Abstract
Both experiencing homelessness and having survived a violent firearm injury are well-known risk factors for being a victim of violence. Despite there being significant racial disparities in these factors, there is no qualitative research examining the experiences of Black men who survive a gunshot wound and were homeless after their injury. Drawing on over a year of ethnographic research at the two busiest hospital-based violence intervention programs in the state of Maryland, this research centers the experiences of violently injured homeless Black men to understand how to best support their health, healing, and social goals. Emergent themes from the research included the significant need for housing after injury, challenges with healing while homeless, and difficult experiences with housing institutions. The findings suggest that additional supportive care services for Black men who survive gunshot wounds are needed to increase access to safe and stable housing.
Introduction
There are significant racial disparities associated with fatal and nonfatal firearm injuries—including in terms of homicide, long-term physical disability, and mental illness (Centers for Disease Control and Prevention, 2022; Kaufman et al., 2024; Ralph, 2014; Semenza et al., 2024). National rates of firearm homicide are more than 10 times higher for Black men compared to similarly aged White men, with marked differences relating to age and geographic location (Centers for Disease Control and Prevention, 2022). In Maryland, Black men are 82% of gun homicide victims despite only comprising 15% of the state’s population (Giffords Law Center, 2024). While data on nonfatal shootings are less available than homicide data, the rate of nonfatal firearm injuries is significantly higher for Black Americans compared to their White peers—80.8 per 100,000 compared to 3.8 per 100,000 (Kaufman et al., 2024). Like other health disparities, interpersonal firearm injuries are the result of complex relationships between structural, social, and individual factors (Bancalari et al., 2022; Houghton et al., 2021; Johnson et al., 2021). These factors include legacies of economic and social marginalization, over policing and mass incarceration, concentrated poverty, poor access to healthcare, and complex individual trauma (Benns et al., 2020; Poulson et al., 2021; Uzzi et al., 2023, 2024). Individuals who had substance abuse issues, a history of incarceration, engaged in informal economies, reported fighting or weapon use in the previous year, and did not have stable housing experienced increased risk for repeat violent injury (Richardson et al., 2016).
For many Black men who survive gunshot wounds, discharge from the hospital often means returning to the same social context and location in which they were injured (O’Neill et al., 2020; Richardson et al., 2020). The trauma of a gunshot wound, fear of repeat victimization, and heightened social instability (loss of job, loss of housing, long-term healthcare needs, etc.) may contribute to fraying already tenuous relationships with members of their social network, ultimately decreasing their ability to rely on them for support (Aguilar et al., 2023; Vella et al., 2020; Wical, 2024). Often Black men who survive gunshot wounds are forced to attempt to meet their basic health and safety needs with insufficient support from institutions and limited access to critical services (Liebschutz et al., 2010; Magee et al., 2023; Patton et al., 2019; Wical et al., 2022). Survivors adopt nuanced strategies to increase feelings of safety and decrease the likelihood of a repeat injury—including changes to their patterns of movement and social relationships. These efforts, including what Black men who survived a gunshot wound described as “staying out of the way,” may be impeded by structural barriers to achieving health, healing, and recovery—such as poor access to safe transportation, lack of affordable housing, and insufficient access to structurally competent service providers (Richardson & Wical, 2024; Richardson et al., 2021). Attempts to avoid repeat violent injury are of particular concern for those men who are homeless, 1 as unstable housing status is a well-documented risk factor for violent victimization (Deck & Platt, 2015; Ellsworth, 2019; Fischer, 1992; Kushel et al., 2003; North et al., 1994).
Background
Hospital-Based Violence Intervention Programs as Service Providers
Commonly associated with emergency departments or trauma services, hospital-based violence intervention programs (HVIPs) were created in response to high rates of recurrent violent injuries, including gunshot wounds (Cooper et al., 2006; Juillard et al., 2016; Webster et al., 2022). The Health Alliance for Violence Intervention (HAVI), the national network of HVIPs, explains that the goals of these programs include identifying those who are likely to be injured again and addressing their health and social needs through care provision and facilitating connections to hospital- and community-based resources (Health Alliance for Violence Intervention, 2020). While there is not a standardized HVIP model, programs may provide brief psychosocial intervention (most often completed bedside while someone is hospitalized), long-term and intensive case management, mentoring, support from culturally competent case workers, crisis intervention, and referrals to additional community-based service providers (Harfouche et al., 2023; Schenck et al., 2023; Wical et al., 2020). In theory, approaching someone shortly after their injury increases the likelihood that they will make lifestyle changes (Armstrong et al., 2023; Evans & Vega, 2018; Purtle et al., 2014; Webster et al., 2022). It is during this “golden hour” that case workers or violence intervention specialists approach patients to introduce the program and its available services with the goal of convincing them to seek education, change employment status, stabilize housing situation, and address mental health concerns (Bonne & Dicker, 2020; Ranjan et al., 2022). 2
While some programs have noted reductions in repeat injury and criminal justice recidivism for their participants, there has been limited and contradictory research on the effectiveness of HVIPs (Affinati et al., 2016; Cooper et al., 2006; Juillard et al., 2016; Shibru et al., 2007; Webster et al., 2022; Wical et al., 2022). Importantly, there is a dearth of long-term qualitative research examining the effectiveness of HVIPs, the perspectives and goals of those men who participate in them, and how programs navigate local contexts with high rates of gun violence, significant need for access to healthcare, and poor support for violence intervention work (Baker, VanHook, Ziminski, Costa, et al., 2024; Baker, VanHook, Ziminski, Semenza, et al., 2024; Richardson et al., 2020; Wical, 2024). While these programs can offer referrals and assist with applying for housing through city and state governments, connect participants with shelters, and in some cases provide small financial support to assist with rent, the HVIP model does not prioritize safe housing as a primary mode of intervention. In a systematic review of the literature on the effectiveness of HVIPs, Jang et al. (2023) noted that housing was one of the most unmet needs of participants due to the lack of affordable and safe housing options as well as the lengthy process of obtaining housing. However, the HAVI does not mention homelessness as a significant challenge for HVIP participants, and there are no established best practices for providing care to men who are homeless after their injuries. 3
Homelessness and Firearm Injuries
While homelessness is operationalized differently across various contexts, the United States Department of Housing and Urban Development (USDHUD, 2022) defines someone as homeless if that person does not have a “fixed, regular, and adequate nighttime residence.” This definition includes having a residence which is “a public or private place not meant for human habitation” or living in a temporary housing shelter or hotel/motel paid by either an organization or a governmental program. People who are homeless experience lower levels of health and well-being compared to the rest of the population (Schanzer et al., 2007). Notable health issues include high rates of mental illness, substance abuse, chronic illness, infectious diseases (including HIV and hepatitis C), poor nutrition, and high rates of victimization (Bowen et al., 2019; Fazel et al., 2014; Henderson et al., 2022; Koh & O’Connell, 2016; Kushel et al., 2003; Stafford & Wood, 2017). Housing status is an important factor in rates of hospitalization for violent victimization—with rates of assault being nearly four times higher for people who were homeless compared to those who have stable housing (Silver et al., 2023). Similarly, housing status is an important factor in rates of violent reinjury, as people who were homeless with a history of violent injury were significantly more likely to be injured again in a similar manner compared to people who were injured but had stable housing (Courtepatte et al., 2023; Kaufman et al., 2016; Richardson et al., 2016). The combination of multiple different health disparities contributes to the approximately 30-year difference in life expectancy for people experiencing homelessness compared to the general population (National Alliance to End Homelessness, 2021).
While HVIPs do provide support to participants who are unstably housed or homeless, there are notable challenges with engaging this population—including difficulty meeting the needs of clients, barriers with effectively contacting participants, and outright refusal to engage with program services (Pino et al., 2021; Wical, 2024). Thus, it is likely that Black men who survive a gunshot wound and are subsequently homeless have a significant need for comprehensive services and are at a high risk to be violently reinjured. Hwang and Burns (2014) noted that tailoring services and interventions toward the specific needs of people who are homeless—including intensive case management for substance misuse, supportive housing, mental health care delivery—offers the best means of improving health and social outcomes for this population. Importantly, these interventions are similar to the services outlined by the HAVI as being beneficial for victims of violent injury. HVIPs may not be able to provide these services due to burned-out staff, insufficient funding, and challenges with connecting participants to community-based resources (Schenck et al., 2023; Webster et al., 2022; Wical et al., 2022). HVIPs are often exclusively funded through grants which may not offer sufficient funds to assist with the housing needs of participants or may restrict how programs spend their money (Bonne et al., 2022; Wical, 2024; Wical et al., 2022). Thus, most HVIPs are not positioned to offer temporary housing for participants and have not developed specific interventions to address the complex needs of Black men who have survived a gunshot wound and who experience homelessness.
Structural Barriers to Safe Housing for Black Men
In the United States, homelessness is an intensely racialized and gendered phenomenon. Using the Point-in-Time Count mandated by USDHUD, the Mayor’s Office of Homeless Services (2023) in Baltimore issued a report that found that 73% of people experiencing homelessness in the city were Black and 65% were men. In Washington, DC, 86% of the homeless population is Black and the rate of homelessness among individual men is by far the highest in the country (104.6 per 10,000 compared to the next highest rate in California of 52.5 per 10,000; Moses & Janosko, 2018). Importantly, racial disparities in the percent of people receiving temporary housing at a shelter have increased over time (National Alliance to End Homelessness, 2021). These disparities are the consequences of historical and contemporary structural racism and gendered exclusion which contribute to disparate rates of wealth, incarceration rate, and morbidity and mortality between Black men and their peers (Dumont et al., 2013; Gilbert et al., 2016, 2022; Massoglia, 2008; Sullivan et al., 2015; Williams, 2017, 2022).
Income and Wealth
According to the report issued by the Mayor’s Office of Homeless Services (2023), homeless people in Baltimore indicated that the primary causes of their homelessness were inadequate income, loss of job, eviction from previous residence, or kicked out by their family. These reasons for homelessness are particularly significant given that approximately 25% of Baltimore’s residents are at or below the federal poverty line. Of those who are below this line, half are considered to live in “deep poverty” (below 50% of the federal poverty line; Healthcare for the Homeless, n.d.). In terms of racial wealth disparities, the median net worth of Black families in Baltimore was $ 0 compared to $59,430 for White families (Colston et al., 2021). Prince George’s County sees higher levels of economic parity between Black and White families; however, in the areas closest to Washington, DC, there remain stark differences in income (Hendey & Posey, 2017). In three of the four wards that border Washington, DC, over 50% of Black families do meet the threshold of a living wage, as calculated by the Massachusetts Institute of Technology Living Wage Calculator. Reflecting patterns of racial segregation, two of these wards did not have a high enough White population to be analyzed, and less than 40% of White families in the other two did not meet the living wage threshold (Hendey & Posey, 2017). Similarly, in Washington, DC, median household incomes for White families are approximately three times as high compared to Black families (Kijakazi, 2016). The disparities are even more pronounced in terms of wealth—with White families having 81 more times wealth compared to Black families (Kijakazi, 2016). In the District, over 21% of Black families are below the federal poverty rate (over 3.5 times that of White families) and Black residents are nearly five times more likely than White residents to be unemployed (Patterson et al., 2021).
Incarceration and Felony Disenfranchisement
USDHUD does not have explicit restrictions on receiving a public housing voucher when someone has a felony except in instances of people that meet the requirements for lifetime registration on a state sex offender list or have a conviction for manufacturing methamphetamine at a federally assisted housing location. Denial of vouchers may be made based on if a person is determined to use illegal drugs or abuse alcohol (USDHUD, 2022). Critically, public housing agencies are barred from making determinations about applicant eligibility solely based on a record of arrest; however, the reason for arrest may still be a key factor in admissions decisions. According to USDHUD, public housing agencies are given “broad discretion” on how they choose to determine if applicants with prior convictions are eligible for vouchers (USDHUD, 2022). A history of incarceration has been shown to increase the likelihood of being homeless after release by approximately 700% compared to the general population (Couloute, 2018). A lack of stable housing is a significant predictor of future arrest and incarceration due to the criminalization of homelessness (Amster, 2003; Aykanian & Fogel, 2019; Foscarinis et al., 1999; Westbrook & Robinson, 2021). 4 This cycle of repeated incarceration and release without stable housing results in those who have been incarcerated more than once being homeless at a rate 13 times higher than that of the general population (Couloute, 2018). In concert with other forms of social marginalization, disenfranchisement in accessing public housing support disproportionately impacts formerly incarcerated Black men—this contributes to an over 1.5 times higher rate of homelessness compared to White men who were incarcerated (Couloute, 2018).
Limited Housing Options
In 1996, with the passing of the Housing Opportunity Program Extension Act, public housing agencies were given increasing leeway on being able to evict tenants and request criminal background checks on applications. Since USDHUD has not limited the ability of agencies to use “lookback periods,” decades old convictions may still impact someone’s ability to receive housing. Craine and Martin (2015) note that felony disenfranchisement in terms of housing assistance has been a particular issue in Maryland. Until 2003, people with criminal convictions were not allowed to receive any public housing assistance in Baltimore City. While the city did remove the permanent restriction, it maintained that individuals who were released from incarceration were not eligible for public housing for between 18 months and 3 years after their release. Prince George’s County has even harsher restrictions, barring people with criminal convictions from receiving assistance for 7 years—regardless of the crime. While Washington, DC does not have specific restrictions for people with felonies other than the federal mandated exclusions, the chance of receiving assistance is unlikely for people who were incarcerated, as the housing waiting list is tens of thousands of people long with only 300 to 400 vouchers for single adults being given out each year (Criminal Justice Coordinating Council, 2020). Lastly, even in cases where public housing agencies do not factor in having a felony, the exclusion from the job market precludes many people from being able to afford rising rents. These exclusions, which are intensely racialized, disproportionately impact the lives of Black men. Pager (2003) noted that the effect of having a criminal record was more profound for Black applicants than their White peers. These disparities are particularly significant as she found that White applicants with a criminal record were more likely to get a call back than Black applicants without a criminal record.
While there have been some efforts to explore hospital-based interventions for people experiencing homelessness (Hwang & Burns, 2014; Khan et al., 2022; Luchenski et al., 2022; Sadowski et al., 2009), there has yet to be any examinations of the specific needs of Black men who survive a gunshot wound and who subsequently experience homelessness. This dearth of knowledge is particularly concerning as the needs of this population differ significantly from others who were violently injured but had housing and other people who are experiencing homelessness but had not been injured. In centering the experiences of Black men who survived a gunshot wound and were homeless after their injury, we emphasize the need for HVIPs to develop best practices for supporting their homeless participants, expand services to meet the social needs of those men who need housing assistance, and foster partnerships with housing agencies.
Methods
Participants and Sites
This work was conducted as part of a multi-sited ethnographic study at the two busiest HVIPs in the state of Maryland. The research focused on the emotional experiences of Black men who survived a gunshot wound and received care from either program. Both HVIP staff and participants were recruited for participation in this study. Of the total sample of program participants interviewed for the larger project (N = 23), 35% were homeless after their injury (n = 8). 5 Three of these participants received services from University Hospital (pseudonym) and five received services from County Hospital Center (pseudonym). Participants stayed in shelters, with family or friends for less than a week at a time or were unsheltered. The length of homelessness ranged from less than a month to over 4 years after being injured. Half of the men (n = 4, 50%) included in this sample had been homeless for some period prior to their injury. Program staff included frontline case workers, program directors, a credible messenger, a trauma outreach coordinator, and a social worker (N = 8; 3 from University Hospital and 5 from County Hospital Center).
University Hospital
Located on the West side of Baltimore, MD, University Hospital is a Primary Adult Resource Center, a designation reflecting a higher standard of staffing and resources compared to Level I trauma centers. It treats the highest number of violent injuries in the state of Maryland. HVIP staff reported that the trauma center sees nearly 1,600 patients annually who were shot, stabbed, or assaulted with a blunt instrument. Of these patients, anyone over the age of 18 who resides in Baltimore is considered eligible to receive services through the HVIP. However, program staff noted that they approached less than one-third of those patients who were eligible for bedside recruitment, as many of them were treated for their injuries and discharged from the hospital over the weekend when no HVIP staff were working. 6 Staff were also told not to recruit patients during periods of the COVID-19 pandemic because the program did not have the capacity to offer services to new clients. In years prior, the program offered peer support groups, assistance with job placement, individual therapy, access to free personal care items (toilet paper, soap, socks, clothes), backpacks, nonperishable food, and mentoring. However, following multiple leadership changes that deprioritized support for the HVIP, the program was only able to provide referrals to other institutions in the city, reduced access to personal care items and nonperishable food, and halted any formal mentoring. This lack of available services was exacerbated by high staff turnover. During the duration of this study, all case workers quit working at the HVIP, leading to a period when it was temporarily closed.
County Hospital Center
County Hospital Center is a Level II trauma center located in Prince George’s County, MD near the border of Washington, DC. During this research, approximately 80% of participants were from Prince George’s County and 20% were from Washington, DC. 7 Staff reported that the hospital treats nearly 750 patients for violent injury each year—many for gunshot wounds. While the program previously offered individual therapy, pro bono legal services, long-term case management, transportation, in-person peer support groups, and mentorship to participants, its available services were greatly curtailed after the program was shifted under the purview of a new manager, and restrictions to in-person peer group meetings were put in place during the pandemic. Despite these restrictions being lifted as transmission rates of COVID-19 decreased and the hospital removed limitations on who could visit, the HVIP did not return to in-person service provision of any kind throughout the duration of this research. Rather, the program only offered a virtual peer group once a week that was loosely based on the Men’s Trauma Recovery and Empowerment model. This peer group was attended mostly by participants who started receiving services from the program prior to the pandemic. The primary case worker for County Hospital Center had a caseload of over 60 “active” participants (with needs varying greatly). 8 Having a great deal of experience navigating the different networks of other social service providers in both Prince George’s County and Washington, DC, the case worker often relied on these connections to facilitate access to support for program participants. At no point during the research did the program have a clinical counselor. In the final months of the research, a violence intervention specialist was hired part-time to assist with recruitment and leading peer support groups.
Data Collection and Procedures
IRB approval was obtained from the University of Maryland, College Park. Ethnographic research was conducted from December 2021 to January 2023. This methodology was chosen to gather long-term qualitative data on the social, psychological, and emotional experiences of program participants, their views on the effectiveness of hospital-based violence interventions, and their hopes for the future post-violent injury. The research also focused on the perspectives and experiences of frontline staff as they navigated changes in support from the hospital, restrictions on service provision due to the COVID-19 pandemic, and high levels of gun violence in the surrounding communities. An IRB-approved consent form was completed with all participants prior to the beginning of the interviewing process.
One wave of interviews was completed with program staff. The only inclusion criterion was having worked at the program for at least 6 months. Interviews focused on roles in working at an HVIP, challenges in being able to successfully accomplish their work, views on the causes and consequences of gun violence, perspectives on prevention, and the needs of participants. Interviews lasted between 44 and 92 min. Program participants were recruited using a purposive sampling strategy to ensure their ability to address the primary research questions of this study (Bernard, 2017; Charmaz, 2014). Inclusion criteria for HVIP participants were: (a) Black man, (b) age 18 or older, (c) survived a gunshot wound, and (d) engaged with one of the research sites at some point. 9 Additionally, study participants had to live in Washington, DC, Maryland, or Virginia. Participants were excluded from recruitment if they were: (a) treated for a traumatic brain injury, (b) under police custody, (c) medically unable to give consent, or (d) did not meet the residency requirements in the inclusion criteria. Two interviews were conducted with program participants; they occurred approximately 3 months apart. 10 Questions included asking about recruitment to the program, broader understandings of effective violence prevention, the relationship between injury and trauma, and the social impact of their injuries on relationships with family and friends. The first interviews lasted between 37 and 95 min, with most lasting approximately 60 min (n = 8, 100%). The second interview included questions about coping, views on safety, emotional experiences of trauma and healing, use of HVIP services, and definitions of success for HVIP participants (n = 5, 63%). These interviews lasted between 40 and 117 min, with most lasting approximately 60 min. HVIP participants were compensated $25 for each interview they completed.
This manuscript focuses on a subset of the total interviews for the project, as it examines the experiences of those men who experienced homelessness after their injury and the staff at the programs where they received services. Using the definition of homelessness outlined by USDHUD (2012), HVIP participants were included in the sample if they met any of the following criteria after their injury:
(1) Had a primary nighttime residence that is a public or private place not meant for human habitation,
(2) Lived in a publicly or privately operated shelter designated to provide temporary living arrangements (including congregate shelters, transitional housing, and hotels and motels paid for by charitable organizations or by federal, state, and local government programs),
(3) Exited an institution where he has resided for 90 days or less and who resided in an emergency shelter or place not meant for human habitation immediately before entering that institution.
Because of changes to HVIP programming during the COVID-19 pandemic, participant observation was conducted both in-person and virtually. This method of data collection provided detailed descriptive data of the daily practices of HVIP staff and modes of intervention. Furthermore, it offered an important avenue to establish rapport between the ethnographer and program participants and staff. In-person participant observation included observing bedside recruitment, attending staff meetings, and, prior to its closing, engaging with participants in-person at the University Hospital program. Observations of staff efforts to connect participants with other nearby service providers (therapists, homeless shelters, food banks, etc.) were also completed. Virtual observations included attending research meetings at University Hospital where staff associated with the hospital discussed violence prevention research and new directions for the HVIP. Additionally, nearly all virtual weekly peer group meetings held by the County Hospital Center HVIP were observed. This provided an opportunity for feedback on the direction of the work from program participants. Detailed fieldnotes were completed throughout both in-person and virtual observations; all fieldnotes were formalized within 2 days (most often within 24 hr) to ensure accurate recollection of events.
Qualitative Data Analysis
All semi-structured interviews were transcribed verbatim and inductively analyzed using a three-wave coding strategy (open, focused, and axial) in the qualitative data analysis software MAXQDA (VERBI Software, 2021). Data analysis was completed iteratively throughout the duration of the project in order to ensure that participants were able to provide feedback on preliminary findings and the interpretation of data. As themes were developed, key informants were routinely asked their perspectives about the relationships between themes. This analytical approach was chosen as there is a shortage of literature on the social, emotional, and psychological experiences of Black men who survive a gunshot wound. A codebook was generated using representative quotes, phrases, and patterns; it was used to uniformly apply codes across the entire data set (Bernard, 2017). All codes and themes were discussed and unanimously agreed upon by two members of the research team (WW and JR) during routine research meetings throughout the duration of the study. As Guest et al. (2006) and Morse (1994) noted, analysis of the experiences of at least six participants provides a robust sample to establish the majority of codes on a given topic. Thus, with eight participants, data saturation was achieved for all presented themes. Pseudonyms are used throughout this manuscript to protect the privacy of both staff and participants.
Results
Both HVIP staff and participants emphasized the importance of stable, safe housing for people after they survived a gunshot wound. Analysis of their perspectives revealed three themes: (a) significant need for housing for program participants, (b) challenges with healing while homeless, and (c) difficult experiences with housing institutions.
Significant Need for Housing
Staff and participants at both programs reported that housing—both temporary and permanent—was one of the most pressing needs for Black men who survived a gunshot wound. Peter, the primary case worker at County Hospital Center, emphasized that it was “the number one need” for men from both Prince George’s County and Washington, DC. Despite this pressing demand, neither HVIP was equipped to substantively address these needs in large part because of their unstable and limited funding and prioritization of other intervention modalities (primarily peer groups and referrals to other organizations). In years prior, University Hospital’s program was able to assist with covering the cost of a first month’s rent, pay for groceries, and provide other necessities for clients. Staff reported that being able to offer these resources greatly assisted with the recruitment and retention of participants who were experiencing social instability and homelessness after their injury. However, with the reduction in available services due to changes in leadership, staff were often unable to offer immediate assistance with finding a place to stay. Staff at both programs reported that they wished they could ensure that HVIP participants were discharged from the hospital to a safe location.
Both program staff and participants noted that having stable housing was a prerequisite for being able to begin to recover from an injury and make meaningful progress toward the goals of securing employment and pursuing education. While the primary case workers from each program had experience and expertise in navigating the shelter systems near the hospital, there were often challenges with connecting program participants to these institutions—these included participants being unwilling to go to a specific shelter because of prior negative experiences or there being no available space at nearby shelters. HVIP participants noted the importance of finding a shelter close to their place of employment, public transportation, and the physician offices where they had follow-up medical appointments. Reflecting the gendered nature of homelessness, finding a shelter that accepted single men was often a challenge. In Prince George’s County, there is only one shelter that serves single men; it has the capacity to house 24 people. In order to receive assistance in the county, individuals must call the county’s shelter hotline in the morning to check the availability of open space. While the shelter system in Washington, DC is more robust than in Prince George’s County, program participants noted that these shelters are crowded and not conducive to recovering from a gunshot wound. The men’s homeless shelters in Baltimore routinely did not have any available space (Box 1).
Selected Quotes About the Need for Housing Services
Challenges With Recovery While Homeless
HVIP participants emphasized the difficulty of simultaneously recovering from their injury and being homeless. Critically, they noted that being unsheltered, temporarily staying with friends or family, or residing in a homeless shelter was not conducive to attending to their physical and psychological well-being. These challenges were notable when injuries required long physical recoveries, routine wound care (cleaning wounds, changing bandages, etc.), or multiple subsequent surgical procedures. Participants noted that they wished they had more privacy while on bed rest, clean and private spaces for dressing their wounds, and quiet locations to attend virtual appointments (check-ins with their physicians, individual therapy, or virtual peer group meetings). Furthermore, for those men who had some form of long-term disability from being shot—including significant pain disorders, loss of mobility, a colostomy, or serious mental health diagnoses—it was particularly difficult to feel comfortable while living in a shelter or being unsheltered. Struggles with finding stable housing, stress and pain relating to physical injuries, and dissatisfaction with available services resulted in participants limiting their engagement with the programs.
Participants who were homeless experienced significant barriers to participating in HVIP services. Notably, compared to the other men in the program, those who were homeless were more likely to not have a stable internet connection or a private location to join the peer group. Additionally, this made contacting the case manager for individual support more difficult. These challenges were particularly notable for those participants who lived in shelters in Baltimore, as there were shelter-specific requirements to leave the premises during the day. In these cases, participants relied on Wi-Fi from restaurants, libraries, or using limited cellphone data to try and connect with their case manager. On multiple occasions, participants experiencing homelessness would stop contacting program staff for extended periods of time (up to 3 months) before returning to ask for assistance with a pressing need—a meal, warm clothes during the winter, a referral to a nearby mental health clinic, or transportation to a medical appointment. During these times, those men who were homeless reported that most of their time was spent trying to secure stable housing, often feeling forced to choose between focusing on recovering from their injuries and finding shelter. The men who had significant physical disabilities from their injury attempted to return to work well before the medical advice they received in order to try and earn enough money to afford housing. All participants noted that their poor mental health was exacerbated by not having safe and stable housing. They expressed feeling isolated, abandoned by their family and friends, and an increased burden of traumatic stress while staying in shelters and motels or while unsheltered (Box 2).
Selected Quotes About the Challenges of Recovering From a Gunshot Wound While Homeless
Note. HVIP = hospital-based violence intervention program.
Challenges With Housing Institutions
Black men who were homeless after surviving a gunshot wound repeatedly emphasized that they did not feel safe staying in shelters; these fears were heightened in the time immediately after their injuries. For multiple men, shelter-specific rules about how long people could stay in the building during the day made it difficult to effectively “stay out of the way.” 11 This resulted in men feeling stressed about being seen by the person who injured them. Importantly, fears about being victimized were most pronounced for those men who were disabled after being shot, as they noted that the loss of being able to physically defend themselves from other people increased the likelihood of being injured again. Concerns for safety in a homeless shelter were significant enough for men to choose to stay either in a car (if available) or remain unsheltered. Because of the COVID-19 pandemic, homeless shelters had significant shifts in their policies for accepting people. In Baltimore, this included requiring people to agree to staying in one shelter for multiple months. In cases where people left early, they were temporarily denied re-entry to the facility. For two participants in Baltimore, these restrictions resulted in being unsheltered for a period of time.
HVIP participants did not feel as if they were treated well by staff at the shelters—often describing the shelters as being “like a jail.” Men reported being racialized and criminalized by shelter staff, often resulting in harsh and punitive treatment compared to their peers. In some cases, men had such negative experiences with shelters that they refused to return to them even if they were the only option to not be unsheltered. Poor treatment and a lack of available resources for healing contributed to worsening mental health issues and higher levels of stress. For those men who had a felony or criminal conviction, denial of housing services was a further barrier in finding a long-term place to live. Even while some participants were able to get temporary housing (lasting between 6 months and 18 months) in Washington, DC, they remained at a significant risk for not being able to secure long-term housing. As one participant described, having a felony decreased the likelihood of finding stable employment, and therefore, being unable to make rent payments without assistance from a housing agency (Box 3).
Selected Quotes About Challenges With Housing Institutions
Discussion
While the ethnographic study did not initially set out to consider the experiences of Black men who survived a gunshot wound and were subsequently homeless, participants from each site underscored that their housing was a critically important aspect of their experiences with trauma, healing, HVIP participation, and hopes for the future. Despite this population having experiences that are unique among both victims of violent firearm injury and people who are homeless, little is known about how to best meet the needs of these men. The consequences of this dearth of knowledge are two-fold—there is a lack of understanding of how HVIPs can meet the specific needs of their participants who are homeless and little engagement with the perspectives of those men who experience high risk for reinjury. The themes of this work, as detailed by both staff and participants at the HVIPs, underscore the significant need for housing, challenges with healing from injuries, and difficult experiences with housing institutions. Reflecting the gendered and racialized nature of homelessness, participants and staff noted that accessing safe and stable housing was particularly challenging for Black men. This thematic analysis underscores the need for access to both temporary and long-term comprehensive services to support the needs of Black men who survive gunshot wounds. Furthermore, the perspectives of these men challenge dominant narratives about Black men’s willingness to engage with psychosocial and healthcare providers. Their experiences emphasize the need to examine structural barriers that “disengaged” participants experience to consistently participating in services—including housing status.
A significant strength of this work is its centering of the experiences and views of Black men who survived violent firearm injury and who were subsequently homeless. To our knowledge, it is the first research to qualitatively examine the unique barriers these men experience as they seek to heal from their injuries. As men described, there are important aspects of their experience that should inform the delivery of services and understandings of their needs—including the inability to address their trauma and physically recover from their injuries without a stable residence, inability to engage in virtual services, barriers to receiving public housing, and poor treatment at shelters negatively impacting their comfort in staying at them. In contrast to other populations of people experiencing homelessness, Black men who survive a gunshot wound may be at a particularly high risk for violent reinjury. While further research is needed to examine the specific risk factors associated with housing status, it is clear that HVIP participants felt as though the person who injured them was likely to know their exact location because of the limited options for temporary housing. Thus, promoting access to housing offers a critical avenue for HVIPs to meet the needs of their participants in order to reduce the likelihood of repeat violent injury.
This study is not without limitations. First, because there was a small sample size of HVIP participants who experienced homelessness after their injury, the findings cannot be generalized to all people who survive a gunshot wound and who experience homelessness. Second, since there is great variation in the kinds of supportive services available for homeless people depending on the city they live in, the experiences of men in Baltimore, Prince George’s County, and Washington, DC metro areas may differ significantly from other locations. Third, as HVIPs are largely grant-funded and do not follow a standardized model, there are major differences in their financial ability to directly meet the needs of their homeless participants and the kinds of services they can offer to these men. Fourth, since this research was conducted during the COVID-19 pandemic, both HVIPs experienced significant challenges with staffing and resources (see Wical et al., 2022). Thus, it is important for more research to be done at other programs to see how Black men who survive gunshot wounds experience the landscape of supportive services, heal from their injuries, and navigate finding housing. Lastly, the experiences of Black men who survive a gunshot wound and who experience homelessness are likely to vary depending on geographic location. Further research is needed in both suburban and rural locations to understand how men experience differing levels of support based on the differing levels of resources.
In examining the specific structural barriers that harm Black men who survive violent injury—including poor access to safe, stable, and affordable housing—it is clear that determinations of successful intervention must be broadened to include how well programs are able to meet the self-determined goals of participants. Thus, it is our aim that this research contributes to Gorman et al.’s (2022) clarion call for adopting a more comprehensive set of criteria for determining the success of HVIPs. Critically, we do not expect HVIP staff, often already burdened with large caseloads and poor resources, to address the housing needs of these men on their own. Rather, it is imperative that programs foster relationships with public housing agencies to assist successful placement of participants. HVIPs may benefit from having dedicated staff who are skilled in navigating the shelter systems and public housing agencies to best meet the needs of their participants. Furthermore, HVIPs must structure their interventions to meet the needs of the men who receive services from them. This includes prioritizing having in-person services for those men who do not have access to a private location for virtual participation. Additionally, offering financial support for mobile phone data, access to mobile wireless hotspots, and technological devices (phones, tablets, or laptops) is imperative for improving service usage. While HVIPs are not equipped to assist with the legal needs of participants, partnerships with public attorneys and agencies who specialize in felony expungement may be useful in meeting the needs of participants. In understanding the unique needs of Black men who survive a gunshot wound and experience homelessness, it is our hope that HVIPs can better support their participants to achieve their health and social goals.
Footnotes
Acknowledgements
We’d like to thank the men who participated in this research for their honesty, critical perspectives, and willingness to share their experiences; their insight serves as an invaluable foundation for understanding and implementing transformative solutions for gun violence reduction.
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by generous funding from the National Science Foundation (Award number 2117054), the Wenner-Gren Foundation (Award number 10164), the Lee Thornton Endowed Fellowship (University of Maryland, College Park), and the Charlotte W. Newcombe Dissertation Fellowship (Institute for Citizens & Scholars). Additional support was received from the University of Maryland, College Park, through the Dean’s Research Initiative Doctoral Dissertation Award and QRIG Advanced Doctoral Student Dissertation Award, and the Harvard Injury Control Research Center.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.