UCLA Campuswide Homelessness Initiative

Background People experiencing homelessness (PEH) are at high risk for COVID-19 complications and fatality, and have been prioritized for vaccination in many areas. Yet little is known about vaccine acceptance in this population. The objective of this study was to determine the level of vaccine hesitancy among PEH in Los Angeles, CA and to understand the covariates of hesitancy in relation to COVID-19 risk, threat perception, self-protection and information sources.

Methods and findings A novel mobile survey platform was deployed to recruit PEH from a federally qualified health center (FQHC) in Los Angeles to participate in a monthly rapid response study of COVID-19 attitudes, behaviors, and risks. Of 90 PEH surveyed, 43 (48%) expressed some level of vaccine hesitancy based either on actual vaccine offers (17/90 = 19%) or a hypothetical offer (73/90 = 81%). In bivariate analysis, those with high COVID-19 threat perception were less likely to be vaccine hesitant (OR=0.34, P=.03), while those who frequently practiced COVID-19 protective behaviors were more likely to be vaccine hesitant (OR=2.21, P=.08). In a multivariate model, those with high threat perception (OR=0.25, P=.02) were less likely to be hesitant, while those engaging in COVID-19 protective behaviors were more hesitant (OR=3.63, P=.02). Those who trusted official sources were less hesitant (OR=0.37, P=.08) while those who trusted friends and family for COVID-19 information (OR=2.70, P=.07) were more likely to be hesitant.

Conclusions Findings suggest that targeted educational and social influence interventions are needed to address high levels of vaccine hesitancy among PEH.

Los Angeles faces a housing crisis of unprecedented scale. After years of underinvestment, in 2016/2017 LA County voters approved Measures H and HHH, which provided an infusion of resources for homeless services, permanent housing, and integrated outreach through the LA County Homeless Initiative (HI). An estimated 58,936 individuals in LA County remain homeless as of January 2019, 75% of them unsheltered and living on streets, in tents, or encampments. Our best estimates suggest that the homeless population has grown since 2017.

HI takes a Housing First approach to homelessness, with the largest amount of total funds allocated to housing solutions. However, rehousing is often subject to delays in construction and case management. These delays, combined with persistent market forces driving new homelessness, have left the county well short of its targets. While no forecasts were issued, the initial gap analysis for HI had assumed a 34% reduction in the total homeless count from 2016 to 2019. The count has in fact increased by 26% over that period, meaning 28,000 more homeless clients than anticipated on any night. Whereas cities with comparable homeless crises such as New York have focused on increasing the availability of emergency shelters and safe havens in addition to permanent housing, LA County’s relatively low investment in transitional options has resulted in persistent levels of unsheltered homelessness.

Research has shown that homelessness has severe health consequences. Homeless individuals have a high risk of mortality, with a recent LA County Medical Examiner report finding an average age of death of 48 for women and 51 for men. Homeless individuals have much higher risks of mental illness, substance abuse, infectious disease, chronic illness, violence, and reproductive health risks than the general population. Much less is known about the health burdens associated with being unsheltered, but most evidence points to substantially greater health risks given the more intense exposures to violence, weather, pollution, poor sanitation, and behavioral risk. Research is just beginning to quantify the burdens of living on the streets.

Our analysis of the LA County homelessness response drew on expert interviews, data analysis, and document review. Beyond the growing numerical gap between HI’s targets and actual trends, we identified five critical service gaps that require immediate attention: 

Taking a person-centered approach that recognizes both the diversity of client needs and the limitations of existing resources, yet honors the principle that everyone deserves housing; Improving access to emergency shelters by reducing legal and political barriers to construction and adopting “low barrier shelters” that facilitate entry; Delivering comprehensive street medicine and other services to unsheltered homeless populations using evidence-based models that support the path to housing and recovery Adopting more extensive outreach models that engage citizens, empower homeless clients and leverage mobile technology so that case workers can focus on clients most in need; Strengthening data collection and research methods to understand the consequences of unsheltered homelessness, pilot new service models, and evaluate rehousing efforts.

This report estimates the potential hospitalization, ICU use and mortality rates associated with COVID-19 infection among the homeless population in the United States, as well as unmet need for emergency and observational/quarantine beds/units. Results project that homeless individuals infected by COVID-19 would be twice as likely to be hospitalized, two to four times as likely to require critical care, and two to three times as likely to die than the general population. The analysis suggests that 400,000 new beds are needed to meet the emergency accommodation and social distancing needs of the single adult homeless population on a given day, and that the total estimated cost to meet the nation’s emergency shelter and observational/quarantine units need is approximately $11.5 billion for one year. The second edition explores alternatives for emergency accommodation including private accommodations, congregate shelters, sheltering in place, and emergency coordination of care.