Health Care for Homeless Women

It has been estimated that as many as 14% of the U.S. population have been homeless at some time and as many as 3.5 million people (1% of the U.S. population, or 10% of the poor population) experience homelessness in a given year (1, 2). Homeless women aged 18 years to 44 years are more likely to die than women in the general population (3). Those in their mid-50s are as physiologically aged and as affected by chronic disease as women in their 70s who are not homeless (4). Homeless individuals have more morbidity, including higher rates of hypertension, arthritis, mental illness, tuberculosis, and substance abuse, and are more likely to experience violence than the general population (3, 4). These individuals who are at high risk for health problems are less likely to have health insurance, social support, steady income, and preventive health services.

Definition of Homelessness

A commonly used definition describes a homeless person as being “an individual who has a primary nighttime residence that is a supervised shelter designed to provide temporary living accommodations or a nighttime residence in a public or private place not designed for use as a regular sleeping accommodation (eg, vehicle, street, park bench, abandoned building)" (5). Recent legislation expands the definition to include those at risk of immediately becoming homeless (6).

Statistics and Demographics

Women and families make up the fastest growing segment of the homeless population. The 2008 Annual Homeless Assessment Report issued to Congress on July 9, 2009, showed that 664,414 Americans experienced homelessness on a single night with more than 252,000 (38%) being persons in families. At some point during the 12-month reporting period, 1,594,000 persons (1 in every 190 persons in the United States) were in a homeless facility with 517,000 being persons in homeless families (7). The number of homeless families increased by 9% from 2007 to 2008 (7). Whereas 36% of all sheltered homeless persons were women, 81% of adults in sheltered homeless families were women, and more than one half of children in sheltered homeless families were younger than 6 years (7). Whereas 58% of all homeless persons were in emergency shelter or transitional housing, 42% were sleeping on the streets or in places not meant for human habitation (7). Although the sheltered homeless population is concentrated in urban areas, the sheltered homeless population in suburban and rural regions increased from 23% in 2007 to 32% in 2008 (7). It is estimated that 1.5 million more Americans will experience homelessness through 2011 (8).

Risks for Homelessness

Although extreme poverty is a characteristic of the homeless population, the shortage of affordable housing is a major precipitating factor that can render individuals homeless who are not extremely poor. Unemployment or job loss, foreclosures, mortgage defaults, personal or family crisis, an increase in rent disproportionate to income, or reduction in public health benefits all increase the likelihood of loss of a home (9). Other risk factors include lack of job skills, inadequate social support, problems with alcohol or illicit drugs, mental illness, experiences of violence, and previous incarceration (9, 10).

Domestic and sexual violence is the leading cause of homelessness for women and families, and 20–50% of all homeless women and children become homeless as a direct result of fleeing domestic violence (11, 12). Homeless women are far more likely to experience violence of all sorts compared with women who are not homeless because of a lack of personal security when living outdoors or in shelters (11). Many adolescents become homeless after leaving home over conflicts with parents regarding sexual orientation. Among lesbian, gay, bisexual, and transgender persons who are victims of domestic violence, 57% became homeless as a result of domestic violence (13). Domestic violence shelter providers are prohibited from reporting client information; therefore, estimates likely undercount the number of homeless women and families seeking shelter as a result of domestic violence.

Health Issues

Most homeless people seek care in hospital emergency rooms; only 27% go to an established ambulatory care provider. Nearly 75% of homeless individuals who are hospitalized have conditions that could have been prevented if outpatient treatment was obtained (14). Cases of posttraumatic stress disorder, substance abuse disorders, major depression, sexually transmitted infections (STIs), including HIV, unintended pregnancies, and lack of condom use and other contraceptive methods are disproportionately higher among homeless women compared with other populations (9, 10, 15).

Adverse birth outcomes are substantially higher in homeless women than in the general population. A Canadian study found that compared with women who are not homeless, homeless women were 2.9 times more likely to have a preterm delivery, 6.9 times more likely to give birth to an infant who weighed less than 2,000 grams, and 3.3 times more likely to have a small for gestational age newborn, even after adjustment for risk factors such as maternal age, number of previous pregnancies, and smoking (16). In the United States, preterm birth rates and low birth weight rates in homeless women exceed national averages (17). Homeless women are less likely to receive prenatal care, mammograms, and Pap tests than women who are not homeless (18).

Barriers to Health Care

Approximately one third of homeless individuals who reported a need for medical attention in the previous year were unable to obtain care (19). Fifty-seven percent of homeless individuals lack a regular source of health care compared with 24% of poor individuals and 19% of the general population (19). The factors that contribute to homeless women being unable to obtain needed health care include lack of health insurance, inability to purchase or acquire medications, lack of knowledge of where and when to obtain health care, long wait times, and lack of transportation to and from medical facilities. Health care for these individuals competes with needs for food, clothing, and shelter. Mental illness, substance abuse, and being too sick to seek care create additional obstacles in obtaining needed services. Homeless persons may not seek care because of denial of health problems and fear of losing their children if found to be homeless. Medical providers who do not want to care for homeless individuals in their offices and the lack of available treatment facilities result in limited access to health care. Inadequate inpatient discharge planning and follow-up care, as well as lack of referral to services available within the community for homeless individuals also act as barriers (19–22). Providing housing and case management to homeless individuals with chronic medical conditions can result in fewer days in a hospital and fewer emergency department visits (23).

Prevention

 Numerous studies indicate that increasing the availability of affordable housing prevents homelessness more effectively than anything else (8, 9). With increasing rates of unemployment and foreclosures, increasing the availability of affordable subsidized housing and reducing the number of home foreclosures are essential in preventing homelessness. Expanded services for women and families experiencing domestic violence are critical to decreasing the high rate of homelessness in this population.

Recommendations for ACOG Fellows

Difficult economic times increase homelessness and worsen its effects. It is especially during these times that physicians must reach out to homeless women and families and try to make a difference in their access to health care and, thus, their quality of life. Recommendations for accomplishing this follow:

• Identify patients within the practice who may be homeless or at risk of becoming homeless (ie, ask about living conditions, nutrition, substance abuse, domestic violence) (24).
• Provide health care for these homeless women without bias, including preventive care, and do not withhold treatment based on concerns about lack of adherence.
• Become familiar with and inform patients who are (or at risk of becoming) homeless about appropriate community resources, including local substance abuse programs, domestic violence services, and social service agencies.
• Simplify medical regimens and address barriers, including transportation needs for follow-up health care visits.
• Advocate for initiatives to address homelessness such as increased funding for housing, case management services, substance abuse treatment, mental health services, and primary and preventive care for the homeless (see Box 1).
• Volunteer to provide health care services at homeless shelters and other facilities that serve the homeless (25).

Health Care for the Homeless Program—a federal program funded by the Health Resources and Services Administration that makes grants to community-based health centers to assist them in planning and delivering high-quality, accessible health care to people experiencing homelessness.
Web: http://bphc.hrsa.gov/policy/pal9912.htm
Phone: (888) ASK-HRSA (275-4772)

Health Care for the Homeless Information Resource Center—develops and disseminates information on best practices to address the housing and service needs of people who are homeless.
Web: http://www.nhchc.org/hchirc/directory
Phone: (518) 439-7415

National Health Care for the Homeless Council (NHCHC)—advocates for federal policy with regard to issues of health care for the homeless.
Web: http://www.nhchc.org/index.html
Phone: (615) 226-2292

National Coalition for the Homeless (NCH)—has extensive literature on the homeless.
Web: http://www.nationalhomeless.org
Phone: (202) 462-4822

National Alliance to End Homelessness—promotes policy, capacity building, education, and research to prevent and end homelessness.
Web: http://www.endhomelessness.org
Phone: (202) 638-1526

The United States Interagency Council on Homelessness—coordinates the federal response to homelessness.
Web: http://www.usich.gov
Phone: (202) 708-4663

References

1. Gelberg L, Arangua L. Homeless persons. In: Andersen RM, Rice TH, and Kominski GF, editors. Changing the U.S. health care system: key issues in health services, policy, and management. 2nd ed. San Francisco (CA): Jossey-Bass; 2001. p. 332–86.
2. Link BG, Susser E, Stueve A, Phelan J, Moore RE, Struening E. Lifetime and five-year prevalence of homelessness in the United States. Am J Public Health 1994;84:1907–12.
3. Cheung AM, Hwang SW. Risk of death among homeless women: a cohort study and review of the literature. CMAJ 2004;170:1243–7.
4. National Coalition for the Homeless. Homelessness among elderly persons. Washington, DC: NCH; 2009. Available at: http://www.nationalhomeless.org/factsheets/youth.pdf. Retrieved October 26, 2009.
5. General definition of homeless individual, 42 U.S.C. § 11302 (2008).
6. National Alliance to End Homelessness. McKinney-Vento reauthorization. Washington, DC: NAEH; 2009. Available at: http://www.endhomelessness.org/section/policy/legislature/mckinney_vento. Retrieved October 14, 2009.
7. Department of Housing and Urban Development (US). The 2008 annual homeless assessment report to Congress. Washington, DC: HUD; 2009. Available at: http://www.hudhre.info/documents/4thHomelessAssessmentReport.pdf. Retrieved October 14, 2009.
8. National Alliance to End Homelessness. Homelessness looms as potential outcome of recession. Washington, DC: NAEH; 2009. Available at: http://www.endhomelessness.org/files/2161_file_Projected_Increases_in_Homelessness.pdf. Retrieved October 9, 2009.
9. National Coalition for the Homeless. Why are people homeless? Washington, DC: The Coalition; 2009. Availableat: http://www.nationalhomeless.org/factsheets/Why.pdf. Retrieved October 9, 2009.
10. Zlotnick C, Zerger S. Survey findings on characteristics and health status of clients treated by the federally funded (US) Health Care for the Homeless Programs. Health Soc Care Community 2009;17:18–26.
11. Jasinski JL, Wesely JK, Mustaine E, Wright JD. The experience of violence in the lives of homeless women: a research report. Orlando (FL): University of Central Florida; 2005. Available at: http://www.ncjrs.gov/pdffiles1/nij/grants/211976.pdf. Retrieved October 9, 2009.
12. Zorza J. Woman battering: a major cause of homelessness. Clgh Rev 1991;25:421–7.
13. GLBT Domestic Violence Coalition, Jane Doe Inc. Shelter/housing needs for gay, lesbian, bisexual and transgender (GLBT) victims of domestic violence. Analysis of public hearing testimony, October 27, 2005, Massachusetts State House. Boston (MA): GLBT Domestic Violence Coalition; Jane Doe Inc.; 2006. Available at: http://www.thenetworklared.org/GLBTDVPublicHearingReport2006.pdf. Retrieved October 9, 2009.
14. Salit SA, Kuhn EM, Hartz AJ, Vu JM, Mosso AL. Hospitalization costs associated with homelessness in New York City. N Engl J Med 1998;338:1734–40.
15. Gelberg L, Lu MC, Leake BD, Andersen RM, Morgenstern H, Nyamathi AM. Homeless women: who is really at risk for unintended pregnancy? Matern Child Health J 2008;12:52–60.
16. Little M, Shah R, Vermeulen MJ, Gorman A, Dzendoletas D,Ray JG. Adverse perinatal outcomes associated with homelessness and substance use in pregnancy. CMAJ 2005; 173:615–8.
17. Stein JA, Lu MC, Gelberg L. Severity of homelessness and adverse birth outcomes. Health Psychol 2000;19:524–34.
18. Chau S, Chin M, Chang J, Luecha A, Cheng E, Schlesinger J, et al. Cancer risk behaviors and screening rates among homeless adults in Los Angeles County. Cancer Epidemiol Biomarkers Prev 2002;11:431–8.
19. Lewis JH, Andersen RM, Gelberg L. Health care for homeless women. J Gen Intern Med 2003;18:921–8.
20. Nickasch B, Marnocha SK. Healthcare experiences of the homeless. J Am Acad Nurse Pract 2009;21:39–46.
21. Gelberg L, Browner CH, Lejano E, Arangua L. Access to women's health care: a qualitative study of barriers perceived by homeless women. Women Health 2004;40:87–100.
22. Kushel MB, Vittinghoff E, Haas JS. Factors associated with the health care utilization of homeless persons. JAMA 2001;285:200–6.
23. Sadowski LS, Kee RA, VanderWeele TJ, Buchanan D. Effect of a housing and case management program on emergency department visits and hospitalizations among chronicallyill homeless adults: a randomized trial. JAMA 2009;301: 1771–8.
24. Allen J, Bharel M, Brammer S, Centrone W, Morrison S, Phillips C, et al. Adapting your practice: treatment and recommendations on reproductive health care for homeless patients. Nashville: Health Care for the Homeless Clinicians' Network, National Health Care for the Homeless Council, Inc., 2008.
25. Community Involvement and Volunteerism. ACOG Committee Opinion No. 437. American College of Obstetricians and Gynecologists. Obstet Gynecol 2009:114:203–4.