INTRODUCTION

Individuals living unsheltered or homeless are disproportionately vulnerable to severe forms of COVID-19.1 Contributing factors may include high rates of underlying health conditions and barriers to receiving care; however, the effects of the pandemic extend beyond physical health. We recently reported that social isolation and increased difficulties accessing care for chronic medical conditions during the pandemic were associated with poor mental health in unsheltered and unstably housed (UUH) women.2 What this means in the day-to-day lives of UUH women, who have specific social and mental health needs, is unclear but could inform future crisis-related emergency services. Studies prior to the pandemic suggest that many UUH women struggle to prioritize competing needs when managing their health, including transportation, time, and money,3 issues which may be exacerbated by the pandemic.

We conducted a study to understand the impact of the COVID-19 pandemic on the day-to-day lives of UUH women. Our study is one of very few to directly query UUH women about their experiences during the pandemic.

METHODS

Between May and December 2020, we conducted phone surveys with women recruited from San Francisco homeless shelters, street encampments, free meal programs, and low-income residential hotels. Participants were primarily recruited via flyers posted or distributed by service providers. An open-ended question asked participants to describe how they were personally impacted by the pandemic. Detailed notes and quotes were transcribed.

We used thematic analysis of survey data in accordance with steps outlined by Braun and Clarke.4 Two investigators independently read responses and generated codes from participants’ recurring experiences and perceptions. Differences in coding were discussed until unity was reached. Codes were ultimately organized under themes (Table 1). Each theme represented a significant impact on participants’ lives.

Table 1 Main Themes and Related Codes Associated with Unsheltered and Unstably Housed Women’s Responses to the Open-Ended Question “How Have You Personally Been Impacted by the Pandemic?” (N=128)
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RESULTS

All 128 interviews included open-ended responses. We identified three main themes, represented in Figure 1 with illustrative quotes: exposure to significant lifestyle disruptions and losses, increased social isolation, and impaired access to essential resources. Many study participants reported increased feelings of marginalization in the wake of lifestyle disruptions. For others, social isolation and an inability to fulfill important social and familial roles coincided with the disruption of essential resources, leading to substantially increased difficulties meeting basic subsistence needs (Fig. 1).

Fig. 1
figure 1

Thematic map of themes associated with unsheltered and unstably housed women’s responses to the open-ended question “How have you personally been impacted by the pandemic?” (N=128).

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While many in the general population have avoided or delayed seeking care during the pandemic to reduce health risks,5 UUH women faced additional barriers like increased costs or limited availability of transportation, closure of outpatient health services, and lack of internet access to participate in telemedicine. For example, participants described how the elimination of bus routes led to difficulty accessing health clinics and food pantries and created additional financial burdens. One participant ordinarily attended mandatory biweekly urine drug tests to receive pain medication, but transportation vouchers were discontinued during the pandemic and increased transportation costs made it impossible for her to attend appointments. In addition, recently unsheltered participants, who were relocated to temporary housing, struggled to access food and medical care in new and unfamiliar settings.

Few participants specified positive effects of the pandemic and no positive themes were assigned.

DISCUSSION

During the COVID-19 pandemic, UUH women experienced significant lifestyle disruptions and losses, increased social isolation, and impaired access to essential resources. These experiences echo recent COVID-related isolation, loss, and lack of control in the general population.6 However, UUH individuals went into the pandemic with fewer resources and less social capital to lose. Safety measures that reduced services on which UUH women rely made the losses especially profound.

Measures addressing public health crises may have more impact, while also preserving the well-being of highly vulnerable populations, by maintaining accesses to essential resources (transportation, food pantries, and non-COVID health care). For example, creating new or at least temporary crisis-access to technology like mobile phones and/or internet access could promote connections to resources, make telemedicine possible, and reduce isolation.