The Health of Homeless Women:

Information for State Maternal and Child Health Programs

The Maternal and Child Health Services Block Grant acute versus chronic homelessness, and to include the rural

program (Title V of the Social Security Act) provides leadership homeless as well as those in urban areas, where the homeless

to both the public and private sector to build the infrastructure tend to congregate in order to obtain social services. Further,

for health care strategies addressing the needs of all mothers it is also important to recognize the numbers of those at-risk

and children in the Nation, particularly low-income and other for becoming homeless: families who live doubled-up with

vulnerable isolated populations with limited access to health relatives or friends, or in their cars, who have low incomes and

care. One population for which it is particularly challenging to small to non-existent savings. 

provide health care is homeless women. The number of

homeless women and families continues to increase, and the Given these caveats, estimates of the number of homeless

importance of developing strategies to reach these women (and women and/or families are available in each state’s respective

children) becomes even more critical. Consolidated Plan, prepared every five years for the U.S.

Most state governments first became involved in activities recent plans were prepared for 1995; new consolidated plans

for the homeless primarily as the result of fiscal incentives and will be released in 2000. MCH programs can access the

planning requirements of the 1987 Stewart B. McKinney Act, information for their state at

1

which focuses on emergency measures as opposed to the <http://www.hud.gov/states.html>.

causes of homelessness. Funding for these and related

2

programs varies from year to year dependent on the type of Notwithstanding the significant challenges of enumerating

program, and the political will. Table 1 outlines selected policies the homeless population, we do know that the prevalence of

and programs for homeless persons. Since 1987, many federal women and families among those who are homeless has

and state agencies have become involved in providing and/or increased nationally. According to a survey by the U.S.

ensuring these services. State Maternal and Child Health Conference of Mayors, 37 percent of homeless people in 1999

(MCH) programs can contribute their skill, knowledge, and were families with children, and 13 percent were single women.

networks and take an active role in addressing the health of Thirty-two percent of all homeless clients according to one

homeless women. The vulnerability of this population suggests survey are female, and among homeless families, 84 percent

the importance of homeless women as a priority population for are females. Families with children (about 90 percent of which

public health efforts and programs. are female-headed ) constitute approximately 40 percent of the 3

Characteristics of the Population population. Research indicates that families, single mothers,

of Homeless Women and children make up the largest group of people who are

Determining the number of homeless women, whether on

a national, state or local level, involves crude, often inaccurate,

estimates. The 1990 Shelter and Street Census Count (S-Night,

March 20-21) has been criticized as under-counting the

homeless population, both in shelters and on the street. Most

local estimates of homelessness are higher than the Census

count. In an effort to improve the count accuracy, the 2000

Census has made specific plans to partner with local

governments, community-based organizations, advocacy

organizations, public and volunteer organizations in order to

locate “people without conventional housing.” Deemed

“service-based enumeration,” following advance visits with

relevant personnel, the count will take place at shelters, soup

kitchens, regularly scheduled mobile food vans, and target

nonsheltered outdoor locations between March 27 and March

29, 2000.

Estimates of the size of the homeless population can be

measured using point-prevalence estimates (e.g., a one-day time

period), or by identifying those who come into contact with

public or private assistance programs. When counting the

homeless, it is important to recognize the difference between

Department of Housing and Urban Development. The most

4

5

6

total homeless population. Another study states that homeless 7

women comprise one fifth of the U.S. homeless adult

8

homeless in rural areas.9
2

Table 1. Selected Legislation and Programs Relevant for Homeless Persons

ò Stewart B. McKinney Act, 1987, (introduced as the Urgent Relief for the Homeless Act). Four amendments made in

1988, 1990, 1992 and 1994. McKinney Homeless Assistance Programs, and Continuum of Care, Department of Housing

and Urban Development (HUD)

ò Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), Food and Nutrition Service (FNS),

Department of Agriculture (USDA)

ò Food Stamps, FNS, USDA

ò Medicaid, Health Care Financing Administration (HCFA) and States’ Medicaid Programs

ò States’ Children’s Health Insurance Programs, HCFA

ò Health Care for the Homeless (HCH), Bureau of Primary Health Care, Health Resources and Services Administration

ò Projects for Assistance in Transition from Homelessness (PATH ), Center for Mental Health Services, Substance Abuse

and Mental Health Administration (SAMHSA)

ò Access to Community Care and Effective Services and Supports (ACCESS), Mental Health Knowledge Development and

Application (KDA), Division of Knowledge Development and Systems Change, SAMHSA

ò Substance Abuse KDA, SAMHSA

ò The Community Services Block Grant (CSBG), Administration for Children and Families (ACF): Provides supportive

services to homeless individuals and families in local, communities.

ò Transitional Living Program for Homeless Youth, Family and Youth Services Bureau (FYSB), ACF

ò Education and Prevention Grants to Reduce Sexual Abuse of Runaway, Homeless and Street Youth, FYSB, ACF: Grants

to non-profits for street-based outreach and education.

ò Runaway and Homeless Youth / Basic Centers, FYSB, ACF: Drug Abuse Prevention program previously included, but

unfunded since FY 1996.

ò Special Projects of National Significance, (Homeless-specific Ryan White AIDS grants only), HIV/AIDS Bureau, Health

Resources and Services Administration: Includes HHS/HUD collaborative grants, and evaluation funding.

ò Administration on Children, Youth and Families (ACYF): Tracks families leaving welfare (and possibly becoming

homeless).

ò Head Start for the Homeless, ACYF: FY 97 and 98 funds are blended with the Head Start program, but still target

homeless children.

ò Battered Women’s Shelters, ACF, CDC, and SAMHSA: Funded through Family Violence Prevention and

Services/Battered Women’s Shelter grants, under the Violence Against Women Act within the 1994 Crime Bill.

ò Homeless Services Research, National Institutes of Health

As noted above, women at-risk for homelessness and those who actually become homeless have similar social and financial

situations. Most women in a sample of 409 women receiving Aid to Families with Dependent Children (women considered to be

potentially at-risk for homelessness) did not report having the advantage of family and friends who could provide economic or

social support when times were rough. One of the major differences, however, is that women who remain housed have a stronger 10

support network. Moreover, many homeless women who escape violent relationships are bereft of social supports such as family.11

Obviously a woman’s income and assets also affect her likelihood of becoming homeless. The work history of 436 sheltered

homeless women and low-income women were analyzed by Brooks and Buckner (1996), and 75 percent of the working women

in their study were employed in service and sales industries, compared with 61 percent of all women in the nation. Service

occupations are mostly part-time and offer lower earnings, little advancement, limited benefits, and are of short duration (around

1.8 years).12
3

Principal Health Issues fat. This may be because the most affordable food is often

Seeking attention for health care becomes a low priority for harmful health effects such as increased risk for chronic disease

women who do not know where they or their children will and compromised growth and development for children. The

sleep that night, or where they will find their next meal. In one homeless are twelve times more likely than individuals in stable

study, after controlling for potential confounding factors, housing to have dental problems. Persons living in unstable

homeless mothers had more frequent emergency department housing, such as a hotel or the residence of a friend or relative,

visits in the past year and were significantly more likely to be are six times more likely to have dental problems.

hospitalized in the past year compared with housed mothers.13

Thus, it is even more important to be aware of the health Perhaps the most troubling health issues for homeless

conditions that homeless women face in order to help these women relate to violence, substance abuse, and mental health

women be healthy. These issues are summarized in Table 2. (specifically depression). In general, poor women are at a

Health issues of particular importance to women include a person’s ability to take control of their own environment and

family planning, pregnancy, female genitourinary problems, and seek protective care. In a study of 436 sheltered homeless and

sexually transmitted diseases that are more commonly seen in low-income housed mothers, it was found that 84 percent of all

women than in men. Risks for pregnancy complications due to of these women had at some point been severely assaulted, 63

lack of prenatal care, poor nutrition, stress, and exposure to percent had been assaulted by parental caretakers, 40 percent

violence are higher among homeless women. Homeless had been sexually molested as children, 60 percent had been

14

women may have little choice as to the timing and attacked physically by intimate male partners, and 33 percent

circumstances surrounding conception, and will become had been assaulted by their current or most recent male

pregnant due to victimization, economic survival, lack of access partner. Additional studies among homeless women confirm

to contraceptives, uncertain fertility, and desire for intimacy. this high prevalence of violence, specifically high lifetime rates 15

Homeless women are in great need for family planning services, of childhood physical and sexual abuse, as well as assault by

which could be combined with vocational, social service, and intimate male partners. Further, violence in the lives of these

drug treatment programs. Yet, few family planning agencies women serves as a barrier to employment. The social

16

have special programs for homeless women. consequences include job loss, loss of job productivity, and

17

About one third of medical problems treated at Health

Care for the Homeless locations are chronic physical It has been suggested that homeless people may use drugs

conditions. The most common (excluding substance abuse) are or alcohol to self-medicate mental illnesses. These conditions

hypertension, gastrointestinal problems, neurological disorders, may be alleviated, and even momentarily forgotten to a degree,

arthritis and other musculoskeletal disorders, chronic by using marijuana or alcohol. Lack of appropriate health care

obstructive pulmonary disease, and peripheral vascular and stressful living conditions may lead to increased substance

disease. More research is needed on how homeless women abuse. Homeless women comprise a subpopulation at-risk for 14

with chronic diseases receive treatment. substance abuse with rates of disorder ranging from 16 to 67

Common illnesses (such as colds or the flu) that are easily need for substance abuse treatment and access to these

treated in the general population often escalate to more severe services. Homeless, substance-abusing women face severe

problems in the homeless population, and chronic health barriers to care, and more research is needed to understand

18

problems common among the housed population are made the barriers to treatment that are specific to this population.

much worse by the stress and exposure of homelessness, as

well as lack of access to ongoing treatment. A condition as

14

serious as tuberculosis may not be reported until the condition

worsens due to limited access to screening and treatment

services. In a study of homeless persons seeking medical

treatment at a free medical clinic in a small Florida community,

the 73.8 percent of those seeking services reported that they

were suffering from a recurrence of a health problem that they

had experienced within the past year and for which 58.3

percent previously had received treatment.18

Other health issues, such as stress and nutrition, affect the

lives of homeless women more negatively than their housed

counterparts. Compared to other low-income women,

homeless women seem to be worse off in terms of their

emotional and physical welfare. Homeless mothers are more

likely to report higher stress levels, avoidant behavior, and anticognitive coping strategies. Although they are more likely to 19

have less food to eat, homeless women and their dependents 5

are more likely to consume higher than desirable amounts of

20

the most unhealthy. Low nutrient intake may have several

20

21

higher risk for violence as poverty increases stress and lowers

22

22

23

social isolation that reinforce the pattern of violence.24

percent. Unfortunately, there exists an imbalance between the

25
4

Table 2. Summary of study findings related to health problems faced by homeless women.

HEALTH ISSUE KEY FINDINGS

Chronic gastrointestinal problems, neurological disorders, arthritis and other musculoskeletal disorders,

Disease chronic obstructive pulmonary disease, and peripheral vascular disease.

Ç The most common chronic physical conditions (excluding substance abuse) are hypertension,

14

Infectious Ç Homeless patients with tuberculosis were more likely to present with a more progressed form than

Disease non-homeless.

Ç The most common infectious diseases reported were chest infection, cold, cough, and bronchitis;

reporting was the same for those formerly homeless, currently homeless, and other service users.5

Ç Widespread screening for TB in shelters may miss most homeless persons because many do not live

in the shelters, and instead present in emergency departments.33

STDs/ abnormal Pap smears--14% with atypia and 10% with inflammation; the incidence of chlamydia was

HIV/AIDS 3%, gonorrhea 6%, and trichomoniasis 26%.

Ç A mobile women’s health unit in Chicago reported that of 104 female homeless clients, 30% had

34

Ç HIV infection was found to be 2.35 times more prevalent in homeless, drug-abusing women than

homeless, drug-abusing men.3

Stress Ç Homeless mothers reported higher levels of stress, depression, and avoidant and anti-cognitive

coping strategies than low-income, housed mothers.19

Nutrition the 1989 RDA for iron, magnesium, zinc, folic acid, and calcium.

Ç Currently and formerly homeless clients are more likely to report not getting enough to eat (28%

and 25%) than among all U.S. households (4%) and among poor households (12%).5

Ç Contrary to their opinion, homeless women and their dependents were consuming less than 50% of

20

Ç Subjects of all ages were consuming higher than desirable quantities of fats.20

Ç The health risk factors of iron deficiency anemia, obesity, and hypercholesterolemia were

prevalent.20

Smoking Ç More than half of both homeless mothers and low-income, housed mothers were current smokers,

compared to 22.6% of female adults 18 years and over.13

Violence adulthood; 60% had experienced severe physical attacks by a male intimate partner; and 33% had

Ç Poor women are at higher risk for violence than women overall; poverty increases stress and lowers

the ability to cope with the environment and live safely.22

Ç In a study of 436 sheltered homeless and poor housed women: 84% of these women (average age =

27) had been severely assaulted at some point in their lives; 63% had been severely assaulted by

parental caretakers while growing up; 40% had been sexually molested at least once before reaching

been assaulted by their current or most recent partner.22

Ç Studies of homeless women reveal high lifetime rates of childhood physical and sexual abuse and of

assault by intimate male partners.23

Ç A study of fifty-three women homeless for at least three months in the past year demonstrated that

this group is at a very high risk of battery and rape, with 91% exposed to battery and 56% exposed

to rape.35

Substance access, which suggests that homeless, substance-abusing women are facing severe barriers to care.

 Abuse Ç Some homeless people with mental disorders may use drugs or alcohol to self-medicate.

Ç Homeless women comprise a subpopulation at high risk for substance abuse; rates of substance use

disorder range from 16% to 67%. There exists an imbalance between treatment need and treatment

25

36

Mental alcohol abuse, drug abuse, antisocial personality disorder, and also had less adequate family

Health/ support.

Depression Ç Many homeless women with serious mental illness are not receiving care; this is due to lack of

Ç A case-control study of 100 homeless women with schizophrenia and 100 non-homeless women

with schizophrenia found that homeless women had higher rates of a concurrent diagnosis of

37

perception of a mental health problem and lack of services designed to meet the needs of homeless

women.8
5

Studies show that lifetime rates of post-traumatic stress homeless families. Strategies around use of mobile medical

disorder (PTSD), major depression, and substance abuse units and other mobile forms of health outreach that bring

disorders are overrepresented among homeless women when health care services to the women (and their families) at more

compared to the rates found in the National Comorbidity flexible hours could help overcome barriers such as

Survey. Despite this, a cross-sectional study of mothers and transportation and clinic schedules. 26

their children living in homeless shelters showed that

homeless mothers have a high level of unmet need for mental State MCH programs have access to clinics and specialized

health services. A similar study showed that homeless knowledge about how to reach women in general, and

27

women with serious mental illness are not receiving care, specifically underserved, low-income women. This

perhaps due to the lack of perception of the extent of mental knowledge can be applied in several ways. As managed care

health problems and the lack of services designed to meet has become more prominent in the states’ Medicaid

mental health needs. Bogard et. al (1999) critique recent programs, State MCH programs can work to promote (to the 8

service-intensive shelter programs for homeless mothers. greatest extent possible) the implementation of

This study showed that mental health services had little recommendations such as: 

impact on depression levels and that isolation from social

networks is what increased depression levels among homeless ò including identification of homeless Medicaid

mothers. The authors suggest putting less emphasis on beneficiaries in the outreach and education phase; 

providing services and more emphasis on integration into the ò using housing status or homelessness as markers for

community by providing housing. However, this does not increased health risk; and, 28

address a woman’s ability to remain housed and the events ò development of specific quality assurance activities

that led up to her homelessness in the first place. Women and outcome measures focusing on homeless

with serious mental illness, such as schizophrenia, may be enrollees, in collaboration with advocates and

unable to function independently without adequate experienced homeless service providers.

treatment. Those that experience depression may be

encountering other hardships that would not allow them to In working with their state’s Medicaid office, MCH

fully integrate into society or a new housing situation. program staff can encourage provider-screening of women

The Role of State Title V Programs additional social services, or are homeless, and thus also in

There are several roles State Title V programs can play To do this, Title V programs might assist with screening

to assure the health of homeless women of reproductive age. tools, referral resources, and training. Health care providers

States can assist in collecting the necessary data and relevant and others who interact with the homeless could assist more

information in order to form better policies and provide women by doing assessments and referrals in settings

better health care. Research studies tend to focus on women homeless women frequent with their children (immunization

they can find: homeless women in shelters. This ignores the clinics, schools, child care, pediatricians’ offices, etc.). Title V

women who are at-risk of becoming homeless (those women programs can improve referrals to domestic violence

who are living doubled-up with friends and relatives, low- programs (as available), which then could lead to referral to

income women with inadequate support networks), and the additional supportive services.

street homeless (those women living in their cars, in parks,

under bridges, etc.). State Title V Programs should work with Other issues around which State Title V programs could

their state’s office of homeless services and health care for be advocates include promoting the use of portable health

the homeless program (in those states that have them) to insurance to facilitate eligibility for and access to services, and

determine ways to reach out to homeless women both in and addressing the special needs of mentally ill women who are

outside of shelters. Also, surveys need to distinguish between homeless. State Title V programs also can advocate for more

women who are mothers with children, as opposed to solitary available inexpensive housing for the low-income population.

women, since health care service delivery implications will One recommendation that has been made is for shared

differ. housing facilities where women are provided a private room

State Title V programs can assist other relevant federal socialization. Social and other wrap-around services can be

and state programs (e.g., community health centers) with the located there as well.

charge of providing services to homeless women, especially

through existing referral and networking opportunities. If State Title V programs are not doing so already, they

Although one study’s findings raised concerns that should participate in the development of the state’s or

specialized services for homeless persons, and/or the stigma community’s Consolidated Plan for HUD, providing their

of a person’s being homeless, may disrupt ties to private expertise, and facilitating citizen input where available. The

physicians or health maintenance organizations, it also states Title V program also could participate on the state’s

that institutional providers (e.g., community health centers Interagency Council and/or Task Force on Homelessness (in

and public clinics), which generally have more commitment those areas that have them). Keeping homeless women’s

to serving homeless and other vulnerable populations, may be issues on the Title V program’s agenda should lead to

better suited to meet the needs of the homeless or formerly improved coordination and provision of health care for these

29

30,31

32

about their housing situation in order to determine if their

patients are at-risk for homelessness, and in need of

need for a specialized prevention or therapeutic plan of care.

and access to shared space for meals, laundry, and
6

most vulnerable of women.

Given the broad definition of “health,” it is important to

recognize that homeless women inherently cannot be healthy.

Until these women find housing, a stable source of income,

and food on a regular basis, etc., they will not be able to

benefit fully from the health care services that Title V

programs are attempting to ensure.

The authors wish to thank Jean Hochron, Chief, Health Care of the

Homeless, Bureau of Primary Health Care; Sarah Szanton of the

Urban Medical Institute and the Johns Hopkins School of Nursing;

Karen Hughes, Chief of the Bureau of Child and Family Health

Services (and her colleagues) within the Ohio Department of Health;

Ann Koontz, Maternal and Child Health Bureau; as well as Cynthia

Minkovitz and Holly Grason of the Women’s and Children’s Health

Policy Center for their thoughtful review of and comments on this brief.

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6.
8

The Health of Homeless Women: 

Information for State 

Maternal and Child Health Programs

Gillian Silver and Rea Pañares

March 2000

Development of this summary was supported by a

Cooperative Agreement (Grant # U93 MC 00101-04) from

the Maternal and Child Health Bureau (Title V, Social

Security Act), Health Resources and Services Administration,

Department of Health and Human Services.

This brief can be viewed on the 

Women’s and Children’s Health Policy Center’s 

web site at <http://www.med.jhu.edu/wchpc>.

Women’s and Children’s 

Health Policy Center, 

Johns Hopkins University, 

School of Public Health