationals with 50%, followed by 20% with African nationality, 20 with Romanian nationality and 10% with French nationality.
With regard to the employment situation 79.6% are unemployed, 7.7% retired and, with equal percentage we find subjects without employment contract and serving suspended sentence. Fifty percent of the research subjects have been attending the Public Shower Room for less than 1 year, 30% for more than 4 years and 20% for 2 years. On average, our subjects have been living on the street for 4.6 years. We found minimum situations of 1 month homeless and maximum 30 years living in this condition.
Regarding family typology 69% of the subjects constitute single-family families and 31% live in heterosexual couples.
In summary, the subjects of the sample are mostly male, are in the active phase, are single and of Portuguese nationality. Most are unemployed, have been using the Public Shower Room for less than 1 year and have been homeless for more than 4 years on average. Most live alone and one third as a couple.

Significant life events/phenomena for the family's transition to homelessness
In the first dimension of analysis, the main category -personal/ family factors fall into four subcategories with the following matrix.
Autonomy/independence that in the words of a subject justify that the absence of autonomy and personal independence weaken the person. Loss and grief are life events that, not overcome by individual or family incapacity, often also guide that condition and ineffective coping.

My brother died when I was in the hospital, and I couldn't go to the funeral. (I1)
The event that led me to be in this street situation was in the first place my addition. (I5) In this same dimension, the category -social factors, in turn, breaks down into three subcategories.  Legal nature is another subcategory that feeds the social factors category as we can see in this subject's record.

Dimensions of analysis
It was the judge; she wouldn't let me go to work! I'm on suspended sentence, I've never been arrested! She seized me the documents all (I4).
Dependence on others also subscribes to the same category as we can see in the words of another research subject. In summary, in the transition from family to homelessness, the data suggest, in personal and family factors: loss of autonomy, difficulty in managing conflicts, experience of loss and response strategies ineffective difficulties. In social factors, labor and legal phenomena and dependence on others justify the transition to homelessness.

Relationship between life events and homelessness
In the second dimension of analysis, relationship between significant life events and homelessness, the main category, mental illness is divided into two subcategories: Difficulty in managing conflicts (expressed by the narrative that characterizes the disability of the subjects to the to do) and Living with Additive Behaviors, as it reads: In short, mental illness -difficulty in managing conflict and addictive behaviors seem to underlie the relationship between life events and homelessness.

Expectations for the future
In the third and final dimension of analysis, expectations for the future, we find two main categories, future expectations and no expectations that, in turn, fall into subcategories. The future expectations category is divided into two subcategories: Resilience, marked by the resistant speech of a subject: [...] I am convinced that it is a phase and that we can go through! I have an inner strength and I will succeed! (I6) Hope, expressed in the following speech: The second main category, without expectations, is subdivided into:

Locus external control, in a narrative outside the individual
It's hard! My social worker can't get anything, all full! Just Vitae, and I don't want to! I'm trying! (I13) Hopelessness, in words that lead us to situations of blockage where the subjects do not see any kind of exit. There is in fact a finding in the expectations for the future linked to personal self-determination, expressed in the narratives, as well as aspects linked to the reorganization of family relationships.
In short, expectations for the future, according to the subjects, alternate between the total absence of expectations, marked above all by hopelessness and future expectations based on resilience and hope.

DISCUSSION
In the present study we verified that in the transition from family to homelessness, personal/family and social factors are involved. Such evidence has emerged in other studies that point out that this transition begins with a combination of crises, such as the separation, divorce, or death of a parent or caregiver (16) . Other events that may trigger this transition, as well as social ones, are the loss of employment of the "head of the family" and the decline in family income; loss of long-term parental support system and increased family conflict (17) .
From the perspective of the subcategories autonomy, conflict management, loss and grief, these subjects will be close to families with tenuous relationships with their own parents and siblings since adolescence, living in childhood with only one of the parental elements, with grandparents or other relatives. All of these factors that emerge from the reports significantly mark the lives of these people with profound repercussions on their personality structure, well-being and lifelong coping. It is clear from people's history that phenomena linked to mental suffering later appear. In this study, as in others, there is a clear relationship between the mental illness that fuels the difficulty in managing conflicts and the addictive behaviors (3,(18)(19) . Due to the prevalence, mental illness and the factors underlying it, of an individual, family and social nature, seem to be the factors that best justify the situational transition (1,7) of the family to homelessness.
There is an association between mental illness and homelessness. Regarding addictive behaviors, alcoholism is considered to be a chronic disease with foreseeable effects on welfare degradation (18) .
By the conditions in which they live we find people with no expectations for the future, in hopelessness (20)(21) . We also find a group of people who guide life with future expectations based 6 of Family transitions to homelessness: a qualitative approach Figueiredo AS, Ferrito C, Santos AS, Deodato S, Seabra P, Vidal T. et al.
on resilience and hope. These expectations were also revealed in North American research, where participants report taking advantage of the situation by experiencing the encounter of cultures and a new expression of family dimensions as well as the opportunity for learning (20)(21)(22) .
The literature has shown that many people who move from one country to another, even in situations of great difficulty in adapting and with inappropriate behaviors inherent to their situation, show potential resilience, hope and coping that makes them not give up and resist difficulties, which is also true of some of the participants in this study (23) .
There are still some families who look to their future with selfdetermination. They express that the evolutionary dimension of the family is maintained despite homelessness, reinforcing family practices and the strengthening of social capital through social structures of the national health system and service, similar to the results of other studies (21)(22) .
Family crisis is complex because it requires from health professionals, expertise in responses since people have no control over the actions and thoughts of the subjects (19) .

Study limitations
We consider as limitations of the study the fact that data were collected only in a community resource.

Contributions to nursing, health or public policy
The present study allows a greater understanding of the phenomenon of homelessness, namely in identifying the causes and expectations of this population, which may contribute to the definition of intervention strategies in response to the needs of the population.

FINAL CONSIDERATIONS
Subjects in our study are mostly male, are in the active phase, but most are unemployed. They are single and of Portuguese nationality. They have been using the Public Shower Room for less than 1 year and have been homeless for more than 4 years on average. Most live alone, but one third live with partner.
The results of the study are superimposable to other studies found, namely, regarding the significant life events for the transition from family to homelessness, where social factors (such as unemployment, suspended sentence), personal and family factors (such as family conflicts, loss of autonomy and mental illness) are highlighted.
Expectations for the future are expressed in hopelessness, which marks the total absence of expectations, and hope based on resilience factors.
Beyond the identified categories, it can be seen in the study participants' discourse that family relationships, in a homeless context, are reorganized, since some subjects reconstitute a new family by sharing their daily lives with a new companion.