Funded by the VA HSR&D (Project# SDR 10-012)

Spotlight on Women Cyberseminar Series 
Risk Factors for Homelessness among 

Women Veterans: 

Implications for Prevention and Services

Donna L. Washington, M.D., M.P.H.

Alison B. Hamilton, Ph.D., M.P.H.

VA HSR&D Cyberseminar

Spotlight on Women’s Health

March 14, 2012

VA HSR&D Center for 

the Study of Healthcare 

Provider Behavior
ACKNOWLEDGEMENTS

Funding:

• DHHS 04-04-PO-36011

• VA HSR&D RCD-00-017 & GEN-00-082 

• QUERI RRP-11-421

• Women Veterans Health Strategic Healthcare 

Group

Acknowledgements:

• Vivian Hines, MSW, ACSW; Ines Poza, PhD

Disclosures: no conflicts of interest
POLL QUESTION #1

Which category describes your current role in 

working with women Veterans who are 

homeless (select all that apply)? 

• Primary care provider

• Mental health provider, substance use or other 

counselor

• Social worker, case manager (e.g., HUD-VASH)

• Administrator

• Researcher
POLL QUESTION #2

In which setting do you serve women Veterans 

who are homeless?

• VA medical services (e.g., primary care, ER)

• VA mental health

• VA homeless program/housing services

• Settings outside of the VA (e.g., community 

organization)

• Not applicable
POLL QUESTION #3

For those who do not work in homeless services, 

how often do you screen patients for 

homelessness? 

• Most or all of the time

• Some of the time

• Rarely 

• Never

• Not applicable
POLL QUESTION #4

How many people, including yourself, are using 

your computer/phone line to listen to this 

presentation? 

• 1 – I am viewing this presentation alone

• 2 

• 3-5 

• 6-10

• >10 
BACKGROUND 

• Eliminating homelessness among 

Veterans is a federal and VA priority 

– VA, HUD, Dept of Labor, DHHS

• Best estimate is that 107,000 Veterans 

are homeless on any given night; and 

200,000 over the course of 1 year

• Women Veterans up to 4 times more 

likely to be homeless than women who 

are not Veterans
BACKGROUND: 

Homelessness in Women Veterans

• Homelessness takes many forms: 

unsheltered, sheltered, doubled up

• In healthcare settings, it is often not readily 

apparent that a woman Veteran is 

experiencing homelessness

• Important to know what puts women Veterans 

at elevated risk for homelessness to address 

those risks and deter or prevent homelessness
OBJECTIVES 

• Characterize risk factors for 

homelessness among women Veterans

• Describe how risk factors interplay and 

accumulate over women Veterans’ life 

course to result in homelessness

• Highlight implications for prevention and 

services
METHODS: Study design & sample

Washington et al., 2010, Journal of Health Care for the Poor and Underserved; 21: 81-91. 

• Matched case control design

• Women Veterans in Los Angeles County who 

were homeless each matched with five housed 

historical controls from Women Veterans 

ambulatory care use study

– Enrollment criteria: spent at least 1 night of the 

prior 30 in a shelter or transitional residential 

facility, voucher-paid hotel, car, abandoned 

building, nonresidential building, another nondwelling, or on the street

– Matching criteria: geographic region, military 

service period, age group
Study design & sample (continued)

Washington et al., 2010, Journal of Health Care for the Poor and Underserved; 21: 81-91. 

• Recruitment 12/05 – 01/06 through VA and 

non-VA homeless service organization contacts

• Homeless Women Veterans Coordinator 

outreach included:

– shelters, soup lines, county jail

– transitional housing programs

– residential substance use rehabilitation programs

– “Skid Row” (area of downtown LA)

• Total sample size: 198 
Procedures & measures

Washington et al., 2010, Journal of Health Care for the Poor and Underserved; 21: 81-91. 

• In-person (91%) and phone (9%) interviews

• Survey items drawn from both the housed 

women Veteran’s survey and a previously 

fielded homeless women’s survey

• Homelessness measures: length of time 

homeless, number of entries into and exits 

out of homelessness

• Veteran-specific factors: period of military 

service, service-connected disability rating, 

and military sexual assault (MST) history
Analysis 

Washington et al., 2010, Journal of Health Care for the Poor and Underserved; 21: 81-91. 

• Comparisons of homeless versus housed: 

Fisher’s exact test for binary measures, 

chi sq for categorical, t-test for continuous

• Independent risk factors assessed using 

multiple logistic regression model with a 

Monte Carlo algorithm to estimate exact std 

errors of model coefficients and p-values

• Measures with bivariate p<0.2 included if 

not a matching criteria, correlated with other 

measures, or highly skewed distribution
RESULTS: Characteristics of 

Women who were Homeless

Washington et al., 2010, Journal of Health Care for the Poor and Underserved; 21: 81-91. 

• Age in years, mean (SD): 49.7 (6.9)

• College grad 9%, employed 6%, married 10%

• Children under age 18 living with them in the 

prior 12 months: 16%

• Prevalence of: psychotic symptoms 36% 

 polysubstance abuse 32%
Homelessness characteristics

Washington et al., 2010, Journal of Health Care for the Poor and Underserved; 21: 81-91. 

• Average of four cycles in and out of 

homelessness

• Median length of time homeless (over lifetime) 

2.1 years (interquartile range 3.5)

• Median length of time since last stably housed 

1.0 years (interquartile range 1.8) 
BIVARIATE RESULTS:

Socio-demographic characteristics

Washington et al., 2010, Journal of Health Care for the Poor and Underserved; 21: 81-91. 

• Homeless women Veterans significantly 

more likely than housed women Veterans:

– to be unemployed, disabled, low-income

– to have experienced MST

• Homeless women Veterans significantly 

less likely: 

– to be college graduates, employed, married

– to have health insurance
Health characteristics

Washington et al., 2010, Journal of Health Care for the Poor and Underserved; 21: 81-91. 

• Homeless women Veterans significantly 

more likely than housed women Veterans:

• to have diagnosed medical conditions

• to screen positive for an anxiety disorder, 

PTSD, or tobacco use

• to have lower self-reported physical and 

mental health

• to be in fair or poor health
Health care use in prior 12 months

Washington et al., 2010, Journal of Health Care for the Poor and Underserved; 21: 81-91. 

• Homeless women Veterans 

significantly more likely than housed 

women Veterans to have:

• Mental health services use 

• VA health care use

• Hospitalization
MULTIVARIATE RESULTS

Washington et al., 2010, Journal of Health Care for the Poor and Underserved; 21: 81-91. 

• Not included in multivariate model to assess 

independent risk factors for homelessness:

– Matching factors: age, military service period 

– No matching data: substance use, psychotic 

symptoms

– Skewed data distribution: income, VA use, 

mental health use
Independent risk factors for 

homelessness in women Veterans

Washington et al., 2010, Journal of Health Care for the Poor and Underserved; 21: 81-91. 

• Unemployment

• Disability

• Single/divorced/separated

• Not a college graduate

• PTSD screen (+)

• Prior military sexual assault

• Anxiety disorder screen (+)

• Fair or poor overall health

13.1 (2.7, 63.0)

12.5 (3.5, 45.0)

10.0 (2.5, 100.0)

 5.0 (1.1, 25.0)

 4.9 (1.9, 12.7)

 4.4 (1.4, 14.0)

 4.1 (1.3, 13.2)

 3.2 (1.3, 7.9)

Adjusted OR (95% CI)
A closer look: focus groups with 

women Veterans experiencing 

homelessness
METHODS: Sample & setting

• 3 focus groups with 29 participants

• Los Angeles, CA, 12/05-01/06

• Recruitment concurrent with case 

control study

Hamilton, Poza, Washington, 2011, Women’s Health Issues; 21: S203-9. 
Analysis 

• Focus groups audiotaped & transcribed

• Constant comparison method to analyze 

transcripts in Atlas.ti

– Focus group as unit of analysis 

– Top-level codes derived from interview guide

– Each top-level code divided into subcodes

– Compared & contrasted content across focus 

groups

Hamilton, Poza, Washington, 2011, Women’s Health Issues; 21: S203-9. 
RESULTS: Participant characteristics

• Average age

– Military discharge – 26 years

– First homelessness – 36 years 

– Focus group participation – 48 (range, 32-68)

• Race/ethnicity: African American (52%), 

White (31%), Hispanic (7%), did not state (10%)

• 58% not service-connected

• 88% single or divorced/separated

• 0% employed, 65% disabled

Hamilton, Poza, Washington, 2011, Women’s Health Issues; 21: S203-9. 
Roots of homelessness

Five predominant “roots” (precipitating experiences) 

initiated pathways to homelessness: 

1. childhood adversity

2. trauma or substance abuse in military service

3. post-military abuse, adversity, and/or 

relationship termination

4. post-military mental health, substance abuse, 

and/or medical problems

5. Unemployment

Subsidiary factor: 6. criminal justice involvement

Hamilton, Poza, Washington, 2011, Women’s Health Issues; 21: S203-9. 
MAJOR THEME: Web of vulnerability 

with distinct pathways into homelessness

• (1) – (5) predominant 

“roots” initiating pathways 

into homelessness

• (6) subsidiary factor

• (*) contextual factors

• Pathways (arrows) may 

be unidirectional or 

bidirectional, with the 

latter linking to factors 

that both lead to and 

result from homelessness 

(leading to a cycle)

Hamilton, Poza, Washington, 2011, Women’s Health Issues; 21: S203-9. 
Contextual factors reinforcing 

homelessness

• Contextual factors: promoted development or 

maintenance of homelessness 

– “survivor instinct” 

– lack of social support and resources

– sense of isolation

– pronounced sense of independence

– barriers to care

Hamilton, Poza, Washington, 2011, Women’s Health Issues; 21: S203-9.
Three main barriers to care

1. Lack of information about available 

services

2. Limited access to services 

3. Lack of coordination across services

Plus:

Sense of isolation and abandonment

Hamilton, Washington, et.al. 2012, Journal of Social Work Practice in the Addictions; 12: 52-68.
Barrier: Lack of information 

• Women unsure about many aspects of services:

– eligibility requirements

– location

– terms of use (e.g., duration of stay)

• Women used focus groups as opportunity to 

share information about services

• Women wanted information and help from 

other women Veterans

Hamilton, Washington, et.al. 2012, Journal of Social Work Practice in the Addictions; 12: 52-68.
Barrier: Limited access to services

• Access to services limited by several factors: 

– lack of options for gender-appropriate care 

(e.g., safety issues in mixed gender programs, 

few women-only programs)

– geographic distance/inconvenience

– lack of long-term housing options 

– restrictive entry criteria of many programs 

(e.g., current/past substance abuse)

Hamilton, Washington, et.al. 2012, Journal of Social Work Practice in the Addictions; 12: 52-68.
Barrier: Lack of coordination across 

services

• From screening to services

• From jail/prison to community

• From temporary to permanent housing

• Challenges with money management

• Difficulty connecting VA and non-VA services

Hamilton, Washington, et.al. 2012, Journal of Social Work Practice in the Addictions; 12: 52-68.
SUMMARY

• Women Veterans who are homeless face 

numerous challenges accessing 

information about and entry into programs 

to address their multiple needs

• Women expressed a fundamental need for 

safe and stable housing

• Homeless women Veterans’ want and need 

coordinated, women-only services 
IMPLICATIONS: Screening & 

homelessness prevention in women 

Veterans

• Screen for homelessness in VA clinical 

settings and assess for vulnerability to 

homelessness (risk factors)

– Current VA efforts

• Outside VA, screen for Veteran status, and 

for MST if Veteran
IMPLICATIONS: Services

• VA / HUD / DOL engaged in several initiatives 

to address homelessness among Veterans

• Our findings suggest the need for:

– Greater availability of women-only programs 

– Attention to entry criteria: families, substance use

– Tailoring of mixed-gender programs to address 

safety concerns of women Veterans & improve 

continuity of care

– Interventions that reflect homeless women Veterans’ 

preferences for peer support & information-sharing
Services (continued)

• Need to address victimization experiences in 

women’s histories, and to reduce/eliminate 

(re)victimization in women’s post-military lives

– Need for trauma-informed care

– Need to screen for domestic violence and 

other trauma in primary care

– Need to address relationship issues

• Consider strengths-based approach, building on 

women’s problem-solving skills

• Empowerment-oriented approach
LITERATURE CITED

• Washington DL, Yano EM, McGuire J, Hines V, Lee M, 

Gelberg L. Risk factors for homelessness among women 

veterans. J Health Care Poor Underserved. 2010 

Feb;21(1):82-91. 

• Hamilton AB, Poza I, Washington DL. Homelessness 

and trauma go hand-in-hand: Pathways to 

homelessness among women veterans. Women’s 

Health Issues. 2011 Jul-Aug; 21(4 Suppl):S203-9. 

• Hamilton AB, Poza I, Hines V, Washington DL. Barriers 

to psychosocial services among homeless women 

veterans. Journal of Social Work Practice in the 

Addictions. 2012 Mar; 12(1):52-68.
DISCUSSANTS

Vince Kane, MSW

Director, National Center on Homelessness among Veterans

Director, Housing and Urban Development -

VA Supportive Housing (HUD-VASH) Program

Robert W. O'Brien, PhD, MA

Scientific Program Manager

Mental and Behavioral Health Research Portfolio

VA HSR&D

Email: Robert.OBrien7@va.gov