Although homelessness among some ethnic minority groups in the United States has been the subject of systematic empirical study (
1,
2,
3), no studies have examined the problems faced by homeless Native Americans. Because Native Americans constitute a small portion of the U.S. population, .79 percent (
4), previous studies of homelessness and related problems among minority groups have not included separate analyses of this group.
Native Americans have experienced a long history of social disadvantage, and their disproportionate substance abuse and psychiatric problems have been well documented (
6). Alcohol-related mortality and hospitalization for alcoholism are higher in Native American populations than in the U.S. general population (
7). Psychiatric illness, such as major depression, has also been observed to be higher in some Native American populations (
8).
The purpose of the study presented here was, first, to estimate the proportion and representation of Native Americans among homeless veterans. Second, it examined their distinctive demographic characteristics and mental health problems. Increasing our understanding of differences between ethnic groups on these measures will aid in the identification of gaps in mental health services and contribute to the planning of services targeted for this vulnerable population.
Results
Proportion of Native Americans
The proportion of Native Americans in the HCHV program sample was compared with the estimated proportion of Native Americans in the general veteran population based on data in the 1992 National Survey of Veterans (
10). Because the age distributions of the two samples differed, the comparison was adjusted using the age distribution of the HCHV program population as the standard (
12). The HCHV program intake sample included 1.56 percent Native Americans. The age-adjusted estimated percentage of Native Americans in the general veteran population was 1.31 percent. This comparison suggests that approximately 19 percent (1.56/1.31) more Native Americans are in the homeless population than would be expected, given the proportion of Native Americans in the general population and the age structure of the HCHV program population. The difference between these proportions was significant (z=2.01, p= .044).
Sample characteristics
The first section of
Table 1 summarizes information on eight important demographic or background characteristics for which significant differences were found among the ethnic groups. These variables were used to statistically adjust comparisons between ethnic groups on all of the dependent measures.
Alcohol dependence measures
Table 1 also lists descriptive results from clinical measures of alcohol abuse. Analyses of comparisons of ethnic groups on variables related to alcohol problems are shown in
Table 2. The differences between groups shown in
Table 2 were fairly consistent over the four measures, with Native American homeless veterans reporting significantly and substantially greater alcohol-related problems than the other groups.
Relative to the white reference group, blacks were significantly less likely and Native Americans were significantly more likely to indicate current alcohol abuse. Similarly, Native Americans reported significantly more days of drinking to intoxication than whites (5.4 and 3.9 days, respectively). Relative to whites, blacks and Hispanics were significantly less likely to report previous hospitalization for alcohol problems, while Native Americans were significantly more likely to report such hospitalization. These self-report measures were consistent with the clinician's diagnosis of dependence. Compared with whites, blacks were significantly less likely and Native Americans significantly more likely to be judged alcohol dependent. On each of the measures of alcohol abuse, the proportion of Native Americans was about 40 percent greater than the proportion of the white reference group.
Drug dependence measures
The pattern of ethnic differences on drug dependence measures was quite different from that observed for alcohol dependence. As
Table 2 shows, Native American homeless veterans were significantly less likely than whites to indicate current drug abuse, while blacks were almost three times more likely and Hispanics were more than two times more likely than whites to indicate current abuse. Native Americans reported the fewest mean number of days of drug use (1.6 days), while blacks reported the most days (4.3 days). Native Americans did not differ from whites on this measure.
The percentage of Native Americans reporting previous hospitalization for drug dependence was lower than for all other ethnic groups (22.3 percent); the highest percentage was among blacks (45.8 percent). Native Americans also had the lowest percentage of diagnoses of drug dependence (24.6 percent), while blacks had the highest (55.8 percent). Relative to the white reference group, blacks were more than three times as likely and Hispanics were more than two times as likely to be judged drug dependent by the interviewing clinician, while Native Americans did not differ from whites on this measure. Thus compared with white veterans, on all four measures of drug dependence, blacks and Hispanics showed a consistent pattern of greater dependence and Native Americans a nonsignificantly lower level of dependence.
Psychiatric problem measures
As shown in
Table 3, the percentage of homeless veterans in the sample indicating current psychiatric problems was high, 46.5 percent overall. The prevalence of such reports was lowest among Native Americans (41 percent) and highest among Hispanics (50.1 percent). Native Americans and blacks were significantly less likely to report current psychiatric problems than whites (34 percent and 25 percent less likely, respectively). A similar pattern was observed for reports of previous psychiatric hospitalization. Native Americans had the lowest percentage of such reports (24.5 percent), while whites had the highest (33.8 percent). All ethnic minorities were less likely to report previous hospitalization than whites; Native Americans were 49 percent less likely, Hispanics 33 percent less likely, and blacks 17 percent less likely.
Clinicians' ratings of serious psychiatric problems were least prevalent among Native Americans (40.6 percent) and most prevalent among Hispanics (48.5 percent). Blacks and Native Americans were significantly less likely than whites to be diagnosed as having these problems. Blacks and Hispanics were significantly more likely than whites to receive a dual diagnosis, although the magnitude of the difference was small (8 percent and 15 percent, respectively). Finally, on mean number of psychiatric diagnoses, Native Americans had significantly fewer psychiatric disorders than whites (1.7 versus 1.8 disorders), while blacks and Hispanics had significantly more (1.9 in each group); however, the differences were small. In summary, consistently fewer Native Americans than whites presented with psychiatric problems at intake. The pattern was less consistent for black and Hispanic veterans.
Discussion and conclusions
This study addressed two questions. First, are Native American veterans over- or underrepresented in the homeless veteran population? The answer appears to be that Native Americans are somewhat overrepresented. An age-controlled comparison of veterans in the Health Care for Homeless Veterans program to a sample of the general veteran population suggested that there are about 19 percent more Native American veterans in the homeless population than would be expected. This estimate is likely to be conservative because the national survey includes veterans from both urban and rural areas, while the homeless sample includes veterans predominantly from urban areas. More Native Americans tend to be in rural areas than urban areas. Had the comparison of the national sample and the homeless sample adjusted for geographic differences, the difference in the proportion of Native Americans might have been even higher.
The second question asked by this study was, What are the alcohol-dependence, drug-dependence, and psychiatric problems presented by homeless Native American veterans, and how are they different from those presented by members of other ethnic groups? The answer is that homeless Native American veterans, like other homeless veterans, have high levels of mental health problems and substance abuse problems. However, compared with other ethnocultural groups, their problems are mainly alcohol related. Consistently, Native Americans were about 40 percent more likely than whites to report problems with alcohol abuse, previous hospitalization for alcoholism, and more days intoxicated.
The prevalence of a clinician's diagnosis of alcohol dependence among Native Americans was also about 40 percent higher than among whites. At the same time, Native Americans were no more likely than whites to have drug abuse or dependence, and they were significantly less likely to report psychiatric problems or previous hospitalization or to be diagnosed by the clinician as having a serious psychiatric disorder. This pattern among Native Americans contrasts sharply with those among blacks and Hispanics, whose problems centered around drug dependence rather than alcohol.
Although comparisons of this type are useful, we reiterate that the majority of veterans in this study are extremely disadvantaged and that the overall prevalence of substance use and psychiatric disorders was quite high.
These results are consistent with those of Howard and colleagues' study (
9) of substance-abuse-related VA hospital admissions. Like the study reported here, that study found that Native American veterans were more likely than others to be admitted with a diagnosis of an alcohol-related disorder and less likely to be admitted with a drug-related diagnosis or other psychiatric diagnoses. Similarly, Westermeyer and Neider (
13) noted that Native Americans admitted to a substance abuse treatment program were more likely to have a diagnosis of alcohol dependence or alcohol dependence plus drug dependence; that is, they were less likely to have a diagnosis of drug dependence only. The study reported here extends this pattern of results to the homeless veteran population and adds controls for potentially confounding demographic characteristics.
The nature of the alcohol abuse and dependence observed in this study is not clear. Native Americans reported both more days intoxicated in the past month (
Table 2) and more days using any alcohol (results not shown). Previous studies have argued that the predominant form of alcohol abuse in at least some Native American tribes is "binge drinking" (
14). Moreover, Levy and Kunitz (
15) found a higher percentage of abstainers in their study of the Navajo population relative to the general population. In this study, Native Americans were less likely than other veterans to abstain from alcohol (results not shown). Thus insufficient behavioral data were gathered to elaborate on the veterans' self-reports of current alcohol abuse.
Several limitations of the study must be noted. First, these data are based only on veterans who were contacted by the HCHV program for treatment and case management; they may not represent the entire population of homeless veterans. Second, the data are based on self-report and clinicians' impressions. The possibility of bias in reporting must be acknowledged. Because of the history of alcohol misuse among Native Americans, veterans in this group may be more aware of their alcohol problems or may be more willing to report them than veterans in other ethnic groups. Similarly, the interviewing clinician may be more likely to record an impression of alcohol dependence for a Native American due to sensitization or stereotyping.
Third, the measures of alcohol, drug, and psychiatric problems used in this study were based on single items rather than fully developed assessment scales. Thus they depend heavily on face validity. However, the extremely large number of individuals included in the study may have minimized the impact of these problems. That is, such biases would have to be consistently applied by dozens of independent clinicians to almost a thousand Native American veterans for the results reported here to be affected.
This study has documented a specific pattern of a high level of alcohol problems and a relatively low level of drug and psychiatric problems among homeless Native American veterans. The results argue for providing preventive treatment services targeted toward alcohol abuse to this population. Further work should be directed toward assessing the appropriateness and effectiveness of services for this population, as well as the relevance of specific culturally sensitive services.