Abstract
For people experiencing homelessness, COVID-19 underscores existing health and social inequities, introduces additional threats to health and safety, and calls for rapid, creative solutions to reduce risk. This column focuses on the particular challenges of two frequently intersecting subpopulations of individuals experiencing homelessness: pregnant women and survivors of domestic violence. The authors describe rapid efforts and cross-agency collaboration in Los Angeles—home to the nation’s largest number of unsheltered individuals—to provide these groups with safe interim housing in the context of COVID-19. Authors discuss gaps in care and recommendations moving forward, calling attention to the unique mental health and social needs of these highly vulnerable women.
The risk of COVID-19 is heightened for individuals experiencing homelessness. For many people living in congregate shelters or street-based encampments, physical distancing and handwashing guidelines are not feasible. Access to public facilities for maintaining hygiene, such as sinks and toilets, is insufficient in many areas. Distancing may be particularly challenging for families experiencing homelessness, who often “double up” in shared spaces with other families. While cities increase capacity of congregate shelters, reports emerge of COVID-19 outbreaks in these settings—including findings that 36% of residents of a Boston shelter were positive for COVID-19, the majority without symptoms (1). These outbreaks suggest that congregate housing, even with implementation of precautionary measures, may be inadequate to protect individuals experiencing homeless from COVID-19.
In addition to increased risk of infection, people experiencing homelessness face widening social and medical inequities in the context of COVID-19. Homelessness is associated with increased likelihood of a range of psychiatric diagnoses, from anxiety to schizophrenia. Homelessness is also correlated with poor physical health and decreased life expectancy. Structural racism has spurred deep racial inequities in homelessness, with people of color—particularly those who are Black—significantly more likely to experience homelessness and its consequences (2). As a result of COVID-19, access to usual options for critical services, including mental health and medical clinics, drop-in centers, libraries, food pantries, meal centers, and street outreach, are limited, while individuals continue to be subjected to police sweeps and harassment (3). Even when available, individuals may hesitate to utilize services, given potential exposure risks.
Homelessness, Domestic Violence, and Pregnancy in the Context of COVID-19
Domestic violence (DV) is the leading cause of homelessness for women, and a significant risk factor for suicidality, depression, and PTSD (4). Among women experiencing DV, homelessness and unstable housing predict worse mental health (5). DV incidents are widely believed to be on the rise as a result of the COVID-19 pandemic. Sheltering in place results in increased exposure to abusive partners, with fewer options for leaving or safely reporting dangerous situations. Isolation, intimidation, and emotional abuse—tactics often used in DV— are likely to increase under stay-at-home orders, while unemployment and food insecurity may lead to increased use of financial control and coercion. Firearm sales are up nationwide, and the presence of a firearm in the home is a well-documented risk factor for homicide in situations of DV (6). While DV concerns increase, DV shelters in many cities are full, limiting options for women to leave abusive partners.
Pregnant women experiencing homelessness are another particularly vulnerable population. Compared to other women, women experiencing homelessness—including pregnant women— are more likely to have experienced childhood abuse, sex and human trafficking, and sexual assault (7), exposures highly correlated with the development of PTSD, depression, and anxiety. Pregnant women experiencing homelessness face heightened barriers to healthcare, including prenatal care, mental health services, and substance abuse treatment (8,9). This is of particular concern given that pregnancy and postpartum are high-risk periods for worsening of mental health disorders. Unsurprisingly, homelessness is associated with poor birth outcomes, including preterm delivery, low birth weight, and neonatal abstinence syndrome in the infant (10). Following delivery, new mothers experiencing homelessness must face the very real possibility that their infant will be removed by Child Protective Services—a separation often devastating to mental health (11).
Case Study: Providing Housing to Vulnerable Women in Los Angeles
In Los Angeles County—home to over 42,000 unsheltered individuals, more than any other U.S. city (2)—the COVID-19 crisis brought about unprecedented efforts to rapidly house medically vulnerable individuals experiencing homelessness. The multi-level housing effort included: 1) expanded capacity through the creation of additional congregate shelters; 2) a pledge to provide 15,000 hotel rooms to people with high-risk medical conditions through California’s “Project Roomkey” interim housing program, which includes meals and case management; and 3) establishment of “medical shelters” in RVs and motels, to provide isolation and medical supervision for individuals with possible or confirmed COVID-19. This plan to move thousands of individuals off the streets and into supportive housing required an impressive degree of interagency cooperation—particularly notable in Los Angeles’ traditionally siloed health care and social services landscape.
Project Roomkey, while ambitious, initially left out pregnant women experiencing homelessness, since pregnancy is not considered by the U.S. Centers for Disease Control and Prevention to be a “high-risk” condition relative to COVID-19 infection. In Los Angeles, these women were forced to choose between living unsheltered or moving into congregate shelters, both of which may feel like dangerous options due to risk of COVID-19 exposure and its potential impact on pregnancy (12). Beyond this, past trauma and current vulnerability can lead pregnant women to feel unsafe in congregate settings. Seeing this gap in coverage, local advocates successfully fought to add pregnant women to the list of high-risk populations eligible for private interim housing through Project Roomkey.
Similar collaborative efforts were needed as DV increased in the context of COVID-19 and women were turned away from already-full DV shelters. With the support of a large private donation, the Mayor’s Fund for Los Angeles launched Project Safe Haven to house DV survivors and their children in hotel rooms, with funding for up to 900 families. Like the broader emergency housing efforts, this work has required a high degree of interagency collaboration, coordination and advocacy. Together, numerous agencies provide clients with a range of services including mental health care, case management, transportation, food, clothing, educational resources for children, crisis intervention, advocacy, safety planning, legal support, and housing security plans, while facilitating provider training and information exchange.
These efforts are not without challenges. Housing is but one social determinant of health impacting these women; how can we rapidly and effectively address pressing mental health, medical, legal, social, and financial needs during a time in which in-person contacts have been all but eliminated? While these programs offer temporary housing regardless of immigration status, how can we ensure permanent housing for women whose immigration status may make it difficult to obtain? How can the system adapt to the additional needs of women with children? Given the high prevalence of PTSD and other mental health problems among women experiencing homelessness, how will we effectively provide mental health and trauma-informed services in a proactive, preventive manner during this crisis? More positively, how can these initiatives tap into the significant resilience and resourcefulness often demonstrated by women experiencing homelessness? Finally, how will we transition these highly vulnerable women to safe and permanent supportive housing, rather than returning them to unsafe living situations and perpetuating the catastrophic cycle of homelessness?
Recommendations
Similar to the Housing First model for addressing homelessness (13), the programs described here prioritize rapid provision of housing, including explicit plans to move vulnerable individuals within Project Roomkey to permanent housing. Also like Housing First, these programs recognize the role of supportive services beyond housing—services that are especially crucial for women with complex mental health and social needs. In Box 1, we offer recommendations to address both current and anticipated needs, based on best practices in women’s health and homelessness services. These recommendations reflect three overarching themes, directly relevant to mental health services. First, interagency collaboration is key to ensure access to critical services influencing mental health. Issues of housing, child and family support, DV, and immigration are deeply connected to mental health and must be addressed. Second, agencies should actively lower barriers to mental health care for these women, through measures such as universal screening for mental health concerns during housing intake and increased use of telehealth and field-based services. Third, agencies must urgently address gaps in providers’ skills and knowledge around trauma-informed and gender-sensitive care; screening for and addressing DV; and peripartum mental health care, including screening, diagnosis, and medication management.
Box 1. Recommendations for local health and social services organizations.
Housing
Rapidly identify and house vulnerable women, through proactive outreach and minimization of administrative barriers.
Provide housing based on need, regardless of immigration status.
Maintain family units by accommodating women with their children.
Ensure access by accommodating women with animals.
Maintain high levels of privacy and security at housing sites.
Expedite access to housing vouchers, affordable rental subsidies, and rapid rehousing programs.
Develop a plan to transition from interim to permanent supportive housing, in safe neighborhoods, for all women experiencing homelessness.
Extend capacity of interim programs to house individuals until transition to permanent supportive housing is complete.
Prevent further homelessness, through rent freezes and eviction prevention.
Mental and Physical Health
Rapidly deploy easily-accessible telehealth services for women experiencing homelessness.
Ensure access to high-quality mental health care, particularly assessment and treatment for trauma-related and perinatal disorders.
Ensure access to substance use treatment, with adaptations or alternatives to residential treatment while COVID-19 risk remains high.
Ensure access to vital women’s health services, including prenatal care, contraceptive counseling, and testing for sexually transmitted illnesses.
Build interagency collaboration and provider-to-provider communication to facilitate coordination of care.
Coordinate mental health and medical services for children in families experiencing homelessness.
Increase access to free feminine hygiene products at housing sites.
Social
Provide transportation to facilitate access to services.
Facilitate access to pro-bono legal services for custody, housing, and immigration issues.
Collaborate with local law enforcement to ensure timely response to reports of DV.
Facilitate an expedited process for obtaining temporary restraining orders.
Support families in interim housing with computers to facilitate access to online learning.
As schools operate virtually, continue to provide school-based homeless support services in accordance with the McKinney-Vento Homeless Assistance Act.
As women transition to permanent housing, facilitate community re-integration through linkage to support groups, peer services, and parenting groups.
Ensure reliable access to healthy food.
Facilitate connection to employment options.
Facilitate a wraparound community approach by assigning a victim’s advocate, a housing case manager, and a social worker to each survivor of DV.
Engage individuals with lived experience for input and as peer supports.
Provider Training
Train all providers to utilize a trauma-informed, client-centered approach.
Train providers to recognize and respond to possible DV.
Educate providers on the disproportionate impact of COVID-19 on communities of color.
Train providers to respect women’s individual needs and desires regarding pregnancy and parenting, regardless of socioeconomic or housing status.
Train providers in perinatal women’s unique mental health needs, including screening, diagnosis, treatment, and considerations in medication management and substance use treatment.
Employ trainers with professional expertise in working with vulnerable women.
Conclusion
Among people experiencing homelessness, pregnant women and survivors of DV have unique needs and vulnerabilities that are underscored by the COVID-19 pandemic. Providing these women with safe, private interim housing, along with necessary mental health, medical, and social services, is an important first step. As the COVID-19 pandemic and the needs of these women continue to evolve, our safety net system must remain diligent in understanding and meeting those evolving needs. Finally, while we have focused here on particularly vulnerable groups of women, it is important to note the moral and public health imperative to ensure that all individuals experiencing homelessness are offered safe options to shelter in place and quarantine (3). Furthermore, as the immediate crisis dissipates, we must ensure provision of safe, permanent housing for all. The current pandemic has exposed our systematic and catastrophic failure to address the needs of hundreds of thousands of individuals experiencing homelessness in Los Angeles and nationwide; we can and must do better.
Highlights.
The COVID-19 pandemic poses significant and unique risks to the safety and mental health of pregnant women and survivors of domestic violence experiencing homelessness.
Los Angeles County provides a case study for the collaborative, intensive response necessary to serve these vulnerable women through rapid provision and coordination of emergency housing alongside comprehensive mental health and social services.
Acknowledgments
The authors report no conflicts of interest. Dr. Goodsmith was supported by the VA Office of Academic Affiliations through the UCLA National Clinician Scholars Program. The content and views expressed in this article are those of the authors and do not necessarily reflect the position or policies of the National Institutes of Health, the Los Angeles County Department of Mental Health, the U.S. Department of Veterans Affairs, the United States Government, or affiliated institutions.
Dr. Ijadi-Maghsoodi receives funding from the National Institute on Drug Abuse of the National Institutes of Health under Award Number K12DA000357, the Greater Los Angeles VA UCLA Center of Excellence for Veteran Resilience and Recovery, and the UCLA Pritzker Center for Strengthening Children and Families.
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