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Social Determinants of Mental Health
Published Online: 10 November 2020

Addressing the Urgent Housing Needs of Vulnerable Women in the Era of COVID-19: The Los Angeles County Experience

Abstract

For people experiencing homelessness, COVID-19 underscores existing health and social inequities, introduces additional threats to health and safety, and calls for rapid and 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. The authors discuss gaps in care and recommendations for the future, calling attention to the unique mental health and social needs of these highly vulnerable women.

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.
The risk for contracting COVID-19 is heightened for individuals experiencing homelessness. For many people living in congregate shelters or street-based encampments, physical distancing and hand-washing 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. As cities increase shelter capacity, reports emerge of COVID-19 outbreaks in these settings—including findings that 36% of residents of a Boston shelter tested positive for COVID-19, with most not showing symptoms (1). These outbreaks suggest that congregate housing, even with the implementation of precautionary measures, may inadequately protect individuals experiencing homelessness against COVID-19.
In addition to an increased infection risk, people experiencing homelessness face widening social and medical inequities in the context of COVID-19. Homelessness is associated with an increased likelihood of psychiatric diagnoses ranging from anxiety to schizophrenia. It is also correlated with poor general medical health and decreased life expectancy. Structural racism has spurred deep racial inequities, 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 police sweeps and harassment continue (3). Even when services are available, many individuals may hesitate to use them, given the potential exposure risks.

Homelessness, Domestic Violence, and Pregnancy in the COVID-19 Context

Domestic violence (DV) is the leading cause of homelessness for women and a significant risk factor for suicidality, depression, and posttraumatic stress disorder (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, and unemployment and food insecurity may lead to increased use of financial control and coercion. Firearm sales have increased nationwide, and firearms in the home are a well-documented risk factor for homicide in DV situations (6). Although concerns about DV have increased, shelters in many cities are full, limiting the options for women who need to leave abusive partners.
Pregnant women experiencing homelessness are another particularly vulnerable population. Compared with other women, women experiencing homelessness—including those who are pregnant—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 health care, including prenatal care, mental health services, and substance abuse treatment (8, 9). This is particularly concerning, given the high risk for worsening of mental health disorders during pregnancy and the postpartum period. Homelessness is associated with poor birth outcomes, including preterm delivery, low birth weight, and neonatal abstinence syndrome (10). After 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 the mother’s 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 in any other U.S. city (2)—the COVID-19 crisis brought about unprecedented efforts to rapidly house medically vulnerable individuals experiencing homelessness. The multilevel housing effort included expanded capacity through the creation of additional congregate shelters; 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 establishment of medical shelters in motor homes/recreational vehicles and motels to provide isolation and medical supervision for individuals with a possible or confirmed COVID-19 infection. 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’s traditionally siloed health care and social services landscape.
Project Roomkey, although ambitious, initially left out pregnant women experiencing homelessness, as the U.S. Centers for Disease Control and Prevention did not consider pregnancy a high-risk condition relative to COVID-19 infection. In Los Angeles, these women were forced to choose between living in unsheltered conditions or moving into congregate shelters, both of which may feel like dangerous options because of the increased risk for COVID-19 exposure and its potential effects on pregnancy (12). Additionally, 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 incidents 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 broader emergency housing efforts, this work has required a high degree of interagency collaboration, coordination, and advocacy. Together, numerous agencies provided clients with services (mental health care, food and clothing, children’s educational resources, crisis intervention, legal support, housing security plans, and others) while facilitating provider training and information exchange.
These efforts are not without challenges. Housing is but one social determinant of mental and general medical health affecting these women. How can we rapidly and effectively address pressing mental health, medical, legal, social, and financial needs during a time when in-person contacts have been all but eliminated? Although these programs offer temporary housing regardless of immigration status, how can we ensure permanent housing for women whose immigration status may make housing 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 conditions among women experiencing homelessness, how will we effectively and proactively provide mental health and trauma-informed services during this crisis? On a more positive note, 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, permanent, supportive housing rather than return them to unsafe living situations, perpetuating the catastrophic cycle of homelessness?

Recommendations

Similarly 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, as in Housing First, these programs recognize the role of supportive services beyond housing, which are especially crucial for women with complex mental health and social needs. Box 1 lists our recommendations for addressing current and anticipated needs based on best practices in women’s health and homelessness services. These recommendations reflect three overarching themes relating 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 about 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 Needs

Rapidly identify and house vulnerable women through proactive outreach and minimization of administrative barriers
Provide housing on the basis of 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
Extend the 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 General Medical 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 Services

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 domestic violence (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 homelessness support services in accordance with the McKinney-Vento Homeless Assistance Act
As women transition to permanent housing, facilitate community reintegration 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 use a trauma-informed, client-centered approach
Train providers to recognize and respond to possible DV
Educate providers on the disproportionate effects 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

Conclusions

Pregnant women and survivors of DV who are experiencing homelessness have unique vulnerabilities that are underscored by the COVID-19 pandemic. Providing these women with safe and private interim housing and with necessary mental health, medical, and social services is an important first step to address their urgent needs. As the COVID-19 pandemic and the needs of these women continue to evolve, our safety net systems must remain diligent in meeting those needs. Finally, although we have focused here on particularly vulnerable groups of women, we note the moral and public health imperatives 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 permanent safe 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.

Acknowledgments

The authors would like to acknowledge all of the domestic violence agencies and homeless service providers working in Los Angeles County to address homelessness during the COVID-19 pandemic.

Footnote

The content and views expressed in this article represent the opinions of the authors and not necessarily 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 U.S. Government, or affiliated institutions.

References

1.
Baggett TP, Keyes H, Sporn N, et al: Prevalence of SARS-CoV-2 infection in residents of a large homeless shelter in Boston. JAMA 2020; 323:2191–2192
2.
The 2019 Annual Homeless Assessment Report (AHAR) to Congress, Part 1: Point-in-Time Estimates of Homelessness. Washington, DC, US Department of Housing and Urban Development Office of Community Planning and Development, 2020. https://files.hudexchange.info/resources/documents/2019-AHAR-Part-1.pdf
3.
Auerswald C: For the Good of Us All: Addressing the Needs of Our Unhoused Neighbors During the COVID-19 Pandemic. Berkeley, CA, University of California, Berkeley, School of Public Health, 2020. https://publichealth.berkeley.edu/wp-content/uploads/2020/04/For-the-Good-of-Us-All-Report.pdf
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Ellsberg M, Jansen HA, Heise L, et al: Intimate partner violence and women’s physical and mental health in the WHO multi-country study on women’s health and domestic violence: an observational study. Lancet 2008; 371:1165–1172
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Gilroy H, McFarlane J, Maddoux J, et al: Homelessness, housing instability, intimate partner violence, mental health, and functioning: a multi-year cohort study of IPV survivors and their children. J Soc Distress Homeless 2016; 25:86–94
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Campbell JC, Webster D, Koziol-McLain J, et al: Risk factors for femicide in abusive relationships: results from a multisite case control study. Am J Public Health 2003; 93:1089–1097
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Wenzel SL, Tucker JS, Elliott MN, et al: Prevalence and co-occurrence of violence, substance use and disorder, and HIV risk behavior: a comparison of sheltered and low-income housed women in Los Angeles County. Prev Med 2004; 39:617–624
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Bloom KC, Bednarzyk MS, Devitt DL, et al: Barriers to prenatal care for homeless pregnant women. J Obstet Gynecol Neonatal Nurs 2004; 33:428–435
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Crawford DM, Trotter EC, Hartshorn KJS, et al: Pregnancy and mental health of young homeless women. Am J Orthopsychiatry 2011; 81:173–183
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Stein JA, Lu MC, Gelberg L: Severity of homelessness and adverse birth outcomes. Health Psychol 2000; 19:524–534
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Ijadi-Maghsoodi R, Quan M, Horton J, et al: Youth growing up in families experiencing parental substance use disorders and homelessness: a high-risk population. J Child Adolesc Psychopharmacol 2019; 29:773–782
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Donders F, Lonnée-Hoffmann R, Tsiakalos A, et al: ISIDOG recommendations concerning COVID-19 and pregnancy. Diagnostics (Basel) 2020; 10:E243
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Patterson M, Moniruzzaman A, Palepu A, et al: Housing First improves subjective quality of life among homeless adults with mental illness: 12-month findings from a randomized controlled trial in Vancouver, British Columbia. Soc Psychiatry Psychiatr Epidemiol 2013; 48:1245–1259

Information & Authors

Information

Published In

Go to Psychiatric Services
Go to Psychiatric Services
Psychiatric Services
Pages: 349 - 352
PubMed: 33167810

History

Received: 6 May 2020
Revision received: 22 June 2020
Accepted: 7 July 2020
Published online: 10 November 2020
Published in print: March 01, 2021

Keywords

  1. Women
  2. Homelessness
  3. COVID-19
  4. Domestic violence
  5. Housing
  6. Pregnancy

Authors

Details

Nichole Goodsmith, M.D., Ph.D. [email protected]
VA Greater Los Angeles Healthcare System, Los Angeles, and National Clinician Scholars Program, University of California, Los Angeles (UCLA), Los Angeles (Goodsmith); Division of Population Behavioral Health, Jane and Terry Semel Institute for Neuroscience and Human Behavior, Los Angeles; HSR&D Center for the Study of Healthcare Innovation, Implementation, and Policy, VA Greater Los Angeles Healthcare System, Los Angeles; and Department of Psychiatry and Biobehavioral Sciences, UCLA, Los Angeles (Ijadi-Maghsoodi); East Los Angeles Women's Center, Los Angeles (Melendez); Los Angeles County Department of Mental Health, Los Angeles; and Department of Psychiatry and Biobehavioral Sciences and Department of Obstetrics and Gynecology, Keck School of Medicine, University of Southern California, Los Angeles (Dossett). Ruth S. Shim, M.D., M.P.H., and Michael T. Compton, M.D., M.P.H., are editors of this column.
Roya Ijadi-Maghsoodi, M.D., M.S.H.P.M.
VA Greater Los Angeles Healthcare System, Los Angeles, and National Clinician Scholars Program, University of California, Los Angeles (UCLA), Los Angeles (Goodsmith); Division of Population Behavioral Health, Jane and Terry Semel Institute for Neuroscience and Human Behavior, Los Angeles; HSR&D Center for the Study of Healthcare Innovation, Implementation, and Policy, VA Greater Los Angeles Healthcare System, Los Angeles; and Department of Psychiatry and Biobehavioral Sciences, UCLA, Los Angeles (Ijadi-Maghsoodi); East Los Angeles Women's Center, Los Angeles (Melendez); Los Angeles County Department of Mental Health, Los Angeles; and Department of Psychiatry and Biobehavioral Sciences and Department of Obstetrics and Gynecology, Keck School of Medicine, University of Southern California, Los Angeles (Dossett). Ruth S. Shim, M.D., M.P.H., and Michael T. Compton, M.D., M.P.H., are editors of this column.
Rebeca M. Melendez, M.A.Hum.
VA Greater Los Angeles Healthcare System, Los Angeles, and National Clinician Scholars Program, University of California, Los Angeles (UCLA), Los Angeles (Goodsmith); Division of Population Behavioral Health, Jane and Terry Semel Institute for Neuroscience and Human Behavior, Los Angeles; HSR&D Center for the Study of Healthcare Innovation, Implementation, and Policy, VA Greater Los Angeles Healthcare System, Los Angeles; and Department of Psychiatry and Biobehavioral Sciences, UCLA, Los Angeles (Ijadi-Maghsoodi); East Los Angeles Women's Center, Los Angeles (Melendez); Los Angeles County Department of Mental Health, Los Angeles; and Department of Psychiatry and Biobehavioral Sciences and Department of Obstetrics and Gynecology, Keck School of Medicine, University of Southern California, Los Angeles (Dossett). Ruth S. Shim, M.D., M.P.H., and Michael T. Compton, M.D., M.P.H., are editors of this column.
Emily C. Dossett, M.D., M.T.S.
VA Greater Los Angeles Healthcare System, Los Angeles, and National Clinician Scholars Program, University of California, Los Angeles (UCLA), Los Angeles (Goodsmith); Division of Population Behavioral Health, Jane and Terry Semel Institute for Neuroscience and Human Behavior, Los Angeles; HSR&D Center for the Study of Healthcare Innovation, Implementation, and Policy, VA Greater Los Angeles Healthcare System, Los Angeles; and Department of Psychiatry and Biobehavioral Sciences, UCLA, Los Angeles (Ijadi-Maghsoodi); East Los Angeles Women's Center, Los Angeles (Melendez); Los Angeles County Department of Mental Health, Los Angeles; and Department of Psychiatry and Biobehavioral Sciences and Department of Obstetrics and Gynecology, Keck School of Medicine, University of Southern California, Los Angeles (Dossett). Ruth S. Shim, M.D., M.P.H., and Michael T. Compton, M.D., M.P.H., are editors of this column.

Notes

Send correspondence to Dr. Goodsmith ([email protected]).

Competing Interests

The authors report no financial relationships with commercial interests.

Funding Information

Dr. Goodsmith was supported by the VA Office of Academic Affiliations through the UCLA National Clinician Scholars Program. Dr. Ijadi-Maghsoodi receives funding from the National Institute on Drug Abuse (award K12 DA-000357), the Greater Los Angeles VA UCLA Center of Excellence for Veteran Resilience and Recovery, the UCLA Center for the Study of Women, and the UCLA Pritzker Center for Strengthening Children and Families.

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