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The experience of service provisioning for homeless pregnant women

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The experience of service provisioning for homeless pregnant women

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The Experience of Service Provisioning for Homeless Pregnant Women
by
Heather Chiu

Rossier School of Education
University of Southern California
A dissertation submitted to the faculty
in partial fulfillment of the requirements for the degree of
Doctor of Education

December 2022

© Copyright by Heather Chiu 2022
All Rights Reserved

The Committee for Heather Chiu certifies the approval of this Dissertation

Mary Andres
Melissa Singh
Kimberly Hirabayashi, Committee Chair

Rossier School of Education
University of Southern California
2022

iv
Abstract
This study aimed to better understand the experience of provisioning services for women who
experience homelessness while being pregnant from both service providers’ as well as homeless
pregnant women’s perspectives. In 2021, during the COVID-19 pandemic, I conducted 14
qualitative interviews with people representing multiple phases of the service provisioning
process from initial intake to post-natal care. By analyzing the data utilizing an inductive
thematic coding process, numerous challenges and successful operations were uncovered.
Challenges primarily revolved around the themes of lack of resources, collaboration, and
communication. The most effective systems were run by large government organizations but did
not cater to individualized needs like the smaller, niche organizations did. Findings provide
broad understandings of the microsystem, mesosystem, and exosystem as presented in the
conceptual framework and are based on the qualitative insights into the challenges service
providers and homeless, pregnant women face while accessing services.

v
Dedication
To all the people who face rough times and all the people who help them, I dedicate this to you.

vi
Acknowledgements
The process of writing this dissertation was a labor of love. It is rather miraculous this
was ever completed. There is no possible way I would have finished it without the help and
support of some of the most amazing people I know. As cliché as it may be, the countless late
nights, the weeks away at writing retreats, the short temper, the unending need for fresh coffee,
and basic living support that kept me going were made possible by my mother, Bonnie Doolan,
and my partner, Erik Mathy. Without them, I would never have started, much less completed,
this quest. Of course, the rough writing spells of chaotic word salad, my popcorn-like
organizations skills, the evil change from APA 6 to APA 7 mid-writing, and my wavering faith
in myself were tended to by my incredibly patient Chair, Dr. Kimberly Hirabayashi, my mentor
and friend, Dr. Marc Pritchard, and my committee members Dr. Mary Andres and Dr. Melissa
Singh. As fixated on this dissertation I was, I must thank the people who kept me grounded and
living outside my dissertation: Michi Toy, Twyla Szeto, Lisa Horner, Mark Chiu, John Chiu,
Karin Adams, Frank and Sandy Mathy, Chris Dotson, Heather Davidson, Nico Kokol-Gamache,
Jacquie Willhoite, and many more. A special thanks to my classmates who kept me laughing and
shared their wisdom: Yvette Castillo-Seymour, David Allen-Matheson, Akes Holdbrook-Smith,
Laura Cardinal, Kim Crawford, Amanda Hoffman, Vincente Miles, Pablo Otaola, Maria Silva-
Palacios, Liz Starr, Susan Zarnowski, Rene Prupes, and Liz Seabury I wouldn’t be at this school
without the kind words of Dan J. Gala, Ryan Elwood, Brenda Williams, and Shane Durkee. I
wouldn’t be inspired to make this world a better place without my amazing children: Tyler Bates,
Garrett Von Garvisch, Jessica Garvisch, Cassandra Cox, and Adam Mathy. Lastly, I thank my
participants. These are your insights for which I am grateful. To all the others who cannot fit on
this page: thank you, all. I hope to make you proud.

vii
Table of Contents
Abstract .......................................................................................................................................... iv
Dedication ....................................................................................................................................... v
Acknowledgements ........................................................................................................................ vi
List of Tables ................................................................................................................................. ix
List of Figures ................................................................................................................................. x
List of Abbreviations (Optional) .................................................................................................... xi
Chapter One: Overview of the Study .............................................................................................. 1
Context and Background of the Problem ............................................................................ 2
Purpose of the Project and Research Questions .................................................................. 3
Importance of the Study ...................................................................................................... 3
Overview of Theoretical Framework and Methodology .................................................... 6
Definitions ........................................................................................................................... 7
Organization of the Study ................................................................................................... 8
Chapter Two: Review of the Literature ........................................................................................ 10
Common Characteristics of HPW ..................................................................................... 10
Barriers to Service Provisioning ....................................................................................... 18
Effective Service Provisioning Strategies ......................................................................... 32
Conceptual Framework ..................................................................................................... 35
Summary ........................................................................................................................... 39
Chapter Three: Methodology ........................................................................................................ 42
Research Questions ........................................................................................................... 42
Overview of Design .......................................................................................................... 42
The Researcher .................................................................................................................. 43
Recruitment ....................................................................................................................... 45

viii
Data Sources ..................................................................................................................... 46
Validity and Reliability ..................................................................................................... 51
Ethics ................................................................................................................................. 52
Participants ........................................................................................................................ 53
Chapter Four: Findings ................................................................................................................. 63
Research Question 1: What are the Challenges to Provisioning Services for HPW? ....... 63
Research Question 2: What are Effective Programs and Practices that Support
HPWs? .............................................................................................................................. 89
Research Question 3: What Resources do HPWs Require? ........................................... 100
Summary of Results ........................................................................................................ 109
Chapter Five: Discussion and Recommendations ....................................................................... 111
Discussion ....................................................................................................................... 111
Recommendations for Practice ....................................................................................... 117
Limitations and Delimitations ......................................................................................... 122
Recommendations for Future Research .......................................................................... 124
Conclusion ...................................................................................................................... 125
References ....................................................................................................................... 126
APPENDIX A: Interview Protocol Formerly Homeless Pregnant Women ............................... 156
APPENDIX B: Interview Protocol Service Providers ................................................................ 160

ix
List of Tables
Table 1: Data Sources ............................................................................................................... 43
Table 2: Participant Data ........................................................................................................... 54
Table 3: Research Question 3 Findings .................................................................................. 101

x
List of Figures
Figure 1: Conceptual Framework ............................................................................................... 38
Figure 2: A Sample of Tasks Required to Begin Service Provisioning ...................................... 88
Figure 3: Services Recalled by SPs Offered by Government Programs .................................... 91
Figure 4: Large Organizations Recalled by Participants by Primary Funding Source ............... 94
Figure 5: Types of Services Provided by Entity Type ................................................................ 96

xi

List of Abbreviations (Optional)
CoC Continuum of Care
DSP Direct Service Provider
FHPW Formerly Homeless Pregnant Woman
HPW Homeless Pregnant Woman
IPV Interpersonal Violence
MDSP Managing Direct Service Provider
MSP Managing Service Provider
PIT Point in Time homeless counts
PTSD Post Traumatic Stress Disorder
SP Service Provider
1

Chapter One: Overview of the Study
Homeless pregnant women (HPWs) require access to unique health and education
services. According to the U.S. Department of Housing and Urban development (2019), there are
219,911 counted homeless women in the United States (U.S. Department of Housing and Urban
Development, 2019), and up to 22% of those women may be pregnant (Crawford et al., 2011).
Obtaining maternity services while homeless is difficult because of the time, knowledge, and
perseverance required to navigate the complex policies (Fordham, 2015). There is little research
surrounding the support systems for HPWs (Ake et al., 2018, p.37). In juxtaposition to this, there
is ample research on the negative mental and physical health impacts of homelessness on
motherhood (Ake et al., 2018; Dworsky & Meehan, 2012; Feinberg et al., 2014).
HPWs access few traditionally accepted health care practices. Research shows only
between 3% and 5% of reported homeless health “symptoms result in a consultation with a
health provider” (O’Carroll & Wainwright, 2019, p.2). Additionally, some facilities specializing
in maternity health services do not offer the first appointment until the 28
th
week of pregnancy
(Fordham, 2015) and many youth service and family shelter providers fail to support homeless
minors who are parents (Dworsky, 2010). With between 30% and 60% of the homeless youth
experiencing past or current pregnancies (Begun, 2015), delays in services produce poor
outcomes including increased fatalities (Pilliod et al., 2016). These issues persist for homeless
mothers and double the needs of the homeless children (compared to housed peers) for additional
future support, creating a cycle of increased intergenerational resource requirements in an
underfunded system (Feinberg et al., 2018). Thus, understanding the unique experiences of
HPWs and the service providers (SPs) offer insights into improving access and overall
effectiveness of care and supports.
2

Context and Background of the Problem
The largest concentration of homelessness in America is on the west coast and increasing
in that region. Six and a half million Americans are at risk of becoming homeless due to costs of
housing and living (NAEH, 2020) which California leads (HUD, 2019). California represents
47% of all homelessness in the United States (The Council of Economic Advisers, 2019). Rates
of homelessness in Alameda County area increased 43% from 2017 to 2020 with at least 6%
currently pregnant (Petry et al., 2019). There is a significant number of homeless people in
California, and homelessness is increasing.
Funding for support services is insufficient to support the homeless people in California.
Less than 50% of this population utilized the Coordinated Entry system to get services. Alameda
County’s Coordinated Entry system, also known as 211.org, is a single access point that
organizes service provision to homeless people. Despite $340 million of homeless program
funding over three years in 2018, Alameda County’s 2019-2020 Draft Legislative Platform
(2020) determined 69% of the homeless population remains unhoused. When considering the
requisite $80,370 annual income required of an adult to support two children in this region, the
need of support services for HPWs is evident (Alameda County, 2020). These set-aside funds by
Alameda County divided amongst the more than 8,000 homeless people allocate approximately
$14,000 annually per individual including administrative costs (Alameda County, 2020). This
level of funding is inadequate for supporting HPWs and exacerbates the challenges accessing
necessary supports.
Little is known about the experience of procuring services for HPWs. Research on HPWs
focuses heavily on the mothers’ experiences, adolescent mothers, health implications, housing
interventions, and drug use implications. However, minimal research exists on the perceptions of
3

availability, utilization, and continuity of care (CoC) for HPWs. This study focuses on the East
Bay region of the San Francisco Bay Area, where homeless populations are trending against
reported national rates, and increased to 198% of those counted in the 2015 census (Applied
Survey Research, 2019). Alameda County monitors homelessness and services through three
organizations: Alameda County’s Homeless Information System (HMIS) which maintains the
InHOUSE homeless population database, 2-1-1 Alameda County (211) which coordinates care,
and the Community Development Agency (CDA) which is responsible for physical housing
provisions. Participants for this research originate from a local housing and services provider, a
crisis interventionist team, an adoption facilitator, a county hospital, two different government
public safety agencies, and a non-profit service coordinator.
Purpose of the Project and Research Questions
The purpose of this research is to explore HPW's and SP's experiences regarding
obtaining support services. The study utilizes the Bronfenbrenner (1979) ecological model to
better understand the environments and systems affecting critical support structures for homeless
women during pregnancies and after childbirth.
The guiding research questions are:
1. What are the challenges to care provision for HPWs?
2. What are effective programs and practices to support HPWs?
3. What resources do HPWs require?
Importance of the Study
There are many factors that affect the outcome of service procurement for HPWs. Carrion
et al. (2014) summarize the risks associated with pregnancy outcomes due to homelessness
which include: physical and mental health issues for the child, and health risks including
4

increased death rates of HPWs. For the HPW, homelessness increases her susceptibility to
disease, IPV, hunger, nutritional deficiencies, preterm deliveries, and other physical ailments
(Bloom et al., 2004; Richards et al., 2020). Combined, these issues affect the outcome of HPWs’
maternity. While homelessness negatively impacts birthing outcomes, there are confounding
medical, personal, and financial factors presenting significant barriers to care.
HPWs confront multiple compounding stressors. Evidence suggests as many as 61% of
homeless families consist of a single-mother and her children (HUD, 2013). Hollowell et al.
(2011), Robinson et al. (2018) and Carrion et al. (2015) recognize the increased mortality rates of
homeless women and their children despite global downward trend of mortality. Additionally,
Salm Ward et al., (2017) confirm significant correlation between stressful life events such as
interpersonal violence (IPV), homelessness, financial difficulties, and others, with negative birth
outcomes including postpartum depressive symptoms which affect both mother and child after
the birth. All these factors contribute to increased drug use and decreased stability of the mothers
while also resulting in increased externalized behaviors and chronic health problems in children
(Milligan et al., 2010; O’Carroll & Wainwright, 2019). Comorbidities extend past the HPW to
eventually affect her child.
Children face lifetime mental and physical health problems from being born into
homelessness. Cutts et al. (2014) acknowledge being homeless while pregnant increases the risk
of preterm labor by three-fold which is associated with neonatal morality and lifetime
disabilities. Prematurity and low birth weight are associated with increased maternal trauma,
IPV, and chronic financial stress (Ake et al., 2018). After a child is born into poverty, they have
higher rates of chronic health problems and more mental health issues that require treatment
(Braveman et al., 2018; Hayes et al., 2019; Kaminski et al., 2013). The children are at risk of low
5

birth weight, developmental and emotional delays, chronic disease, and nutritional deficiencies
over their lifetimes (Cutts et al., 2014, Richards et al., 2020). Providing pre and post-natal care to
HPWs will lead to improvements in the quality of life for their children.
HPWs experience barriers to accessing health care. Homeless people are bound to a
system that increases their likelihood to utilize emergency and extended inpatient care as well as
get readmitted more frequently. Shetler and Shepard (2018) identified these repetitive visits as a
source of lost revenue to the hospitals who serve them. Additionally, such usage is associated
with higher mortality rates (Shetler & Shepard, 2018). With these challenges and heightened
negative outcomes, Chambers et al. (2014) cite numerous additional barriers of homeless women
accessing continuous care. SPs are bound to funding and policies that interfere with immediate
and personalized coordinated care (Jocoy, 2013). Delays in prenatal care lead to infant mortality,
financial strain due to medical care, congenital birth defects, and exacerbation of preexisting
medical conditions in mothers (Ayoola et al., 2010). Understanding HPWs’ situations informs
SPs’ ecological context.
Provisioning systems complicate health and wellness for HPWs. SPs and HPWs face
interpersonal stressors as well as bureaucratic challenges. Lemieux-Cumberlege and Taylor
(2019) evaluated people who work directly with homeless people and noted they had higher
levels of depression, stress, and secondary traumatic stress which led to burnout and anxiety due
to high stress work environments. Part of this stress is due to confounding variables and resulting
mistrust response they get from those they serve (Lemieux-Cumberlege & Taylor, 2019). When
SPs believe they are doing work for the better good, they are more resilient (Lemieux-
Cumberlege & Taylor, 2019). However, that same sense of purpose obligates them to bend
6

narratives of their clients to fit service provision requirements (Marvasti, 2016). This
demonstrates the impact of the policies, systems, and outcomes for HPWs on the SPs.
Overview of Theoretical Framework and Methodology
Bronfenbrenner's (1979) ecological systems theory provides a lens to view the SPs’ roles
in relation to the HPWs’ roles in this body of research. This theory recognizes the impact that
various aspects of the environment have on an individual’s experience (Gardiner & Kosmitski,
2005). To fully understand factors that result in lapses of coverage, examination of the variant
perspectives of SPs as well as HPWs is essential and begins with a holistic view of the HPW’s
environment. Bronfenbrenner's (1979) ecological systems theory explains how larger exosystems
are outside the realm of control of individuals in microsystems. It is through decisions and
actions of intermediaries in the mesosystem, such as SPs and law enforcement, that HPWs
navigate. The uncontrollable nature of the exosystem influences SPs’ responses and actions
when interacting with HPWs. Using this lens for the conceptual model, the research explores the
experience of procuring services at both HPWs’ and SPs’ levels. By approaching this project
from a bi-directional perspective, this research informs interventions that could improve
enrollment, participation, and outcomes.
This application of the Bronfenbrenner’s (1979) ecological systems theory explores the
role of each realm of the ecological setting. Because the ecological settings and participants’
intrinsic experiences and natures vary, using a qualitative interview approach offers deeper
understanding of the SPs’ and formerly homeless pregnant women’s (FHPWs’) experiences.
Each SP has different resources, and each FHPW has taken different approaches toward getting
support. Serving the research questions is an explanatory qualitative research design where
analysis of FHPWs’ experiences inform understanding of SPs’ experiences and vice versa
7

(Creswell & Creswell, 2018, p. 237). Additionally, website analysis allows for triangulation of
policies, service availability and requisites. From there, determining how FHPWs responded to
these ecological system dynamics informs necessary changes to improve services for this
population.
Definitions
To ensure accurate understanding, the following definitions provide a foundation for the
application of words and terms utilized within this study.
Direct Service Provider (DSP)
DSPs directly interface with and procure services for HPWs.
Formerly Homeless Pregnant Woman (FHPW)
FHPW is a single woman currently housed but who has been homeless while pregnant in
the past.
Homelessness
This refers to a period when a person has “no suitable and permanent occupancy at a
residence and who may be unsheltered, (living directly on the streets or other spaces not intended
for habitation [by them]) in emergency shelters or temporary accommodation” (Heerde &
Hemphill, 2016, p. 469).
Homeless Pregnant Woman (HPW)
This includes a single woman who is experiencing or has ever experienced being
pregnant while homeless.
Inter-Personal Violence (IPV)
IPV includes, but is not limited to, intimate-partner violence, and refers to emotional,
physical, financial, and/or sexual abuse (Stauffer, 2017).
8

Managing Direct Service Provider (MDSP)
MDSPs directly interface with and procure services for HPWs as well as manage other
DSPs.
Managing Service Provider (MDSP)
MSPs manage DSPs but do not directly interface with and procure services for HPWs.
Point-In-Time (PIT) Counts
PIT counts are driven by the department of Housing and Urban Development's CoC
requirements and are conducted a single night in January in odd numbered years to determine the
number of sheltered and unsheltered homeless in a region (Applied Survey Research, 2019).
Services
Services include private and government funded programs providing shelter, food,
clothing, education, hygiene (Murphy & Tobin, 2012) and/or adequate medical and mental
health care.
Service Provider (SP)
The SP includes any organization, private, government, cooperative, non-profit, or
otherwise that provides or coordinates services to homeless people.
Organization of the Study
Chapter One provides an overview of the current HPWs’ and SPs’ environments as well
as current challenges and barriers. Chapter Two explores common characteristics of the HPW’s
population, barriers to exiting homelessness, and effective strategies for HPWs’ services and
their provisioning. Chapter Three examines the methodology of this qualitative research project
from which a discussion of the findings follows in Chapter Four. Chapter Five presents a
9

discussion on each research question, and recommendations for future practices and potential
future research studies derived from this research.

10

Chapter Two: Review of the Literature
In reviewing the literature, common themes emerged under three categories: common
characteristics of HPWs, barriers to service provisioning, and effective service provisioning
strategies. Each of these themes provides insights and context into the process of obtaining
services from both the SP's and HPW's perspectives. After exploring each theme, the conceptual
framework based on Bronfenbrenner's (1979) ecological theory is elucidated upon for further
context of my approach.
Common Characteristics of HPW
The relationship between factors surrounding HPWs’ race, age, social connections, IPV,
mental health, and addictions increase the challenges associated with providing quality care. Not
only does the presence of these factors often create the initial homelessness situation, their
interaction and continued presence complicate the ability for SPs to fully address all the HPW’s
individual needs. Each feature and mix of features require unique strategies for provisioning
services. Without inclusive services, HPWs fail to receive the requisite care addressing the
totality of problems they may be facing. A discussion of the six common factors follows and
provides an overview of current HPWs.
Race
More minorities are homeless in America and are significantly overrepresented in the
United States homeless population compared to Asians and Whites (Jones, 2016; Montgomery et
al., 2020). Specifically, despite only being 12.5% of the American population, 40.4% of
homeless in the United States are Black (Jones, 2016). One reason for this disparity is housing
precarity caused by high housing costs and low wages within minority communities (U.S.
Department of Housing and Urban Development, 2020). Some cities direct SPs to “avoid
11

offering comparisons that might lead to interpretations about racial disparities that could rouse
controversy” (Jocoy, 2013, p. 399). The rates of Black homeless women are increasing (Moxley
et al., 2012). Though minorities are over-represented within the homeless population, this
avoidance of race indicates it is an area of concern. Despite the link of race to causes and
outcomes of homelessness and services, there is little research on its impact on homelessness
(Jones, 2016). Wesley (2009) hypothesizes the unique cluster of stressors Black women face
impacts the higher rate of negative birth outcomes. When a Black woman is pregnant, she faces
more scrutiny by SPs. There is evidence that racial discrimination causes stress which produces a
lower quality of life for all minorities, and being homeless exacerbates this problem (Wrighting
et al., 2019). Giurgescue et al. (2015) noted the prevalence of violence on the streets was
associated with maternal depression and associated negative pregnancy outcomes in HPWs of
color (Roschelle, 2017). Flavin and Paltrow's (2013) research highlighted a 48% arrest rate for
Black HPWs compared to 27% of White HPWs. This increased rate of reporting Black women
makes interactions with SPs and law enforcement officials riskier. While race is a significant
factor in homelessness, being younger is for HPWs as well.
Age
Underage Black HPWs are disproportionately represented and undercounted. Kim and
Garcia (2020) noted “the prevalence of family homelessness is higher for young families with
small children, and a female household head and African American homeless families tend to
remain homeless longer than other[s] (p. 4).” As such, underage HPWs, especially those who are
Black, face a multifold risk. Hickler and Auserwald (2009) noted that Black youth were less
likely to identify as homeless and therefore less likely to access services. Even commonly
considered safe-havens of schools show tendencies toward the “use of child protective services
12

as a threat against BSEH (Black Students Experiencing Homelessness)” (Edwards, 2020, p. 143).
While Black youth face unique challenges to homeless pregnancy, all youth who are homeless
while pregnant are at higher risk of premature and/or low birth-weight babies than housed peers
(Dworsky & Meehan, 2012). Additionally, HPWs who are under 18 years old are undercounted
and therefore underfunded for appropriate services.
Pregnancy amongst homeless youth is prevalent. Approximately 2.1 million homeless
youth between 12-24 years old live in the United States. Nearly 700,000 are adolescent minors
between the ages of 13-17 years old (Morton, et al., 2017) and almost half of those adolescent
minors are female. Of those, approximately 116,000 have experienced pregnancy, and nearly
70,000 of those will experience pregnancy during their homelessness (Thompson et al., 2008).
Between counting and definition issues, HPWs who are under 18 also face issues of mandated
reporting compliance which keeps some SPs from including them (Lin et al., 2017). Such
underreporting impacts the application of policies guiding laws, funding, and services that are
applied. Part of the undercounting of homeless, pregnant youth is due to their social connections
who provide temporary shelter.
Social Connections
Social connections provide the first form of temporary housing for many HPWs
(Gultekin et al., 2014) and continue to impact long-term outcomes in housing stability. Often
HPWs stay in shelters, motels, streets, and other situations where they make new social
connections (Gultekin et al., 2014). Social connections can lead to positive or negative
interventions. Who HPWs spend time with and the locations they stay impact their experiences
(Jasinski, 2010). While HPWs are not able to sleep in the homes of many housed friends and
family for various reasons (Gultekin et al., 2014), they do continue to make efforts to visit.
13

Jasinski (2010) notes that most HPWs spend holidays with family and eat with friends and
family. By the time a person is functionally homeless, they have generally exhausted the
resources and generosity of their closest family and friends (Jasinski, 2010). However, that does
not mean they fall out of touch with friends and family. Most continue to dine with and visit
family regularly (Jasinski, 2010). These friends and family of young adults often provide basic
needs and emotional support (Miller & Bowen, 2019) while also encouraging rehabilitation and
application for services (Mayberry, 2016). While these connections may be a conduit for
temporary housing, they are sometimes abusive relationships that can perpetuate instability.
IPV and Mental Health
IPV is strongly correlated with homelessness. Whether IPV leads to or is the result of
other mental health issues, the two are highly correlated (Lagdon et al., 2014). More than 80% of
homeless women with children have experienced IPV (Desmond et al., 2016). Sullivan et al.
(2019) assert that IPV is one of the leading causes of homelessness for women. IPV also
negatively affects birth outcomes for HPWs including prematurity and low birthweights (Grady
et al., 2019). Not only does abuse present itself in HPWs’ personal lives, but it is also prevalent
in their workplaces (Anderson et al., 2013) and on the streets (Bloom et al., 2004). For many
HPWs, the presence of IPV not only serves to introduce the homeless condition, it also leads to
short and long-term mental health challenges.
IPV can precipitate other mental health problems (Lagdon et al., 2014). Homeless women
are associated with elevated risks of mental illness (Somers et al., 2015) which include
depression (Somerville, 2013; Shier, 2011), schizophrenic type disorders, and other psychotic
disorders (Ayano et al., 2019) which impact daily functioning. These disorders affect
approximately 25% to 50% of sheltered homeless and up to 92% of unsheltered homeless
14

(Ayano et al., 2019). Those HPWs who are victims of IPV often require additional services for
treatment and resulting comorbid diagnoses. Because HPWs experience high rates of IPV, they
are vulnerable to abusers’ attacks on credit, work, property, social network, and housing
instability (Sullivan et al., 2018) which each affect eligibility for various programs. They
expound on this noting it happens through subversive actions by the abusers in addition to the
trauma that make HPWs unable to work (Sullivan et al., 2019). After interviewing 278 people
served by domestic violence shelters, Rollins et al. (2012) noted interpersonal violence increases
susceptibility to chronic health problems, mental health problems including but not limited to
Post Traumatic Stress Disorder (PTSD), decreased executive functioning required for daily
maintenance, substance abuse, and physical injuries (Sullivan et al., 2019). Oftentimes IPV leads
to poverty and/or substance misuse which increases exposure to additional physical and
emotional trauma which perpetuates the cycle (Jos et al., 2013). Compromised executive
function is the direct result of IPV, poverty, substance use, and disabilities (Szuhany et al.,
2017). All factors add to the cognitive load making it difficult to attend to tasks like getting to
appointments or following directions (Ambrose et al., 2010). Exposure to violence and abuse
before and during periods of homelessness increases mortality rates (Fazel, 2014). Additionally,
prematurity and low birth weight can be the result of this violence, trauma, stress, and economic
insecurity (Ake et al., 2018, p. 37). IPV puts the HPW and her child at risk of comorbidities that
require additional medical care in the future. Compromised mental health and IPV are both
associated with higher rates of substance abuse (Ferguson, 2009).
Addiction
Substance misuse presents in as many as two-thirds of homeless people (Fazel, 2014). In
the context of 49% of people across the United States misusing substances (SAMHSA, 2018),
15

the rate of 31% of HPWs’ substance misuse is lower than the United States population average.
In researching the directionality of substance misuse and homelessness as causes and effects,
McVicar et al. (2015) determined that alcohol may influence factors that lead to homelessness,
but homelessness does not influence illicit substance misuse. Substance misuse by HPWs often
leads to greater risk of physical and mental deficiencies of her child (Milligan et al., 2010).
Should HPWs struggle with substances while pregnant, Kampschmidt (2015) theorizes the
punitive justice system is counter-productive. Punishing substance use disorders dissuades
HPWs from engaging in prenatal medical care. Some women who actively try to stop misusing
substances do not find success during their pregnancy which compromises their parenting skills
(Milligan et al., 2010). Until it is safe for a pregnant substance misuser to seek services and
rehabilitation is covered by accessible healthcare, utilization of services will remain low
(Kampschmidt, 2015). One outcome from substance misuse is financial instability (Cherner et
al., 2017; Moore et al., 2016).
Finances
HPWs are at heightened risk for financial insecurity. In some cases this is due to
intergenerational and locational factors (Maarten Van Ham et al, 2014), while in others it is due
to gender (Meara, 2020), childcare costs (Pilkauskas et al., 2017; Sadler et al., 2018), housing
costs (Lino, 2014), health care costs, severance from previous financial supporters, mental health
instability, insufficient wages, pregnancy complications or others (Curtis et al., 2013). In non-
pandemic periods, women receive less pay than men (Meara, 2020) and often must care for
children as primary or sole income earners (Karkowsky & Morris, 2016). When researching the
relationship between income and Affordable Care Act health insurance, Fryling et al. (2015)
noted 91% of the homeless women had incomes that met or exceeded the eligibility threshold of
16

138% federal poverty level. Women in part-time, low-income jobs are paid 69% their male full-
time counterparts for the same type of work (Meara, 2020). Furthermore, 40% of pregnant
women are not eligible for job-protected family leave which is often unpaid (Karkowsky &
Morris, 2016). Workplaces do not support pregnant women sufficiently which manifests in
economic hardship and poor birthing outcomes.
Economic hardship is directly related to poor birth and longer-term health outcomes in
both the HPW and her child (Braveman et al., 2018). Federal poverty levels do not support
housed living, and eligibility for benefits intended for those in poverty may be too limited
(Fryling et al., 2015). The resulting economic hardship negatively influences maternal behaviors
that affect her pregnancy as well as her parenting (Braveman et al., 2018). With less access to
healthy food, refrigeration, and places to prepare healthy meals (Lange et al., 2017), HPWs’ lack
of nutrition puts their immediate health and pregnancy at risk. The impact of long-term economic
hardship is evident; for many HPWs, the primary financial perpetuator is their employment
status.
Work
Pregnancy and homelessness are associated with multiple unique employment challenges.
IPV on the street and where they sleep compromises their ability to concentrate (Giurgescue et
al., 2015), and facilities where they stay are not always sufficient to make them clean enough for
work (Hickler & Auserwald, 2009). Anderson (2014) purposely sampled 30 women at a battered
women's shelter to discover that their current and prior abusers often visited work with the
intention to harm the women as well as try to get them fired from their jobs. Only one who
reported such work invasion experienced her employer as supportive while the others faced
termination or no support (Anderson, 2014). Homeless women may engage in sexual or illicit
17

substance sales to survive and receive compensation less than the homeless men (Wesely, 2019).
When drug addicted HPWs engage in illegal work activities such as selling drugs or engaging in
prostitution, they typically do so in exchange for a place to stay or something to eat (Brown et
al., 2012). The people and places that compose typical environments for HPWs are dangerous
and self-perpetuating in their lack of exit options outside of homeless service provisions.
Employment challenges are directly related to qualifying for permanent shelter.
Shelter
What shelter HPWs find while unhoused often adds victimization risk. Sleeping in cars,
hotels, motels, shelters, and homes of others all pose risk of physical and/or emotional injury
(Jasinski, 2010). Oftentimes landlords, friends, and other housing providers to HPWs are violent.
Incidents of violence, gang rape, murder, and death threats are all reported in various temporary
accommodations (Jasinski, 2010). When staying at homeless shelters, HPWs and their children
often encounter violence, interpersonal stressors, and losses of social connections (Gultekin et
al., 2014). A lack of permanent shelter increases mortality rates (Nyamathi et al., 2000). Though
housing with friends and family is the safest form of shelter, it is not always available to HPWs
(Jasinski, 2010). After some time on the streets, they begin to befriend other homeless people
who are sometimes violent and often connected to illicit substance sales, prostitution, and theft
(Jasinski, 2010). Should HPWs spend time in shelters, the temporary nature of the system is not
conducive to creating deep friendships with other HPWs (Esen, 2016). The instability of
homelessness not only affects relationships with friends and family, but also where they stay.
The prevalence of abuse and trauma that leads to homelessness prevents a return to that
environment as HPWs perceive life on the streets as safer than housing with an abusive family
member, friend, or partner (Milaney, 2019). Situations requiring prostitution or drug dealing in
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exchange for housing generally do not lead to housing stability (Brown et al., 2012), and
ultimately, most homeless mothers choose safety over more abuse to protect their children
(Milaney, 2019). Complications, including childcare to attend job training or work, produce
additional housing instability as HPWs juggle work, safety, and housing requirements (Milaney,
2019).
Barriers to Service Provisioning
There are numerous barriers to provisioning services for HPWs. Current counting
methods are unreliable, and the overall representation of need is inaccurate. As these counts
affect funding and policies, there is a clear link between accurate counts and the ability for
traditional SPs or others in the field (e.g., law enforcement) to provide and refer HPWs for
services.
Homeless Counts
Definitions drive the homeless counting methodologies. In 2010, Housing and Urban
Development (HUD) released a multi-pronged strategy to end homelessness (Henry et al., 2013).
To deliver on this goal, they rely heavily on Point-In-Time (PIT) counts which occur on a single
night in the first 10 days of January and have widely variant results because of the “number of
volunteers, weather, and count methodologies” (Glynn & Fox, 2019, p. 573). Furthermore, PIT
counts are unreliable because of variant interpretations of the term homelessness and the data
collection methods (Schneider et al., 2016). The undefined term of homelessness drives
inconsistent counting and leads to an inaccurate understanding of the number of people who fall
under this category (Bogard, 2001). Because the population receiving services varies depending
on the utilized definition and the services funded are dependent on the counts, understanding the
functional definitions driving the counting methodologies is critical.
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Definitions of Homelessness
Definitions vary between government agencies, regions, and organizations. Governments
and funding organizations do not apply the same criteria in their definitions (Lewinson et. al,
2014). This affects how SPs determine eligibility, offerings, and advocacy (Robertson, 1991;
Welch, 2018), while making reporting inconsistent across SPs (Bogard, 2001). When an HPW is
not eligible for services because she is couch surfing or staying with friends, delays in or refusal
of services can result (Balagot, 2019). The lack of consistency between definitions results in a
confusing bureaucratic system of disparate qualifications for services. The most important
definition within the exosystem is the term homeless which influences the counting philosophy.
Federal definitions of homelessness vary between departments. In 2003, HUD, the U.S.
Department of Veteran Affairs (VA) and the U.S. Interagency released a definition of a
chronically homelessness person as one who is unaccompanied and has “either been
continuously homeless for a year or more or had at least four episodes of homelessness in the
past three years” (Department of Health and Human Services [HHS]), 2007, p. 1). HUD (2007)
clarifies the meaning of homeless in this definition as a “person sleeping in a place not meant for
human habitation or living in a homeless emergency shelter” (p. 3) and go on to define “episode”
as “a separate, distinct, and sustained stay on the streets and/or in a homeless emergency shelter”
(p. 4). Comparatively, the McKinney-Vento Homeless Assistance Act uses HUD’s definition for
adults and a different one for youth under the Department of Education (Government
Accountability Office [GAO], 2010). None of these definitions capture people who are sleeping
in budget hotels or couch-surfing (Lewinson et al., 2014). Meanwhile, the Homeless Emergency
Assistance and Rapid Transition to Housing (HEARTH) Act of 2009 includes people facing
eviction within 2 weeks (GAO, 2010). While these are guidelines for SPs, the fluidity of the term
20

homeless results in varying requirements for service provision and retention. As Bogard (2001)
states, “the lack of a consistent definition affects methodological choices made in conducting
individual enumeration studies…[and] undermine[s] the ability to combine studies” (p. 108).
Like homeless, the definition of family is inconsistent across organizations.
Inclusion of an unborn child or unwed/absent father as part of a family affects HPWs’
eligibility. For example, many organizations do not consider a woman pregnant until their 28th
week or later (Fordham, 2015), while others classify her pregnancy as worthy of services at 24
weeks (Esen, 2016). Pregnancy is only one feature of how family is defined. When the Federal
Emergency Relief Administration expanded the definition of a fatherless child to include
children born out of wedlock in service eligibility (Subcommittee on Human Resources, 1998),
more HPWs were eligible for family services and housing. Additionally, this change created an
environment where accepting paternity could lead to benefits in addition to the responsibility of
parenthood instead of only child support responsibilities. The definitions used to train people
during homeless PIT counts result in disparate numbers across regions.
Data Collection Methods
The general confusion surrounding the definition of homelessness impacts data
collection. Burnam and Koegel (1988) emphasize the importance of having a common definition
of who is homeless to provide quality results in homelessness counting. If one set of volunteers
includes youth who are couch surfing under the McKinney-Vento Homeless Assistance Act,
while another does not because they are following the definition released by HUD, their data sets
are incomparable (Burnam & Koegel, 1988). Additionally, the targeted populations represent
divergent samples. Burnes and DiLeo (2016) highlight the shortcomings of PIT counts being
unreliable due to their collection methodologies. Volunteers perform most PIT counts by going
21

into an assigned area and identifying people who appear homeless (Hopper et al., 2008). By
relying on perceptions of what a homeless person looks like, an entire set of people who are
homeless but do not appear homeless places the validity of the count at risk. Another set missed
in this process are those who are homeless but are not easily accessible, the hidden homeless
(Hopper et al., 2008). Agans et al. (2014) highlight the problem of most homeless counts
occurring at night for easier identification while a sizeable portion of homeless strategically hide
for anonymity and safety. These issues of vague definitions, volunteer perceptions, and lack of
total access, make homeless PIT counts unreliable (Schneider et al., 2016). Researchers from the
University of North Carolina at Chapel Hill collaborated with Los Angeles Homeless Services
Authority in 2009 and suggested PIT counts fail to capture 20% of qualifying homeless people
(Greater Los Angeles Homeless Count Report, 2009) while Bogard (2001) and Hopper et al.
(2008) both tested PIT count systems and found them to be approximately 30% deficient. It is
difficult to determine the frequency of data across homelessness when the counts are
inconsistently capturing them (Burnam & Koegel, 1988). When homeless counts are inaccurate,
underestimation of funding requirements often occurs.
Funding Processes
There is not enough funding available for homeless services. Even with counts in place,
Mast (2014) evaluated the availability of beds in comparison to homeless counts across the
United States and revealed that beds for homeless to sleep in are not distributed proportionately
according to the number of homeless in the area. Additionally, they are insufficient to ensure
CoC (Mast, 2014) that many HPWs need for physical and emotional well-being (Moore, 2014).
Shinn et al. (2017) reviewed interventional homeless programs and confirmed the mismatch of
homeless needs to services available.
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Funding determines what services are available and often who receives those services.
Because funding is insufficient and clients are numerous, SPs serve whoever comes in first
regardless of prioritization established by CoC databases (Balagot et al., 2019). Jocoy (2012)
explains that HUD utilizes homeless PIT counts to determine funding by awarding points to
decreases in homelessness and taking points away for increases. The incentivizing points lead to
internal constraints on services that favor the most promising participants to ensure success
(Osborne, 2019) and impacts resultant future funding (Van Den Berk-Clark, 2020). The
reciprocal influence of funding on PIT counts impact services.
The way homeless PIT counts include or exclude people results in funding-motivated
decisions around definitions (Jocoy, 2012). Misinterpretation of decreases in homeless counts as
stemming from successful SP interventions or increases in homeless counts being the result of
poor SP interventions impacts current and future funding (Jocoy, 2012). Though it is difficult to
know exactly how interpretations lead to funding, availability of shelters is not consistent with
homeless rates in geographic areas (Mast, 2014).
The availability of shelters is decreasing in areas of high homeless population
concentration (Alameda County, 2019). Additionally, for every bed added, systemic
inefficiencies lead to only one tenth of a person in decrease of homeless counts in the United
States (Corinth, 2017). Despite homelessness almost doubling between 2011 and 2019 in
Alameda County, approximately 18% fewer people were sheltered in 2019 compared to 2011
(Alameda County, 2019). Between 2010 and 2015, pregnant women who were homeless or
occupying a budget hotel increased 76% indicating there is insufficient housing for HPWs in at
least one place where homelessness is increasing against the national trend (California
Department of Public Health, 2016). Although homeless populations are increasing, policies
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driving funding reliant upon inaccurate counting mechanisms are creating challenges for SPs and
HPWs.
Policies
Definitions and counts determine the focus of politicians on policies. Oftentimes the
government is the primary funding source of services, and the scope of services and eligibility
can change with a new administration’s focus of worthiness (Van Den Berk-Clark, 2020).
Government and the legal system also determine what qualify as services (Balago et al., 2019)
and punishable activities preventing those in need from seeking services (Flavin & Paltrow,
2013). All these factors make a complex system to navigate for SPs as well as HPWs. While
government-enacted laws and policies have unlimited capacity to impact services, the focus is on
factors driving policy development and how those policies affect individual SPs attempting to
provide support to HPWs.
Each level of government in the United States influences homeless policies through the
actions of voters, organizations, and politicians. Hasenfeld and Garrow (2012) acknowledge a
shift from the Progressive Era’s advocacy for basic standards of living for all citizens to current
foci on free markets in the context of privatization of service organizations and localized (versus
federal) control. While the Fair Housing Act of 1968 prohibits discriminatory housing decisions,
Patterson and Silverman (2012) revealed a lack of enforceability and application. When coupled
with the Housing First strategy launched in the 1980’s, the financial and logistical resources
required for housing homeless people resulted in local resistance (McElroy & Szeto, 2017). They
attribute part of this to local businesses and voters who encourage housing for service-worthy
(Marvasti, 2016; Patterson et al., 2012) homeless who are docile, compliant, and can work,
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(Pipinis, 2017) but discourage projects that house unworthy homeless who may exhibit
assertiveness (Parsell, 2011) or not be capable of maintaining a job (Pipinis, 2017).
Service-worthiness manifests through funding stipulations. Government actions directly
influence homeless services. In 1988, the United States Interagency Council on Homelessness
determined safe and stable housing was a requirement in conjunction with other supportive
services for permanent homelessness exit. This action defined all homeless people as worthy of
services and housing. Later, the Temporary Assistance to Needy Families Act of 1996 shifted
funding towards programs that support work development over all others (Van Den Berk-Clark,
2020) which redefined service-worthiness as employability. In 2004, California residents voted
in favor of the Mental Health Services Act which recognized the impact of mental health on
housing stability (Gilmer et al., 2014) and provided funding to prioritize mental health services.
Instead of clients receiving the services most appropriate for their circumstance, homeless people
are often offered those services currently funded or available (Balagot et al., 2019). In most
cases, the funding and availability of medical care is inadequate to meet the demands of the
homeless population.
Medical Care
HPWs sometimes delay seeking medical care to avoid potential reporting to law
enforcement officials. Because HPWs consistently face reporting to authorities for a variety of
activities required for survival or the result of addiction, they are disinclined toward seeking
help. This exosystem dynamic gives insight to the resistance of homeless individuals seeking out
care (Prekumar, 2019) and the inequity in care after enrolling in public systems (Hill, 2010).
Prekumar’s (2019) interviews with HPWs with issues of substance use emphasized the
importance of recognizing the multi-faceted risks HPWs take in engaging public systems of
25

healthcare. Those risks influence decisions that impact child custody, registration, and future
care when enrolling in programs (Prekumar, 2020). Referrals and access to services prove to be a
multi-layered series of complications for HPWs to navigate. Punitive responses depend on SPs’
personal judgements.
Medical care workers use personal judgement when determining worthiness of care. Hill
(2010) evaluated literature to determine the impact of moral judgements made by doctors and
nurses in healthcare settings. While doctors generally did not take personal stories into account,
nurses had more exposure to patients’ histories and engaged more personally with higher status
patients while offering less than standard care to people they deemed unworthy (Hill, 2010).
Patterson et al. (2012) expands on Hill’s (2010) observations through their mixed-methods study
exploring health equity amongst the homeless. Themes emerged from Patterson et al.’s (2012)
data: social devaluation that resulted in public systems of care treating homeless people unfairly,
and a sense of feeling trapped with a lack of autonomy over decisions once enrolled in public
systems of care. This disparity in medical care decisions can diminish outcomes of a pregnancy.
Medical care is essential for healthy birthing outcomes. Without prompt medical care,
risks ranging from weakened immune systems, malnourishment, physical and mental challenges,
and of death increase (Bloom et al., 2004; Carrion et al., 2014; Richards et al., 2020). Such
factors correlate with the three-fold risk of preterm labor for HPWs (Cutts et al., 2014; Richards
et al., 2020). HPWs are particularly susceptible to health problems that increase their and their
unborn babies’ mortality rates. Particularly prevalent are infectious diseases such as HIV,
Hepatitis B and C, parasites, and Tuberculosis with incident rates ranging from twice to 1,600
times higher (depending on the disease) in homeless populations than the general population
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(Fazel, 2014). Collectively, these factors diminish overall health while increasing medical care
need, and lack of housing continues to place HPWs at risk for future health challenges.
Housing Placement
Housing addresses multiple factors for HPWs. When homeless people are unsheltered,
their mortality rates are three times greater than their sheltered homeless counterparts, and almost
ten times greater than the general population (Roncarati, 2018). For instance, since 80% of
homeless mothers have experienced IPV, it is not surprising that 25% of mothers are homeless
because of that violence (Family & Youth Services Bureau, 2016). IPV leads to disabilities
associated with physical and emotional trauma which cause strained relationships (Cutts et al.,
2014). Those strained relationships result in fewer economic support systems which often lead to
homelessness. Because of the decreased financial support, many women do not qualify for
rentals and turn to budget hotels (Lewinson et al., 2014). However, Hanlon et al. (2017) studied
housing options for HPWs who use substances and determined that abstinent-dependent housing
improved outcomes for this population. Similarly, Nilsson et al. (2017) evaluated data to uncover
the reality that homeless women, in particular, are more likely to die regardless of confounding
factors, and need more support than those already in place.
Pregnancy and comorbidities of HPWs can interfere with housing opportunities. Feinberg
et al. (2014) note prohibitions often exist for women with medical risks such as pregnancy when
attempting to obtain housing. Fordham (2015) expounds on this with a narrative study exploring
the experience of homeless women highlighting the dysfunctional interplay of confounding
diagnoses with referrals and care. For example, when HPWs have been previously incarcerated
or struggle with addiction, they are less likely to qualify for housing (Asberg & Renk, 2015).
Until 2018, policies required pregnant women in San Francisco to be in their last trimester of
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pregnancy before being considered high risk and eligible for additional services (Barrett, 2018).
Thus, despite the increased health risk and mortality rates of HPWs and their offspring, HPWs
face barriers to housing which would improve the outcome of their own and their child’s lives.
Even in the limited cases where adequate housing exists, transportation challenges continue to
affect employment, medical care, and social connections.
Transportation
Travel is both costly and time consuming (DeVerteuil, 2000). While less than 5% of non-
Hispanic, White Americans use public transportation, 53% of homeless people use it (Murphy,
2019). Transportation affects employment, medical appointments, housing prospects (Murphy,
2019), and social activities (Jocoy & Del Casino Jr., 2010). The most common ways to move
between two places are to use their own or a friend's motor vehicle (Jocoy & Del Casino Jr.,
2010), walk, or use public transportation alone during the day (Jasinski, 2010). Evening travel
was more popular via private vehicle or public transportation with another person (Jasinski,
2010). Jasinski (2010) identifies transportation between locations as a particularly dangerous
activity for homeless women because there is opportunity for violent attack and low interest of
bystanders in intervening. Additionally, transportation issues make it difficult to get to work on
time (Murphy, 2019). The challenges surrounding the lack of transportation, specifically in
California with a population and system reliant on the personally owned vehicle, a lack of
functional interventions allows the problems facing HPWs to often go untreated.
Interventions
People do not intervene as readily for homeless people as they do for homed people.
Jasinski (2010) notes that homeless women spend most of their time in places where
homelessness is less policed by citizens as well as law enforcement which increases the
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probability of victimization without intervention. One homeless woman recounted the discovery
of finding a woman, presumably raped and discarded in a dumpster with her throat slit (Jasinski,
2010). This violence can be the result of prostitution or selling illicit substances as these survival
strategies to earn income often increase unreported victimization (Hudson et al., 2012).
Additionally, abuse may be encouraged by observers such as the recording of fights between
homeless people for online distribution as entertainment (Bunds et al., 2015). Commonly, the
locations HPWs spend their time are more dangerous, and the individuals who control their
housing situations can be as well; these conditions limit the involvement of the average citizenry
and leave the responsibility for providing services to social workers charged with navigating
both policy and situational challenges to assist HPWs.
Social Workers as Service Providers
SPs must orchestrate the application process to accommodate policies while catering to
each HPW's unique needs. Eligibility for services is intrinsically related to how society and
funding entities define worthiness of services (Marvasti, 2016). Though CoC programs prioritize
clients based on vulnerability, SPs match people more closely to policies and service availability
than vulnerability (Balagot et al., 2019).
SPs must enforce and uphold political and organizational policies (Maynard-Moody &
Musheno, 2012). Not only do policies have unresolvable contradictions to mitigate, but the
unique mixes of needs by clientele add complexity to the service procurement process (Lemieux-
Cumberlege & Taylor, 2019). SPs tasked to care for an HPW must determine whether she is
intentionally homeless and qualifies for support (Fordham, 2015, p. 34). The intricate process of
coordinating services for highly vulnerable people leads to stressful environments that often lead
to SP burn-out (Lemieux-Cumberledge & Taylor, 2019). Additionally, SPs must determine when
29

to report HPWs to law enforcement. In evaluating forced interventions against pregnant women
across 44 states, Flavin and Paltrow (2013) highlight that social service and health care providers
disclose personal private information to public safety agencies which suggests HPWs’ fear of
law enforcement is legitimate.
Service providers cannot always provide some services because of eligibility or
availability reasons. Simultaneously, SPs rely on definitions and counts to secure funding
(Balagot et al., 2019). Funding sources determine what is available and who is eligible.
Consequently, programs decline between one-fourth and one-third of families seeking homeless
services because of ineligibility, and HPWs are on the cusp of this demographic of family (Shinn
et al., 2017). Some of the policies driving the decline in HPWs’ services include fetal viability
(usually determined at 24 weeks), not being technically single because of the pregnancy and
therefore ineligible for single person shelters, and recent stays in a hostel which indicate a
sheltered status (Esen, 2016). Inconsistencies across service eligibility and availability create a
culture of manipulating the facts to procure services (Spitzmueller, 2016).
Applying for services is complicated because organizations have different requirements
and expectations for HPWs. Not only do multiple SPs refuse to begin services until the
fulfillment of certain requirements (e.g., 28 weeks pregnant, not deemed intentionally homeless,
and referred by an appropriate person), it can take as long as 3 hours to engage the service
providers (Fordham, 2015). Shinn et al. (2017) noted, HPWs securing housing on their own did
so at higher rates outside of programs. If homeless programs continue to underfund local
homeless populations (HUD, 2010) for basic care and shelter, HPWs and SPs will continue to
face difficulties in accessing services. SPs provide an indirect linkage to HPWs that directly
influences the policies of the exosystem.
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Political strategies and policies led to the use of cost efficiency models over cost utility
models in human services (Hasenfeld et al., 2012). Transferring the focus from social gain to
economic efficiency affected SPs’ goals (Spitzmueller, 2016). Every SP has a unique way of
defining eligibility for services (Garmisa, personal communication, October 25, 2019).
Sometimes those services are the most effective, while other times they are not (Balago et al.,
2019). In addition to traditional SPs, law enforcement often fulfills political strategies and
service provisioning referrals (Prekumar, 2020).
Law Enforcement
Sometimes SPs use personal judgement in determining whether to refer an HPW to law
enforcement or not. In evaluating the interplay between HPWs and medical services in New
York, Bridges et al. (2010) posited HPWs must share uniquely personal data like immigration
status and any income sources including help from others who participate in illicit business to
access services. Sharing often resulted in state interventions such as criminal proceedings and
taking their children away (Bridges et al., 2010). Enforcement agencies decide if HPWs are unfit
or fit to raise their children, and those agencies exhibit racial bias in their determinations
(Prekumar, 2020). Additionally, HPWs, detained despite complying with substance treatment
orders, did not receive any better care while incarcerated, making those arrests counter-
productive to the purpose of serving and protecting (Flavin & Paltrow, 2013). These punitive
responses to service-seeking HPWs result in fewer utilizers.
Law enforcement affects homeless women through the prison system. Being homeless is
worthy of police response in many areas (Beck & Goldstein, 2018). Economically disadvantaged
women, especially women of color, who misuse substances while pregnant or parenting can be
subject to arrest as an intervention to protect the child (Flavin & Paltrow, 2013). HPWs are also
31

deprived of their liberty for mental illness, failing to get medical care (Flavin & Paltrow, 2013),
prostitution, substance misuse, and drug dealing (Asberg & Renk, 2015). Additionally,
accusations supposing child neglect commonly result in reduced rights to custody of her child. In
reviewing research by Salem et al. (2020), the more victimization a woman experiences, the
more likely she is to become homeless and then incarcerated. After facing incarceration, a
woman’s likeliness for homelessness increases, and her eligibility for housing programs
decreases (Asberg & Renk, 2015; Namathi et al., 2017). Like Jasinski (2010), Anderson (2014)
and others, Salem et al. (2020) discovered the best insulator from recidivism is strong social
connections, especially supportive, service-encouraging family-like members. The interplay of
engaging in illegal behaviors while homeless, increasing the possibility of arrest (Asberg &
Renk, 2015), or losing custody of a child increases the perceived risk of approaching any person
with mandatory and discretionary reporting authority. Not only is getting registered to apply for
services risky from the HPW’s perspective, but once an HPW is ready, the processes for referrals
and access to services remains difficult to navigate.
While not sufficiently trained in social services (Thomas & Watson, 2017), law
enforcement officials must make decisions on how to apply these complex policies and laws.
Maynard-Moody and Musheno (2012) emphasize the role of police officers as front-line policy
enforcers and the impacts of their personal judgement on outcomes. The use of law enforcement
in the processing of state supported resources often leads to criminal proceedings that disincline
the use of available services while homeless and pregnant.
This risk of punitive action causes general mistrust amongst homeless women towards
law enforcement (Fordham, 2015). Even when raped, between 60% and 78% of respondents did
not reach out to police (Jasinski, 2010). Additionally, the fear of incarceration or having a child
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taken away often leads to strategic evasion, tactical disorder, and reveling in subterfuge
(Stauffer, 2017). Strategic evasion is the effort to avoid the topic in conversation and any
ramifications it may have, while tactical disorder often manifests as staying with an abuser to
avoid the wrath of leaving that abuser (Stauffer, 2017). Beaulaurier et al. (2008) postulate that
perceived power over choice is essential for victims of IPV. The third response, reveling in
subterfuge, is an empowering element where homeless victims of IPV find tactically gaming the
system through choices that disempower authority figures of any type feels good, but it inhibits
continuous care interventions (Stauffer, 2017). Empowerment from subterfuge also reflects in a
general mistrust of law enforcement (Fordham, 2015). HPWs’ mistrust of authority extends to
other SPs such as medical personnel who may report them. Although numerous challenges exist
with counts, funding, policies, and willingness to seek services by HPWs, effective strategies
exist to provide supports to this at-risk population.
Effective Service Provisioning Strategies
Social connections provide the first form of temporary housing for many HPWs
(Gultekin et al., 2014) and continue to impact long-term outcomes in housing stability. Though
housing with friends and family is the safest form of shelter, it is not always available to HPWs
(Jasinski, 2010). Often HPWs stay in shelters, motels, streets, and other situations where they
make new social connections. Social connections can lead to positive or negative interventions.
Who HPWs spend time with and the locations they stay impact their experiences. This section
focuses on social connections, shelter, and interventions as they relate to transitioning out of
homelessness.
Consistent social connections impact various outcomes of HPWs. Many HPWs who
misuse substances find safety and encouragement through regular communication with others.
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With 31% misusing substances (SAMHSA, 2018), Neale and Brown's (2016) research about
social supports amongst substance users living in hostels noted while 10 of 30 participants did
not associate with anybody they considered friends, the remainder valued friends who
communicated regularly. Three participants had online friends whom they had never met, but
proved to be important emotional supports who helped them find jobs and avoid substances
(Neale & Brown, 2016). The role of checking-in and communicating regularly helped
participants feel valued and not alone (Neale & Brown, 2016). Part of supportive friendships is
consistency, and it is best nurtured in relaxed environments that allow time for friendships to
develop. Glasser and Bridgeman (1999) extrapolate from the data that the restrictive and
expectation-based culture of a rehabilitation center stifle friendship building whereas a laissez-
faire approach that provides daily necessities encourages them. Social ties build self-esteem and
help people leave the streets (Glasser & Bridgeman, 1999). When HPWs secure permanent
housing, they intend to maintain friendships (Jasinski, 2010).
Outcomes improve for HPWs with personal relationships and access to decision makers
in the social services realm who can help advocate on their behalf (Mayberry, 2016). Assistance
from such individuals initiated homeless-led housing solutions where homeless individuals
participated in the building or rehabilitation of housing sites in their community and developed
successful permanent housing solutions (Glasser & Bridgeman, 1999). The community
connection is invaluable in reducing reentry into homelessness. The successful intervention by
peer navigators of homeless people with mental illnesses supports the previous assertions that
consistent communication is the core of perceived friendship that leads to positive outcomes by
homeless people (Corrigan et al., 2017). Neale and Brown (2016) encourage SPs to foster
friendships through digital communication. Collectively, the building of community through
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consistent communication and strengthened relationships offers a significant tool for preventing
a return to the streets. Furthermore, approaches to providing a more comprehensive solution
continue to emerge as more effective in addressing the long-term needs for HPWs.
Integrated solutions involving housing and medical care are effective for permanently
resolving HPWs’ challenges. Corinth (2017) emphasizes that higher quality shelter and
permanent housing options decrease the number of unhoused homeless. Consequently,
improving housing rates of HPWs also appears to influence prenatal care positively (Richards et
al., 2020). Esen (2017) expands on this need for shelter by emphasizing the importance of
postnatal shelter to ensure the mother’s homeless status does not remove the child from her care
after birth. Shelter improves the health of the HPW and her child which leads to improved birth
outcomes and longer life expectancy (Feinberg et al., 2014). Additionally, giving HPWs a sense
of empowerment over their housing situation reduces stress and increases social support access
which is beneficial for maintaining program continuity (Moore et al., 2014; Ngo-Smith, 2018).
When this empowerment couples with flexible funding that can uniquely cater to that HPW’s
needs over the long term, housing stability increases to 94% (Sullivan, 2019; Glendening &
Shinn, 2017). With the health outcomes so inextricably linked to housing, and success of housing
reliant on flexible funding, the need for integrated care that continues into antenatal care is
obvious (Nestler et al., 2018; Hallowell et al., 2011). Coordination of these services and ensuring
CoC requires review of policies targeting HPWs (Lane et al., 2017). While housing is the best
long-term solution for homelessness, HPWs face unique barriers.
HPWs and their children who require additional services need proper care. Guo et al.
(2014) compared treatment as usual to ecologically-based treatment (EBT). They found
compelling evidence that independent housing in conjunction with CoC based integrated support
35

services help HPWs decrease substance use problems, depressive symptoms, and their children’s
problem behaviors (Guo et al., 2014; Murphy, 2013). Part of EBT is the tactical utilization of
strengths-based case management (Guo et al., 2014) which Hilton et al. (2014) found equally
efficacious in empowering HPWs. This catering to an HPW’s individual needs is also a tactic for
medical care that shows promise as a better approach over standardized healthcare (Jego et al.,
2016; Rooney & Arbaje, 2013). By empowering HPWs with maternal health literacy trainings,
they gain the knowledge necessary to advocate for their personalized care (Oves & Self-Brown,
2014). Another way to offer more catered medical care is by employing mobile nurse
practitioners to improve early intervention access and decrease medical care costs (Fraino, 2015).
Successful implementation requires an integrated approach that improves understanding and
awareness of the unique stressors facing each HPW (Mantovani & Thomas, 2014; Bloom et al.,
2004).
Conceptual Framework
Bronfenbrenner’s ecological systems theory provides the framework for the interaction of
SPs and HPWs while procuring services in a larger context and recognizes the impact different
aspects of the environment have on an individual’s experience (Gardiner & Kosmitski, 2005).
The model provides a tool for understanding how an individual interacts within a given setting,
between settings, and how external elements indirectly influence the individual’s experiences
(Bronfenbrenner, 1979). Figure 1 highlights the application of the ecological systems theory for
HPWs and the SPs in their support of HPWs, as well as provides insights regarding the socio-
environmental influences on the service recipients’ decisions.
In its original form, Bronfenbrenner (1979) defines three systems that impact an
individual. The individual is at the center within a microsystem with immediate molar activity
36

that interacts with them meaningfully on a daily basis (Bronfenbrenner, 1979). The microsystem
includes each HPW's family, friends, where they live, school or workplaces, unconscious bias,
and other forces that influence daily life. The outermost shell of Bronfenbrenner’s (1979) model
is the macrosystem; this conceptual framework excludes the macrosystem as the impact of
culture and history is ostensibly outside the scope of this study. Instead, this conceptual theory
extends only to the exosystem which Bronfenbrenner establishes as the external world that does
not interact directly with the individual but influences the collective environment to encourage or
discourage outcomes (Bronfenbrenner, 1979). Between the microsystem and exosystem is the
mediating mesosystem, containing the people and organizations assisting the individual in the
navigation between settings.
Conceptual Microsystem
To simplify the conceptual framework, the individual combines, with their molar
activities and expectations, the macrosystem imbued upon them (see Figure 1). It is comprised of
HPWs and FHPWs during their homeless pregnancy period in the context of the SP’s
environment. Note that it does not include SP individuals. This is due to the lack of research
available on their individual experiences and molar systems outside of the context of the SP role.
For the purposes of this research, conceptualization of all levels of the theory appears within the
context of service provision for HPWs.
Conceptual Exosystem
The exosystem for the service element of the conceptual framework contains political and
government entities, and any funding institutions (see Figure 1). Such organizations include the
impact of federal and local laws, budgets, definitions, and other machinations that impact the
individual HPWs or the SPs. Influencers include the political affiliation and platform of political
37

leaders along with national trends. Likewise, economic instability, unemployment rates, and
other indicators make impacts on the entities contained in this system, and their decisions.
Elements on the street side of the framework include IPV, mental health, addiction, finances,
race, and age. Each element is outside the control of an HPW but affects their daily existence.
Conceptual Mesosystem
The conceptual mesosystem aligns with Bronfenbrenner’s (1979) theory in its role as an
intermediary between the exosystem and the microsystem. In the context of this research, it
includes systems and entities tasked with applying the rules set forth by the exosystem. This
mesosystem includes SP entities and their employees. Included in this are police, food banks,
medical care workers, social services, shelters, and similar establishments. Their role is to
interpret and act upon exosystemic rules, policies, and interpretations.
Key Concepts
Key features of the environment are overlayed with textures and shading. The left side
with the lighter shading represents the ecological system as it relates to service provision. On the
right is the interaction of exosystem with the HPW while navigating the streets of homelessness.
Within the microsystem are three textures that represent the roles, relationships, and activities of
the HPW. Within the microsystem are cycles of arrows in either direction portraying the roles,
relationships, and activities as they interact symbiotically.

38

Figure 1
Conceptual Framework

Not all aspects of the ecological system appear in this conceptual framework. Numerous
historical, systemic, economic, educational, resource and cultural factors have impacts not
addressed directly in this conceptual framework. Instead, this framework focuses on the role of
the individual’s mental health, addiction, race, finances, IPV, funding, and policies.
Interpretation of these elements by individuals in the mesosystem include other HPWs, friends,
family, SPs, housing placement organizations, medical professionals, and law enforcement. Each
39

individual influences the results of service provision by applying their own ecological context to
the experience.
Summary
Effective processes associated with providing and gaining services for HPWs must
mitigate numerous challenges at multiple system levels. The factors of race (Wesley, 2009), age
(Thompson, 2008), social connections (Desmond et al., 2016), IPV and mental health (Rollins et
al., 2012), addiction (Milligan et al., 2010), finances (Curtis et al., 2013), work (Braveman et al.,
2018), and shelter (Nyamathi et al., 2010) affect birthing and long-term outcomes for the HPW
and child. Race-based policies, mandatory reporting requirements, and insufficient funding all
serve to complicate the provision of adequate care (Lin et al., 2017; Prekumar, 2019). Although
there is general awareness of these barriers, the variance for what constitutes a homeless
individual and the manner in which enumerating them occurs complicates the abilities of
governmental agencies to deliver the requisite care due to basing policy and funding decisions on
inaccurate data (Bogard, 2001).
Organizational policies and funding limitations prevent the prompt application of
supports to HPWs. Policies affect every aspect of an HPW's experiences and inaccurate profiles
of HPWs receiving services affect reporting and future policies (Spitzmueller, 2016). When
ineffective policies and inadequate funding delay services, the HPW forgoes required medical
care increasing the immediate and long-term health risks for both mother and child
(Kampschmidt, 2015). Although acquiring permanent shelter can mitigate some health risks,
temporary shelter often exacerbates medical risks with exposure to larger groups of individuals
with varying contagious medical conditions (Fazel, 2014). Moreover, moving between
temporary locations increases the risk of IPV (Jasinski, 2010). Additionally, for the HPW, an
40

effective shelter requires proximity to public transportation allowing for simplified access to
medical services (Murphy, 2019). These challenges for the HPW are the result of the collective
policies and funding limitations inherent to a system based upon inaccurate data. However,
effective solutions can emerge with a holistic approach to addressing the entirety of HPWs’
needs.
Research suggests social connections, personalized and mobile services, and housing
improve outcomes for HPWs. Social connections who are consistent and encouraging provide
conduits for service interventions and housing (Glasser & Bridgeman, 1999; Neale & Brown,
2016). When services are ecologically based with CoC, mother and child benefit (Guo et al.,
2014). Specifically, when connections, services, and housing collocate and integrate in a
thoughtful manner, the quality of life for the HPW and child improves (Fraino, 2015). The
connective element with traditional and more innovative approaches to the HPW’s problem
remains the SP. Specifically, the SP serves as a conduit between the policy and funding
challenges residing within the exosystem, and the HPWs.
Service providers possess unique ecological experiences informing the myriad of
challenges surrounding HPWs. Collectively, the SPs offer insights into the barriers associated
with the definition of homelessness to the concept of need (Lemieux-Cumberlege & Taylor,
2019). By placing HPWs in high quality shelters and permanent housing, SPs witness the
greatest improvement for HPWs in terms of pre and postnatal care, lifespans, and autonomy
(Corinth, 2017). Policies set by government entities and SP organizations drive SP efficacy, and
establishing systems for SPs to maintain privacy while reporting accurate data would develop
trust with HPWs (Beaulaurier et al., 2008; Fordham, 2015). Adjustments in the way SPs navigate
the various challenges along with the HPW can simplify access to services that maximize long-
41

term outcomes for HPWs (Corinth, 2017). Thus, seeking to understand the needed improvements
to current interventions, the factors affecting autonomy, keys to maintain social supports, and
problem-solving training serve to better address the HPWs’ crisis (Moore et al., 2014; Ngo-
Smith, 2018).

42

Chapter Three: Methodology
This research consisted of qualitative interviews with SPs and FHPWs with the intention
of understanding the experience of procuring services for HPWs. The methodology was designed
to offer maximum privacy and safety while delving deeply into the personal experiences of
participants to answer three research questions.
Research Questions
1. What are the challenges to care provision for HPWs?
2. What are effective programs and practices to support HPWs?
3. What resources do HPWs require?
Overview of Design
This research conducted semi-structured, qualitative interviews with two populations
involved in provisioning services for HPWs: FHPWs and SPs of HPWs. The questions addressed
the experience and process of procuring services for HPWs from the SPs’ and FHPWs’
perspectives. The goal relied on a phenomenological understanding of the experience of
procuring services for HPWs. After collecting the lived experiences of SPs and FHPWs,
examination of responses through horizontalization provided a means to understand and evaluate
the varied responses, as it considers each factor equally influential in the process and yields a
holistic understanding of the experience altogether (Merriam & Tisdell, 2015). By using this
approach, the goal was to explain what was happening in general rather than place blame on one
party or the other.
Due to the unique variable of conducting this research during a pandemic that made
interpersonal contact dangerous, online interviews via video conferencing were the most viable
option. All participants had access to a phone or the internet.
43

Table 1
Data Sources
Research Questions Zoom Interviews Website Analysis
RQ1: What are the challenges to care provision for
HPWs?
X X
RQ2: What are effective programs and practices to
support HPWs?
X X
RQ3: What resources do HPWs require? X

Semi-structured video interviews offered visual cues regarding emotional responses which
created an optimal set of data for horizontalization. The combination of information informed
recommendations for future service provisions and provisioning processes.
The Researcher
I, the researcher, am an Asian-American, middle-aged, self-identified woman raised in an
upper-class suburban environment. I am currently living in a middle-class suburban environment
and has raised two children, three stepchildren, and a teenage foster child. I have direct
experience with IPV, trauma, PTSD, spousal child abuse, partner substance abuse, sudden
financial ruin, and the threat of homelessness as a mother due to divorce. This inspired me
creation of a nonprofit organization that helps people learn work and life skills. Additionally, I
work as a business, strategy, and success coach with a focus on major transitions. These factors
combined create a unique positionality that empathizes with FHPWs and SPs. My own
advantageous background and presentation of race contributed to my ability to avoid
homelessness where others could not. This personal empowerment coupled with my coaching
44

and teaching practices had potential to result in a tendency to ask guiding questions
inappropriately if I went off-script, so sticking to the scripted interview questions and probes was
important. The scripts were different between the two participant types and required empathetic
attention.
Two distinct groups of participants, FHPWs and SPs, posed two issues of positionality to
me. Where positionally, FHPWs may view the interviewer as a person who may have potential
to advocate for their needs, they may also find very personal questions intimidating. To address
this, I interviewed in plain clothes to be more relatable and shared firsthand experiences to
improve rapport. Additionally, I began every interview establishing willingness to share this
research with various SPs to inform their procedures and programs in the future offers an ability
to rapidly implement needed changes. At the end of the interview, respondents offered additional
insights, outside of the scripted questions, to introduce critical perceptions relevant to the HPW’s
experience.
Service provider participants had a different set of positionality issues to mitigate. While
I may be viewed as a peer, there was also potential for the participants to be concerned about
how their employers would react to certain information they shared. To mitigate for this, all SPs
were given pseudonyms and not associated with their organizations when documented. This
process conglomerated issues across organizations and anonymized the source of specific
institutional problems. Additionally, I established at the beginning of the meeting that none of
the data collected in this specific interview will be provided to the employer, but rather a
conglomerate of information across institutions will be shared instead.
45

Recruitment
Recruitment during COVID-19 was challenging. The FHPWs were found through
purposive snowball sampling, which is a technique that uses referrals from previous contacts to
find additional participants who represent an ideal diversity of participants. Finding participants
during the pandemic of COVID-19 required persistence. In the winter of 2020, though I reached
out by email and/or phone to over 300 potential participants across the nation, I did not receive a
single positive reply because of the emerging pandemic and resulting strain on social services
resources. In spring of 2021, I followed up with most of those organizations, in particular an
organization with which I was acquainted, which provided three SP interviewees. Finally, in
summer 2021, vaccines had been distributed, and of the 49 potential participants in the East Bay
region whom I contacted, nine agreed to interviews.
Representatives from each of the following phases were interviewed to elucidate on their
experiences in the process of procuring services for HPWs and include in a somewhat
representative order of processing service procurement thus: FHPWs, a Police Officer, 211.org, a
young adult case manager, two crisis interventionists, a doctor, a county healthcare coordinator
for homeless, a child family services manager, an adoption specialist, a support specialist (also
known as a case manager), a childcare provider, and an executive director of a Housing and
Urban Development site. Participating FHPWs were currently housed women who experienced
homelessness while being pregnant. Government, private, large, and small organizations were
represented.
Included in the concept of large organization in this research are organizations with 250
or more employees and volunteers combined. Some organizations like Alameda County
Community Food Bank employ 127 people according to their Form 990 filed with the Internal
46

Revenue Service but enjoy the help of over 18,000 volunteers. From the organizations discussed
in this study, there were 9 small organizations and 26 large organizations mentioned.
Government organizations include any programs directly managed by the government but
not necessarily all organizations funded by the government. Website analysis indicated many of
the agencies are indirectly funded by the Federal Government. The process of discerning what to
include in this subset was difficult because most of the private organizations also rely on
government grants or contracts. To illustrate, I separated the two types in this dataset based upon
whether facilities/services are run by a government entity or a private entity. Many of the
government organizations contract out to private organizations and list the referral services on
their sites without delineation of who is managing those services. These are still counted as
government organizations because they are funded, referred, and constrained in scope of services
by a government entity as well as advertised with no reference of being contracted out. The
purpose of this sample is to cover the progressive service procurement process for HPWs.
Data Sources
The study took place in the Spring, Summer, and Fall of 2021, and participants chose a
convenient, comfortable login location where they felt safe. All participants chose their home or
workplace for the interview. To maintain optimal safety during the COVID-19 pandemic,
conducting interviews via the Zoom online video platform provided a means for mitigating risks
associated with personal contact. In addition to interviews, documents obtained through the
internet were analyzed for triangulating validity of claims and further understanding of the SP
domain. Documents from websites were analyzed throughout the interview stage.
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Interviews
Participants included any person who currently worked for any organization involved in
the procuring of services for women who are homeless while pregnant as well as women who
had experienced homelessness during their pregnancy in the past but were currently housed.
While the actual time varied, I requested one hour of each participant’s time. Pilots of the
interview indicated this was ample, and the average would be closer to 45 mins each, however,
participants' interest in the topic resulted in an average interview time of 57 minutes.
Immediately after interviews, I gathered information from internet websites to analyze and
triangulate laws, policies, procedures, eligibility, and guidelines surrounding HPWs’ services.
The interviews were conducted and recorded via Zoom and transcribed by Otter.ai to
honor the shelter-in-place protocols in California during the COVID-19 pandemic. Participants
accessed the Zoom meeting at an available location with internet access that was convenient to
them. Participants were asked to use pseudonyms when signing in, and names were edited out if
used (Creswell & Creswell, 2017). One risk in this medium is how “the discrepancy between real
and online personalities occurs even when people are trying to be themselves- or at least an
idealized version of themselves” (Merriam & Tisdell, 2016, p. 177). I verbally confirmed the
name of the participant at the beginning of the Zoom meeting and afterwards started recording
while informing them that the conversation was being recorded. Participants verbally agreed to
an explanation of informed consent per the interview protocols (Appendices A and B) that
included the acknowledgment that the research findings would protect their anonymity. Otter.ai
provided the initial transcription, which I validated and edited for reliability (Merriam & Tisdell,
2015). These recordings and transcriptions were moved to a password protected flash drive that
will be kept in a locked safe for 7 years (Creswell & Creswell, 2017).
48

Interviews averaged 57 minutes which yielded an average of 18 pages of transcripts per
interviewee. One impromptu phone call with the 211.org manager was only 12 minutes whereas
the interview with the support specialist was 118 minutes. In total, 788 minutes of interviews
with 14 individuals and 221 pages of transcripts over 13 recorded interviews were collected.
Additionally, there was one page of notes from the non-recorded interview. The interview
questions were open-ended and intentionally semi-structured to allow participants to guide the
conversation toward novel insights. Questions focused on the lived experiences of participants’
various roles in procuring services for HPWs. The participant descriptions exclude gender and
age to further protect identities. In an effort to keep identification of all participants as
anonymous as possible, due to the small number of men represented in the SP sector, gender is
also excluded by using they/them pronouns, though males are represented in the dataset. All
study protocols were approved by the Chair of this dissertation at the University of Southern
California.
Website Review
Documents reviewed came from the internet. Materials obtained online consisted of
flyers, brochures, pamphlets, and website posts. Documents saved as pdf files were used to
triangulate claims by SPs and FHPWs in the interviews. In reviewing the documents, I made a
conscious decision to only include the services listed on the most prominent websites’ pages
because HPWs and SPs would only be aware of those listed provisions.
Instrumentation
This study used semi-structured interviews and website evaluation to collect data.
Because there are so many interwoven factors involved in procuring services for HPW, from SP
characteristics to FHPWs’ unique profiles, the limitation on this study requires a small source set
49

with deeper insights that a qualitative interview can provide (Singleton & Straits, 2010). The
interview questions explored what is available, what people know is available, what is difficult to
procure, what is easier to procure, what prerequisites are necessary for service, and what both
populations find difficult in the process of procuring services for HPWs. The FHPWs’ interview
questions focused on their needs and experience (see Appendix A) while interviews with SPs add
a layer of policies and service availability (see Appendix B). The combination of answers
provided a multifaceted understanding of interwoven dynamics each ecological variable impacts.
Data Collection Procedures
Proper data collection and documentation is essential for effective analyses (Creswell &
Creswell, 2018). Following the participant recruitment described in the Participants section later
in this chapter, the process followed interview protocols (see Appendices A and B). Review of
Zoom transcriptions created by Otter.ai followed immediately after the interview to ensure
integrity of the contents and to delete any identifying data. Each time an organization was
recalled during the interviews, I accessed their website and postings to download relevant pdfs
for triangulation and further analysis. I then reviewed and redacted any additional private
information.
The interview process with the Crisis Interventionist Program was atypical for research
studies. When contacting the crisis interventionist organization, initial contact was with the
founding manager who read the participant letter and agreed to an interview. Days before the
interview, the initial contact referred me to the other employee at the site by email with the
participant letter attached to the email. The referred employee agreed to handle the interview
instead of the original contact. Upon beginning the interview with the referred employee, I
reiterated the terms of the participant agreement to which they agreed. Some minutes into the
50

interview process, however, the founding manager rolled their chair over to the camera at which
point it was obvious they shared an office, and the interview was not private in that setting, but
comfortable for the employee with whom it was taking place. These unique circumstances were
confirmed later in the discussion. These two individuals are the only paid people on the team and
interviewed in harmonious coordination. Frequently they would end each other's sentences or
simultaneously use the exact same words in answering questions. It is my impression they
operate similarly to best friends: in a holistically understanding and compatible nature. Because
both were given the participant letter and both were in the room to hear the preamble to the study
at the beginning of the call, it was determined that the joint interview posed no risk to the
participants, and they were both willfully engaging as a team.
Data Analysis
For interviews, data analysis and data collection happened concurrently with analytic
memos written after each interview. I documented thoughts, concerns, and initial conclusions
about the data in relation to the conceptual framework and research questions. Once I completed
the interviews, they were transcribed by Otter.ai and coded in DelveTool.com. Analysis began
with open coding and refining those codes to coincide with the conceptual framework that set-up
the next phase of analytic/axial coding. Lastly, these axial codes were examined for emergent
themes in relation to the research questions and conceptual framework. In sum, the codebook
underwent an emergent iterative process until finalized for analysis. Reviewing the coded data, I
applied an inductive thematic approach to further understand the systems and experiences
presented by participants. Information obtained through interviews was triangulated through
document analysis via website access.
51

The websites were analyzed for evidence consistent with the concepts in the conceptual
framework and further insights to the research questions. Of particular focus were the services
recalled by participants and the categories of services organizations provided. The primary goal
was to validate participants’ recollections, and the secondary objective was to better understand
what services different types of organizations provide. This analysis underwent another iterative
process of determining themes across organizations’ provisions through an open coding process.
Validity and Reliability
Multiple validation and reliability methods were used throughout the research process.
Criterion and face validations established authenticity of the participants. By having interviews
last as long as 118 minutes, the prolonged contact established trust and rapport. Additionally, the
FHPWs’ relationships to the people who referred them provided a layer of trust. Because the
research relied on reflection and memories, there was potential for interpretive errors by the
FHPWs being interviewed. To account for this, transcribed notes were compared to the
recordings and sent for additional validation to participants who agreed to review it. When SPs
agreed to validate any service provisioning efforts of FHPW participants, that data was used as
well. The content of participants’ replies were evaluated for consistency across the study through
triangulation with policies and others’ accounts while maintaining sensitivity to possible
discriminatory factors that may exist. I reviewed all methodologies with a committee member to
ensure reliability, neutrality, and consistency. While this was a small study with little potential
for generalizability, sufficient diversity in SPs and FHPWs participants uncovered themes for
future research.
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Ethics
Research was overseen by a dissertation committee and approved by the University of
Southern California's Internal Review Board before commencing. Demographic screening
specifically required FHPWs participants to be adults who are no longer homeless in addition to
having been pregnant while homeless at some point in their lives and SPs to have worked with
HPWs at some point in their past in a SP capacity. After months of failing to get any interview
commitments with FHPWs, the Internal Review Board approved a $25 gift card incentive for
participants which resulted in all FHPW’s participation.
Two distinct groups of participants, FHPWs and SPs, posed two issues of positionality to
me, the researcher. Where positionally, FHPWs may have viewed the interviewer as a person
who may have potential to advocate for their needs, they may also have found very personal
questions intimidating. To address this, I interviewed in plain clothes to be more relatable, and
shared firsthand experiences to improve rapport. Additionally, I began every interview
establishing that the anonymous research results will be shared with various SPs in hopes to
inform their procedures and programs in the future, which the FHPWs found particularly
important.
Service provider participants had a different set of positionality issues to mitigate. While
I may be viewed as a peer, there was also potential for the participants to be concerned about
how their employers may react to certain information they shared. To mitigate for this, all SPs
were given gender-neutral pseudonyms and assured they would not be associated with their
precise organizations when documented by conglomerating and anonymizing the sources of
location-specific institutional problems.
53

Participants
Finding participants who spanned the cycle of service procurement complicated the
process. Some SPs maintain very little interaction with other SPs, so getting a referral for an
interview was not possible. These required persistent phone calls over weeks to finally establish.
Because I researched the experience of provisioning services for HPWs, it was important to
understand the entire process. To get a complete picture of what was happening, my research
subjects came from two populations: FHPWs and providers who serve HPWs. They were
recruited through direct contact by SPs or me by emails, texts, phone calls, and word of mouth.
Initially, I reached out to direct contacts who referred others. The conveniently, snowballed
sampled group resulted in two FHPWs and 12 SPs from eight different organizations available
for interview.
There were 14 participants interviewed. Thirteen took place through Zoom, and one took
place spontaneously by phone. SPs were intentionally snowball sampled by having SPs refer
people in specific roles for interviews. Twelve of the interviewees were SPs at various stages in a
HPW’s experience of procuring services, while the other 2 were FHPWs. Both FHPWs were
snowball sampled from a private organization that offers adoption support, which limits their
representation in terms of other types of HPW’s experiences. Table 2 is in proximal order in
relation to first contact with HPWs. It describes the way each participant will be referred to in the
research, their general role (as manager (MSP), direct interactive service provider (DSP), or
managing direct service provider (MDSP)), the program type they are affiliated with, the
nationality they identified as in the context of either White or Member of a Minoritized Group
(as Minoritized) to protect anonymity, and the duration of the interview. The SPs in this research
consisted of SPs from the public as well as non-profit sectors.
54

Table 2
Participant Data
Pseudonym Role SP Level Program Type Race Interview Duration
Kennedy 211.org MSP
Social Services
Database
White 12
Skyler
Adoption
Specialist
MDSP Private Non-Profit White 47
Alex
Child Family
Services
MSP
Child Family
Services
White 43
Ryan
Childcare
Provider
DSP HUD Housing Minoritized 70
Jessie
County
Healthcare
Coordinator for
the Homeless
DSP County Hospital White 46
Cameron
Crisis
Interventionist 1
MDSP
Women’s Crises
Center Service
Coordinator
White 64
Casey
Crisis
Interventionist 2
DSP
Women’s Crises
Center Service
Coordinator
White 64
Jamie Doctor MDSP County Hospital Minoritized 55
Erinn
Executive
Director
MSP HUD Housing White 41
Tracy FHPW1 FHPW1 White 56
Rene FHPW2 FHPW2 Minoritized 91
Jalen Police Officer DSP
Local Police
Department
White 64
Aubrey Support Specialist DSP HUD Housing Minoritized 118
Riley
Young Adult (18-
24) Case
Manager
DSP
Young Adult
Shelter
Minoritized 81

55

Participants’ Backgrounds
Below are the participants’ backgrounds. As a reminder, because of the disproportionate
representation of gender in the service provisioning sector, all names and pronouns are non-
gendered to ensure anonymity.
Kennedy (211.org Manager)
Kennedy identifies as White and their role is overseeing the regional responder team for
211.org. They ensure sufficient staff and volunteer resources, and protocol adherence. The
organization was developed by United Way to be a single source of local social service offerings
to anybody who contacts them for help. They assess the needs of the client and initially give
three options for the most impactful service required. If none work-out, the HPW may call again
for three more referrals and repeat this process until a suitably available option is secured. After
that process, the client can re-connect with them for additional services or referrals. Because of
the high demand in this role, Kennedy was only available for a shorter, 12-minute interview at an
impromptu time that limited the data collection. Data collected for this conversation is entirely
based on notes rather than transcripts which makes it subject to bias, exclusions, and
misinterpretations.
Skyler (Adoption Specialist)
Being a founder and MDSP, Skyler identifies as White and previously focused on
adoption placements for HPWs but moved into the baby supplies sector due to an underserved
need. Their operations have always been classified as small, having fewer than 25 employees or
volunteers at any time. Previously having worked at CFS for seven years, they found the
government system unable to properly service HPWs in meaningful ways, so they started a
nonprofit to facilitate adoptions for HPWs. As founder, Skyler has spent ten years coordinating
56

approximately 200 adoptions. Over time, the income was insufficient, so approximately six years
ago they pivoted the programs to supplying baby and feminine supplies such as diapers, formula,
and menstrual products to homeless women. Just before COVID-19, the organization was
distributing approximately 15,000 diapers every month to mothers in need.
Alex (Child Family Services)
Alex has been with Child Family Services (CFS) for 24 years and is currently the
manager of the county jurisdiction. They identify as White. As part of a government agency, this
participant represented the county-run CFS agency which exists to ensure the safety of all
children. As the manager of the local regional CFS jurisdiction, Alex oversees the team that
directly interfaces with people requiring intervention. The department investigates accusations of
child abuse or neglect and provides services to defendants navigating the court system because of
an accusation of child endangerment. Their mandates are set by federal guidelines and state
requirements. After assessing the threat to the child(ren), they refer the family to appropriate
services and monitor for compliance as well as changed behavior. CFS is mandated to intervene
in situations that are threatening or harmful to children and coordinates interventions including,
but not limited to mandated therapy, parent training, rehabilitation, child representation in courts,
and foster placements. If the intervention is unsuccessful, they will take additional steps to
ensure the child’s safety.
Ryan (Childcare Provider)
After an HPW has their child and finds permanent shelter, they often need childcare
which is where Ryan becomes involved. This interviewee, who presents as White, has worked in
service provisioning at this organization for seven years ranging from direct interactions with
HPWs to their current role managing and overseeing childcare for permanently housed HPWs.
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They take referrals from support specialists onsite at a housing location and facilitate the process
of getting post-natal and child services for FHPWs along with their primary role of caretaking
children residing in that housing facility.
Jessie (County Healthcare Coordinator for the Homeless)
When an HPW first arrives at the county hospital for medical services, she is directed to
Jessie for coordination of eligibility and additional services. Jessie works both at the hospital as
well as supports the outreach program that regularly drives a mobile unit to homeless
encampments to provide access to services on-site. This self-identified White individual fills
both capacities and has for three years. Jessie’s primary role is coordinating medical care for
homeless people accessing the public health department. Because of this role, they are the
primary contact for HPWs which is exclusively for the county hospital’s services and does not
procure services outside of that realm.
Cameron (Crisis Interventionist) and Casey (Crisis Interventionist’s Assistant)
This interview was atypical in that it was scheduled with the assistant of the founder of a
crisis intervention program, Casey, but because it was over Zoom, the founder, Cameron,
periodically interjected with their own input. This two-person operation performs extensive
outreach to the homeless communities near their headquarters including personal visits, flyers,
and strategic sticker placements indicating their desire to help HPWs along their path. Situated
on a farm, this organization invites all homeless people to help on the farm if they are so
inclined, in exchange for basic supplies such as food and clothing. Their primary focus of HPWs
is to help them get shelter, rehabilitation, medical care, and adoption opportunities. They provide
transportation to and from appointments, hotel vouchers, over-the-counter testing, and occasional
shelter on their premises when there is no other availability. Casey was previously a client of the
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organization and began working in this capacity six years ago whereas Cameron has been
working with this population for 24 years. Six years ago, they began recording the number of
clients they helped, and data indicates they have increased their capacity by 20-40% annually
with 2020 supporting approximately 5,000 individuals. Each of those individuals who are either
pregnant or parenting are contacted at least once per month for check-ins to ensure they are
getting the resources they need.
Cameron identifies as a White MDSP who founded an organization 24 years ago after
facing homelessness, addiction, and pregnancy. They help women in crisis with finding support
programs and providing basic supplies including food. Over the past 5 years, the program has
been increasing its clientele by approximately 20% per year, though funding is lagging. It
includes a mobile outreach program that drives to different homeless encampments and places
stickers nearby to encourage women to get help from them. Their interview was conducted
simultaneously, in the same room with the Crisis Interventionist DSP.
Casey identifies as a White DSP. After being an HPW and going through the crisis
intervention program described above, Casey began working for that organization to help
administer, organize, and market the services provided. After 6 years, Casey is so assimilated
into the processes, that they perform tasks seamlessly with the founder. As mentioned above,
Casey was the scheduled interviewee for this research, and openly spoke as Cameron shared
their office. The two completed each other’s sentences and nodded when the other spoke
throughout the interview.
Jamie (Doctor)
This participant from a minoritized group is an obstetrics and gynecology doctor
specializing in HPWs and substance use disorders at a county hospital. Having practiced at the
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county hospital for eight years, Jamie played a fundamental role in the development of mobile
outreach programs and the rehabilitation programs which have become very robust over the past
three years. The role they play in HPWs’ experiences includes developing trust to ensure
continuity of care coordination with other programs and medical care. Jamie is locally
acknowledged for their unique personalized approach to each of their patients. Having worked
with Tracy, their role directly interacts with, as well as manages, the service procurement
process. Jamie was recently promoted to oversee the homeless outreach and substance use
pregnancy programs.
Erinn (Executive Director)
Though this self-identified White person is the founder and Executive Director of a HUD
housing program that serves numerous FHPWs, it is noteworthy that this person recently stepped
down from the Board of Directors in a large organization to acknowledge the “snow-capped
organization[‘s]” issue of entirely White race representation in leadership. They have never
worked directly with HPWs in this role, only with directly reporting DSPs. After working at this
HUD housing facility specializing in people with disabilities for 14 years, Erinn recognizes the
role of their team supporting homeless people to apply for housing at their location as well as the
essential part of the team’s case management and post-housing support services they provide.
Their direct experience with HPWs is limited to their work in a previous position with the local
Conservation Corps in skills training. They currently oversee housing along with a work
immersion program that gives the opportunity to learn transferrable skills in a retail and
production site.
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Tracy (FHPW)
Tracy identifies as a White woman who has experienced two pregnancies, both of which
resulted in her no longer being welcome in her family home and consequentially homeless. The
fathers of her children were both heavy substance users who were unsupportive and emotionally
abusive. She delivered her first child while still using substances but eventually became sober
through a county run program. Eventually she relapsed in her substance use and became
pregnant again. Through support from her medical doctor and her workplace, she is now sober
with custody of both children.
Rene (FHPW)
This FHPW identifies as Hispanic but acknowledges she presents as European White,
and experienced two pregnancies. She was raised in a literalist fundamentalist religious
household, which she left in young adulthood. Moving away from her childhood home to a
relative’s home in a different state, she explored freedoms she never had previously. This led to
substance misuse and finding a boyfriend who suffered from substance dependency. Upon
discovering she was pregnant, her relatives chose to engage in tough-love by kicking her out of
their home. Eventually she decided to have her child openly-adopted, and she continues to keep
in touch to this day.
Jalen (Police Officer)
This East Bay police officer who self-identifies as White, has worked for 19 years filling
the role of patrol officer and, for the last two years, the dual role of patrol officer and homeless
liaison for their local city. Though the homeless liaison role is budgeted and funded by the state
of California, not all police departments fill it. When there are concerns about the local homeless
population, they are referred to this person for first contact. There was no mentorship or training
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for the homeless liaison role when Jalen started, so they have designed it in ways they felt was
most suitable. Additionally, Jalen was unaware of any real guidelines or directives regarding
how they should conduct themselves in this position. After fulfilling the full two-year assignment
in the position, Jalen has redesigned the role to be more interactive, supportive, and advocacy
focused. At the time of our interview, they had only a few months left in the homeless liaison
role with no clear replacement vetted. This indicates any institutional knowledge gained during
Jalen’s tenure will likely be lost during transition.
Aubrey (Support Specialist)
Aubrey identifies with a minoritized group and worked directly with HPWs with a
previous homeless services employer for several years before taking this position at a housing
facility that specializes in people with disabilities where they have now worked for eight years.
This interviewee has worked in increasingly responsible roles in the service provisioning space
at more than one organization. At the time of the interview, Aubrey had seniority in her position
at this organization, and was not given an opportunity to interview for a promotion despite a
recent opening directly above their current rank. While Aubrey’s primary role is to assess needs
and continuously outreach to current residents to notify of services for which they are eligible,
this person also encounters numerus situations where HPWs are referred for help and guidance.
Additionally, there are times when a resident becomes pregnant and no longer wants to live with
their family at this location, creating a paradigm of potential homelessness without intervention.
They share responsibilities with two other support specialists who currently serve 500 residents
together.
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Riley (Young Adult Case Manager)
As a DSP to young homeless youth, Riley identifies as Black and works directly
temporarily sheltering up to 9 males and 6 females in the county-controlled space. After their
own experience with homelessness as a young adult, Riley decided to give back to the system
and has been a case manager at a youth county shelter that serves homeless people between the
ages of 18 and 24 for three years. While HPWs are welcome to this organization, the limitations
on the HPWs population are between 4-7 months in pregnancy and not currently with another
child or with the father of the child because the shelter is partitioned by gender. While young
adults are staying at this facility, Riley coordinates services of their choosing and interacts with
the population constantly throughout the day. They conduct intake, referrals, travel to and from
appointments, basic supply procurement, and field work where they interface with potential
clients who are currently homeless and living on the streets.

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Chapter Four: Findings
To better understand this multi-faceted system of service procurement, the research
questions explored the challenges, effective programs, and required resources for individuals
involved in any of numerous roles of the process. This research found some recurring themes
throughout the process of procuring services for HPWs as well as some unique themes in
specific phases of the process itself. Fourteen SP interviewees representing eight different
organizations that work with HPWs provided insights. The two FHPWs added their own
perspectives about three of the participating SP’s roles, as well as their own needs throughout the
process. The following sections will review the goals and overarching findings of each research
question followed by the evidence that led to these insights. The end of each research question’s
exploration as well as all sections synthesized at the end of the chapter provide a summary of
findings.
Research Question 1: What are the Challenges to Provisioning Services for HPW?
While the data revealed numerous challenges to procuring services for HPWs, three
overarching themes emerged: (a) there are insufficient shelter beds available for HPWs in the
Bay Area, (b) larger organizations work well together, but do not effectively coordinate with or
share resources with smaller organizations that specialize in niche services for HPWs and (c)
within larger organizations, upper management does not have adequate understanding of their
DSPs’ challenges. Within these themes runs another theme of collaboration and its impact on
services. The following section will explore the experiences of SPs and FHPWs as they
navigated the challenges they faced during service provisioning.
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Shelter Insufficiencies
The results show there are insufficient shelter spaces available for HPWs in the Bay
Area. While HPWs often suffer from mental health issues, COVID-19 also affected shelter
availability. In addition, HPWs face a particularly difficult challenge of finding shelter that
accepts pregnant women’s unique characteristics which can range from a full family, a child
already born, substance use while pregnant, mental health issues, and the pregnancy itself. This
section will discuss shelter durations including impermanence, the difficulty of procuring
services for HPWs, the lack of availability of shelter for HPWs, sheltering in vehicles, and the
impacts of mental health and COVID-19 on procuring shelter.
To serve HPWs fully, shelters require equipment, knowledge, and policies to support an
HPW if she stays there. Consequently, throughout the interviews, participants mentioned that
HPWs would either be ineligible due to their condition or would have their stays shortened to
decrease the potential of the child being born while in the shelter. For instance, Riley noted that
their facility will accept HPWs up to month seven, but do not have the tools to support a woman
later in her pregnancy. However, the duration of sheltering options is also inappropriate for
HPWs who will likely be needing shelter for close to nine months or more. Jessie acknowledged
the short-term nature of HPWs’ shelter stays which are only three months, and it is often the case
that residents move back onto the streets. Riley and Ryan each detailed that shelter stay durations
can range from nightly to up to two years. These different policies lead to HPWs needing to
move from one shelter to another for continued care. Supporting this, Cameron elucidated, “I’m
beyond pissed at our system of care when it comes to our HPWs. Because they run them around
so much that they end up, Heather, just saying ‘Screw it.’” The imagery of running HPWs
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around indicates the more temporary shelter accommodations compared to others for whom
Cameron’s organization coordinates housing. As Jessie recognized:
A lot of the shelters, once they’re pregnant or once they’re no longer pregnant, once they
have the baby, then they have to, they can’t stay in that shelter necessarily. They’d have
to, like, go to our family shelter which is in a whole different part of the city.
Therefore, shelter not only may be transient, but it may also be inconvenient in its distance from
the HPW’s friends, family, and community. Ryan acknowledged obtaining services “is not an
easy system to work its way through unfortunately,” while Jalen recognized “I can, you know,
imagine how an HPW trying to get any sort of services probably feel totally helpless. I mean,
there aren’t a lot of services to begin with.” To further complicate matters, should an HPW
previously have services and discontinue them, Erinn notes “because [our] county has so many
homeless, what that means though, is she wouldn’t necessarily rise to the top, and could
potentially be forced to live years out on the street before they reach that priority” to receive
services again. To address this, Cameron described her approach:
I usually take pregnant homeless women into my home because I can't get them in
programs. I can't get them anything, and it's like, so why are you telling me there's these
availabilities and I'm out here doing huge jumps, whatever, backflips, and I still have a
homeless mama under a bridge after 4 years, 5 years?
Confirming this, Tracy described, “My aunt really had to pull strings to get me a couch” by
calling all the shelters in the area during a cold winter to secure Tracy shelter until a bed became
available. When beds were not available at shelters, both Tracy and Rene slept in their cars.
When sleeping in their cars because of shelter unavailability, HPWs could stay at a safe
parking site such as the one Aubrey described where “if you have a car, you can do their safe
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parking there. They built a fence around the parking lot and then they lock it at night to keep
everybody safe.” While safe parking is less dangerous than sleeping on the streets, shelters are
lower risk as well. In addition to shelter shortages in general, mental health challenges and, at the
time of this research, COVID-19, also complicated the process of securing shelter options.
Mental Health and Shelter Access
Interestingly, mental health issues can increase or decrease access to shelter options.
However, admissions for mental health challenges currently overwhelm treatment facilities,
especially since the onset of COVID-19. All participants mentioned the importance of mental
healthcare for HPWs. Additionally, Aubrey and Erinn stated one must have mental health
challenges or a disability to obtain permanent shelter at their facility. In contrast, some mental
health issues lead to inappropriate behavior at shelters that results in multiple moves that can
further isolate the HPW because of inconsistency as well as distance. For instance, Jalen recalled
one HPW who “did have housing, she had multiple [behavior] issues with the nonprofit that she
had the housing through to the point where they actually had to get a restraining order against
her,” which led to her being in the process of obtaining housing in a different county at the time
of the interview. Sometimes the safety concerns are with associates of the HPW such as when
Riley attempted to keep a HPW safe from her abusive boyfriend by transferring the HPW to
another facility with the capacity to support exactly one family almost 20 miles away. This kept
the HPW safe from the abusive father, but also inaccessible to friends and family. Sometimes
distance from domestic abusers is necessary to maintain safety for all residents and SPs.
However, it is not as possible when HPWs are not believed. Police and other DSPs who initially
encounter an HPW who suffered from IPV are susceptible to “failure of abuse experiences to be
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believed…, a lack of concern…, and marginalization and discrimination (Robinson et al., 2021).
Failure to recognize IPV is both physically and emotionally unsafe for HPWs.
One form of safety is emotional safety for HPWs who face mental health challenges. To
address mental health concerns, six of the 38 organizations evaluated through website analysis
advertised the requirement of a mental health or disability classification to qualify for shelter and
services, making more shelter availability for HPWs with mental health issues. In addition, no
organization in this study specifically excluded any mental health issues for shelter qualification.
Mental health issues can also result in priority status. For instance, Jalen acknowledged
an HPW would become higher priority to first responders and care coordinators, especially if she
also showed signs of mental health challenges. Therefore, even before SPs input an HPW’s
profile into the services system they, and especially ones with obvious mental health challenges,
will be prioritized. Additionally, Erinn explained “everybody who’s homeless in the county is
assessed, put into this database, then they’re prioritized based on a number of factors” of which
mental health is one. Having mental health issues appears to increase the probability of being
eligible for additional resources to help an HPW along her path. However, it may also decrease
the number of suitable shelter options when it adds a secondary constraint around care of
substance use to maternity. Supporting this, Casey stated:
Homeless and pregnant will put you on the bottom of any waiting list, any housing and
any programs. We find it very difficult to get our homeless pregnant drug addicts a
physical or a TB test to get them into recovery [compared to non-pregnant drug addicts].
Because they help both populations, the increased difficulty in placing pregnant substance users
indicates an increased complexity in finding HPWs services. Similar to the shelter situation,
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while there are many government programs available, they are often filled to capacity, which
increases wait times for services.
Shelter and COVID-19
Because this study took place during a pandemic, it is important to consider the impact of
responses to COVID-19 on shelter and mental health services. While Project Roomkey was
received widely with its addition of thousands of housing units for homeless people, it initially
left out HPWs (Goodsmith et al., 2020). Additionally, as Cameron elaborated,
There's not housing availabilities for anybody. So, you know, I'm just more pissed off,
and I hate all the political bullshit [around Project Roomkey], excuse my language,
[inaudible] that is built on that we are pumping hundreds of thousands, millions, of
dollars into the homeless issue, and nobody who's homeless is getting help.
Similarly, Riley acknowledged the lack of vacancies and explained that the capacity of the
shelter decreased from 15 to nine because of COVID-19. Only one woman utilized a women’s
bed of the four available because of reductions due to social distancing during COVID-19. The
three empty beds are due to fewer female youth utilizing the shelter than male youth whose
availability decreased from ten to five, so the capacity disproportionately affected the men’s
availability during this pandemic. Consequently, while organizations added housing, COVID-19
regulations reduced their capacity requiring HPWs to contact more entities to find safe and
available shelter.
Interagency Coordination
While larger organizations work well together, they do not effectively coordinate with or
share resources with smaller organizations that specialize in niche services for HPWs. With the
current system, government organizations represent the bulk of large organizations, although
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some other organizations such as 211.org are also within the scope of this designation. This
section will explore the funding dynamics that impact service coordination, misunderstandings
surrounding the role of CFS in the process of procuring services for HPWs, influences of the
exosystem on these coordinated efforts, and internal influences in SP agencies from various
perspectives. The perceptions of resources and needs revealed the importance of smaller
organizations filling the gaps where larger organizations are not serving, and reasons smaller
organizations are unable to do so effectively.
Collaboration between Government and Non-Government Organizations
When organizations are coordinating services, there is a tendency to favor a small set of
collaborators with whom they have worked previously, rather than refer to longer lists of
providers supplied by local governments or organizations. Ryan explained, “it’s really just more
about who you know, or what programs you know, and then connecting [HPWs] from there.”
When thinking about who they refer to, Jessie said, “it sometimes boggles my mind that, that just
two months ago, I learned that we had a perinatal health we’re just referring to women.” Despite
Jessie’s 4 years of experience within the organization, they were unaware of this resource.
Similarly, while Alex, Jessie, Aubrey, and Riley all had lists of SPs, when discussing services,
they quickly referenced organizations they had worked with numerous times before and did not
have the employer-provided lists as easily accessible as the ones they had created from their own
experience. This suggests DSPs tend to refer HPWs to familiar entities and programs most often.
One government program that is widely misunderstood is CFS.
Misunderstandings Surrounding the Role of Child Family Services
Direct service providers and HPWs do not understand the role of CFS which can result in
unnecessary referrals to the intervening agency. First, this section will explore CFS’s role during
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pregnancy, then after the child is born, and afterwards, how SPs and HPWs misinterpret these
roles.
Child Family Services was in the midst of policy change during the time of this research.
Federal guidelines, state requirements, and county policies/procedures interpret the rules that
define CFS’s mandates (Alex). Accordingly, “if the child hasn’t been born, they don’t exist.”
However, during this research window, on October 1, 2020, The Family First Prevention
Services Act (2021) went into effect which allows CFS to focus some funding on preventing
referrals to their offices. This legislation and funding may create a dynamic where they begin
interfacing with at-risk HPWs. This earlier intervention will likely focus on specific at-risk
behaviors rather than the mother’s homeless status.
Alex spent a significant portion of our time together discussing how CFS is under the
directive to only intervene after a child is born. They acknowledged when they started 24 years
ago, that they knew nothing about HPWs, but that the issue has grown substantially since the
2008 recession. Importantly, Alex explains that “the woman who’s homeless or not doesn’t
matter,” which is relevant, because the concerns focus on the safety of the child, the potential of
the parent to mitigate for dangerous behaviors and HPWs working with the system to avoid
separation from their child(ren). To fulfill this mission, CFS partners with external agencies to
help find services for HPWs and their children.
Misconceptions of CFS’s role often involve three scenarios: leaving a child home alone,
child abuse, and substance use. After a child is born, Alex further explained, there is no
legislation surrounding an appropriate age to leave a child at home, so it would require a
dangerous situation for that to be reportable, of which yelling or spanking would not fulfill,
because they are not considered child abuse. In contrast, another misconception Alex clarified
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was “just because [a prescribed opiate] is legal, doesn’t mean it can’t be an impairment” to one’s
parenting abilities. What many DSPs and HPWs do not realize is that legality or illegality does
not always translate into actionable child endangerment reports. Confusion around CFS is largely
due to misunderstandings surrounding the strict boundaries of their mandate.
One of the most common fears lies in CFS’s ability to take children from an endangering
situation. Importantly, Alex emphasized:
The last thing [CFS] want[s] to do is remove a kid. They will call aunties and uncles and
friends of the family and godparents and say, “Can you guys come take care of this kid
for a while, while mom and dad get their act together?” Because we really don’t want that
child in the system. … You know, it’s traumatic for a child to go live with a stranger. It
is— so is the trauma in their house— but it’s really traumatic.
CFS recognizes that the California foster care system is inherently flawed and causes additional
trauma for children who suffer high homeless recidivism rates with Alex reiterating, “Avoid our
system. Avoid our system.” Though CFS can re-home children who are in dangerous living
situations, Alex estimates they only assign 50% of child endangerment reports to a case worker
for further investigation. This indicates that people are reporting twice as many incidents for
child endangerment as are warranted because of misunderstandings surrounding what is
actionable by CFS.
At least part of this is due to the fines and/or imprisonment of mandated reporters for
failure to report (Child Abuse Reporting Guide, 2021). If DSPs understood CFS’s mandate
better, they would report less frequently which may make HPWs less reluctant to seek services.
If HPWs understood, it would not affect their decisions while pregnant because they would know
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there is no mandate for CFS to intervene at that stage. However, many SPs are mandated
reporters despite being unclear on what behaviors are actionable.
One example of misunderstanding Aubrey expressed is when they felt compelled to
report a HPW who was doing drugs, and noted:
One of my big things that’s a part that I don’t like to do is to have to make CPS reports.
But that’s a big deal in, you know, in this world of case management, that has to be done.
The discomfort of reporting alongside the misinterpretation of what is actionable by CFS
highlights a disconnect between policy and understanding/execution. In another example, when a
substance using HPW enters the county hospital with concerns about keeping custody of her
newborn, Jamie recognizes that CFS will most likely receive a report. According to Alex, which
of these reports CFS perceives as actionable depends on the level of proof and the perception of
that evidence by the person reading the report and making the decision.
SPs expressed mixed feelings surrounding working with CFS. Both Jalen and Jamie
expressed a desire to work more closely with CFS while HPWs are still pregnant to intervene
positively before the child is born. While early intervention may be desirable, DSP’s interactions
reflect the confusion around CFS’s role. For example, Aubrey summarized their perception with
“I’ve had really wonderful, amazing experiences with CPS [Child Protective Services, currently
known as CFS] workers, and I’ve had horrific experiences with some CPS workers. It really just
depends.” A clearer understanding of CFS’s mandate and role could improve reporting processes
by DSPs. The current confusion about CFS’s mandate results in misunderstandings by HPWs as
well.
CFS instills caution with HPWs for fear of losing their autonomy of choice over their
child’s care. Skyler noted that some of the substance using HPWs who come in for adoption
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coordination, make the private decision to give their child up so they can avoid CFS
involvement. Tracy expressed concerns about CFS taking her child away when her blood
pressure was so high due to drug-use immediately before her prenatal appointment, and she was
referred to emergency services. In that situation, Tracy recalls she:
was so scared of losing my baby [to CFS] that I went home.…and I detoxed for like four
days with nothing- And then I went and turned myself into the hospital…. I was so
scared, and I didn’t know if it was all the way out of my system yet, and I was scared that
I was— the detox was affecting the baby, so like four days later I went, and now luckily
he didn’t get taken.
While according to Alex, CFS would have worked with Tracy to find rehabilitation and other
services, instead she risked her own and her child’s life to avoid the interaction altogether.
Consequently, Tracy’s fear of CFS drove her to endangering herself and her child by not getting
medical attention when she needed it because of the threat of losing her child. However, when
posed with a similar scenario, Alex assured me that:
If that person comes into our system, and they’re working with us, we’re looking for
helping them secure housing, good parenting classes [inaudible]. In addition to getting
sober and learning what it is to parent a baby sober, you know, helping shore up their
parenting skills if they, you know, anything we can do to help that family be successful.
In fact, CFS has numerous resources such as substance use programs, psychological services,
and childcare readily available to help parents keep their children. However, government
programs like CFS do not cover a number of unique or non-standard needs, and organizations
positioned to support those needs are often not eligible or chosen to receive funding or referral
opportunities.
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Financial Means Distributions
The systems currently in place to fund services for HPWs limit the availability of options
throughout the process of procuring services. For example, Skyler pointed out that “it’s hard
being a small nonprofit, because there’s so many other, larger nonprofits in this area that people
want to donate to, you know?” In contrast, larger organizations are not only eligible to apply for
more grant money, but their name recognition also yields more private donations. When given
grants that include coordinating services with other organizations, larger organizations tend to
find the least expensive partner-organizations to maximize their return on investment. However,
this strategy leaves the smaller, more specialized nonprofits working for free or well under cost
to meet those larger agencies’ goals and objectives. The following captures the conundrum
smaller organizations encounter of getting more opportunities to do the work they are passionate
about at the expense of not receiving private donations, name recognition, and/or the grant
opportunities larger organizations enjoy. Cameron stated that the county:
…think[s] we’re the greatest thing since sliced bread, but they don’t want to pay because
we’re offering that service. I used to do my services for free to everybody, until the point
was, “How can I keep doing this free?” And you guys now turn around and use my free
stuff and put your name on it, and you’re getting brands and you get recognition?
Additionally, while large organizations receive substantial funding and portions of grants
allocated to multiple organizations for a purpose, small organizations lacking enough rapport for
an invitation to fund-sharing criticize the distribution process. Skyler’s perspective captures their
experience of the closed circuit of coordinated grants:
You go to one of those meetings, and everybody’s sitting around from all the other
agencies. You know, again, if, and the counties try to get organizations to collaborate and
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apply for grants in a united way to get more funding, but people won’t do that. So, if you
start giving away or collaborating, then you’re not going to get as much money when you
go to write your grant. [inaudible] So, you know, “don’t, don’t, don’t venture outside of
our little circle here, because we want to be able to grab as much money as we can when
we need it” rather than looking at, “Why are we doing this work to begin with?”
Consequently, smaller organizations, when invited to the table, collect less money when
collaborating than they would receive independently from a grant, because they must rely on the
generosity of the larger organizations to distribute that money. While larger organizations have
staff to apply for numerous grants, review of grant opportunities on grants.gov shows they are
also eligible for more grants that are often substantially larger whereas smaller organizations
must spend more time writing proposals for a larger number of smaller grants with fewer people
to do so. For instance, Casey “spend[s] about 65% [of their time] writing grants” and doing
fundraising marketing for their two-person operation. While providing larger grants to larger
organizations requires less oversight due to fewer applications and parties to monitor, its
downside is the exclusion of smaller, more specialized services that could provide more options
to HPWs.
Oftentimes, earmarked funding for smaller organizations is for very specific populations,
effectively eliminating the organization’s discretion in how to provide individualized services.
For example, Jessie noted “each site has some funding streams that influence it. Like one of our
county shelters has a partnership with the V.A. (Department of Veterans Affairs), and so that site
has some beds earmarked for veterans.” In this instance, their shelter is now more focused on
veterans and would not be able to provide shelter to an HPW if a veteran-designated bed was
empty and the other beds were full. Funding is political because so many services rely on
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government sponsorship. One of the most impactful government programs is mental health
services.
Uneven Access to Psychological Services
Mental health services, including substance misuse support, have inconsistent
accessibility across the service provisioning domain. First this section will explore the
differences between access at the organizational level. Then it will consider the experiences of
DSPs and the mental capacity of HPWs which can both influence the process. Lastly, this section
will present the issue of not obtaining necessary support and the experience of receiving less
personalized support.
Access to psychological services is strongly dependent upon which organization an HPW
initially encounters for service coordination. As Ryan noted, “I feel like it’s actually way harder
than it needs to be to get somebody access to mental health services, especially adults.” Riley
also recognized these challenges when they stated, “it can be really difficult to connect them with
the right people, especially with, like, state insurance, to get tested [for psychological disorders]
in any sort of timely manner.” Similarly, Jalen relayed recurring situations where medical staff
do not evaluate people brought in for psychiatric emergencies before releasing them to the police
because of substance use. Recognizing the inconsistencies, Jamie states, “in our county, our
mental health system is somewhat fragmented” and further explained that sometimes the only
way to get care quickly is to bring them into psychological emergency or crisis centers for care.
However, Cameron’s, Alex’s, Jessie’s, Jamie’s and Erinn’s organizations all have direct access
to on-site psychological services at least five hours each week. Consequently, going to them may
result in prompter attention to long term mental healthcare than other organizations without that
immediate internal resource.
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While the government programs’ approaches offer a faster, reliable means for referrals,
they also diminish opportunities for smaller organizations to establish new referral lines as well
as to expand the impact of their niche expertise to include mental health support. Therefore,
whereas Ryan conveyed a need to have “easier connection to mental health services,” Jessie
“communicate[s] [directly] with mental health” programs, because services link through the
county’s HMIS electronic systems. Jessie, Jamie, and Aubrey can refer to on-site mental health
programs whereas the other DSPs could not. Though both Jalen and Alex work under legal
mandates to provision mental health support, service organizations promptly fulfill Alex’s
referrals and for longer terms because “state and federal law says you have six months, or that
child can be free for adoption in this state.” That mandate is different from law enforcement’s.
Despite being an officer of the law, Jalen has “a very, very frustrating relationship with [the local
psychiatric hospital], especially in the last two years, where [Jalen will] give legitimate mental
health referrals for people and [the psychiatric hospital] will put them back on the street, you
know, within, you know, a couple hours.” While urgency may provide swift, temporary support,
non-urgent mental health needs encounter additional obstacles.
One reason is because non-urgent needs for mental health support are contingent upon
HPWs being autonomous enough to initiate services independently. Part of the challenge is
related to the affected person’s ability and motivation to advocate for themselves. With non-
urgent calls for help, Aubrey highlighted the autonomy they support when they tell an HPW to
“just pick up the phone, and just call them, and then they will help you the rest of the way” and
how for a “certain issue, [Aubrey] saw that come full circle, and that client got help and
support.” However, not every person has the capacity to do this. Ryan pointed out that people
suffering from IPV or a mental health crisis are “not in a place to do A, B, C, or D, or [they]
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wouldn’t need it. [They] wouldn’t need that level of [psychological] support necessary.”
Therefore, they are not always in the right frame of mind to make those calls, and newer DSPs
do not always know how to encourage self-advocacy like experienced ones. Ryan continued,
“newer workers tend to struggle with [supporting the mental health component more] than a
seasoned worker.” Elucidating on that, Aubrey recognized, “you know that they need help and
support, but they don’t want to accept the support, or they don’t want to admit that they need
support— especially some of my clients who have been pregnant, have been on meth, and
smoking cigarettes.” Therefore, both and HPW’s autonomy and a DSP’s experience influence
access to psychological services.
Should HPWs not get support, they may rely on themselves instead of professionals for
major decision such as when Rene stopped her antidepressants during her pregnancy. Rene’s
decision was not influenced by a psychiatrist’s recommendation. Therefore, access to and
communication with the HPW impacts decisions. Access decreases with either one not working
optimally. When both function well, access increases. Therefore, access to services can be
inversely correlated to need.
When HPWs do finally get mental health services, SPs often put HPWs into group
therapy programs which they do not prefer (Aubrey), or in times of COVID-19, online programs
(Riley). Ryan noted that the general goal of these programs is to stabilize the patients so they are
“not a danger to themselves or others, but that doesn’t mean that they’re stable, and that they
have the connections they need to be mentally healthy or to get mentally healthy.” Both Ryan
and Aubrey felt this approach is not effective for all HPWs and needs to be more individualized
for better outcomes. Having more individualized support resources would be optimal for DSPs’
referral processes. In order to coordinate with those organizations, SPs need to seek out more
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specialized and smaller programs to bridge the gap which may benefit from MSPs establishing
new partnerships and providing their teams with contact information of smaller organizations.
Another gap to address is with social and political movements that can inadvertently affect
service provisioning.
Defunding the Police
When the political threat of defunding occurs, such as during the “Defund the Police”
movement, access to services suffers. For instance, when crime occurs in low-income housing
communities, the SPs and property management teams rely upon police departments to handle
the situations appropriately. In a follow-up conversation with Jalen, they supported Erinn’s
observations that when the Defund the Police and “All Lives Matter” movements were at their
peak in “April or May of 2020 (Jalen).” During that period, the police initiated a “kind of
informal strike where they weren’t getting any officers to help and respond to calls…[which
lasted] a year and a half (Jalen)” to get back to previously typical response times. According to
Erinn, this resulted in an influx of theft and illicit substance transactions in the underserved
community. To address these concerns, Erinn hired 24-hour security to offset the lack of
response by police.
Of particular interest to thieves were cars. The decrease in safety in the safe parking site
adjacent to the HUD housing community jeopardized transportation to work for many in this
community. In addition to physical safety, HPWs need emotional safety. With police no longer
responding to mental health crises except suicide or violence, the duration and intensity of
psychotic breaks increased without intervention, according to Erinn. The police reaction of
stopping responses to mental health calls to public sentiments of defunding the police resulted in
physically and emotionally less safe environments for HPWs. Significantly, funding reflects
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organizational coordination influenced by established relationships in referrals, collaboration,
and SPs’ knowledge.
Organizational Knowledge
Within larger organizations, upper management does not have adequate understanding of
DSPs’ daily challenges and needs. This is apparent in their lack of sufficient training programs at
onboarding and their lack of knowledge about specific responsibilities and connections of their
teams. Because DSPs train themselves, cover others’ jobs, and have so many responsibilities, it
makes sense that MSPs are not fully aware of everything. However, this is an opportunity for
deeper understanding and improvement.
Managerial Challenges
When speaking with MSPs there was a deep respect for their teams coupled with a
disconnect between what their team did and what they knew about it. Erinn was especially
cognizant of travel distances to get to work and racial inequity which he elucidated upon more
than once. However, both Erinn and Kennedy were unable to describe the service provisioning
process or name common support programs their teams worked with effectively, with Erinn even
stating, “I am at least one tier removed from direct services.” Similarly, Kennedy redirected me
to “talk to [their] team members directly for more accurate referrals.” When asked specifically
about pregnant women, Erinn even acknowledged their answer was a “highly uninformed
opinion” and later acknowledged “the support specialists are going to give better answers”
regarding what services are underutilized. Supporting this, Alex and Kennedy also mentioned
how their teams would know more than them about service procurement processes and
connections. Management cannot address that which they do not know, and the absence of
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communication and knowledge surrounding key and new partnerships in the service procuring
process are important neglected pieces.
Another way this lack of communication and knowledge about their DSPs shows up, is in
MSPs’ coordination with their teams. By not including DSPs in key meetings and decisions,
management creates a culture that leads to perceptions such as Riley’s:
They just don’t communicate with their staff. We’re the last ones to find out anything,
and I think me, as the case manager, I should be the first. I should be even like in the
meetings that they have when they make decisions.
This indicates a lack of flow of information in both directions between management and DSPs.
Another example of disconnect between management and DSPs is in their hiring
processes. In the scenario where there was a vacancy in upper management, Aubrey mentioned
their dismay at not having the opportunity for promotion, because her employer gave the position
to an external hire. Their institutional knowledge of 7 years was substantial and more than
sufficient to optimally position them for the job. However, they missed the opportunity to apply
for it due to communication dysfunction which failed to alert current employees to the
opportunity. Thus, more comprehensive communications between MSPs and DSPs would likely
decrease these types of scenarios.
DSP Challenges
Despite insufficient communication and feeling management has room for improvement,
DSPs appreciate their managers and maintain autonomy over their responsibilities. All DSPs
interviewed expressed positive feedback towards their managers. The next sections will discuss
the enormous amount of responsibility DSPs hold in their positions. Seven factors that stood out
as challenges for DSPs were: (a) the lack of initial training for the positions, (b) racism, (c)
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covering others on the team, (d) off-site roles, (e) large workloads, (f) multiple roles, and (g)
emotional load which are presented in the following sections.
Lack of Initial Training for DSPs
While there is an official training program for each position, DSPs generally feel they
had to train themselves. For instance, Jalen acknowledged that “when I came in, I should have
been cross-trained by another officer who’s doing half the workload, but that officer was out on
injury, and so it’s it’s been just me for two years.” Similarly, Riley found the systems so
overwhelming that they “learned on [their] own” and eventually set up a unique paper-based
system which they can now navigate easily. Expressing this experience, Jessie noted that:
In our training, they attempted to give us some understanding of resources, but I, I hadn’t
had to apply them or hadn’t had to actually help patients utilize or try to facilitate patients
utilizing services until I was impacted more, and it is hard.
Even Jamie noticed that their training was based on their personal initiative to learn more. One
issue that is less about training and more about representation and unconscious bias is the role of
race in service provisioning.
Racism
The race of DSPs and HPWs can impact service provisioning. The general population as
well as DSPs can be susceptible to treating HPWs of different races with different biases which
can influence service access. Additionally, race representation in upper management of DSP’s
workplaces can influence the culture and experience of DSPs. This representation also influences
how HPWs interact with DSPs, and how SPs relate to and understand HPWs.
Oftentimes one of the first responders to a HPW’s need for support services is the police
department. Jalen recognized the impact race can have on response depending on the race of the
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HPW involved, the person who called in the concern, and the police officer who responds. For
example, Rene, though identifying as Hispanic, would often rely on her White presentation when
she “would go to Safeway and steal food to eat. [She] would get sandwiches at the deli and tell
them that [she] was gonna pay at the front- things like that” to avoid paying for food. That her
motives were not questioned indicates that race can impact how people treat HPWs. SP referral
practices are influenced by the presence of a report or charge for a crime. In Rene’s case, she was
not reported because of her race, which therefore may have delayed service provisioning that
could have started as the responding police officer entered her information into the HMIS
system. Store owners ultimately decide to report infractions such as shoplifting by HPWs based
on their own racial and profiling biases (Jalen). In the case of Rene, the store owners did not
suspect her, so there were no responding police officers to refer her. Interestingly, this resulted in
her not receiving intervention as soon, provided somebody caught her. An HPW from a
minoritized group may find themselves facing charges while a White HPW may not. Leadership
representation and comprehension of clients’ unique racial challenges are another form of racism
beyond calls to the police.
Erinn and Aubrey both identified their workplace as a “snow-capped organization” where
all leadership is White while the rest of the company is multi-ethnic. During the most recent
promotion opportunity, Aubrey suddenly discovered they had a new White supervisor. Though
Aubrey had been performing very well according to reviews and had been working the longest at
this organization, the opportunity to interview for the position was not offered. “My coworker
had to tell me what happened” regarding having a new manager because, Aubrey believed,
management did not consider their candidacy for the position despite their tenure and seniority.
In this case, Aubrey believed racism was a barrier to representation in management. The
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Executive Director responded by stepping down from the Board with a clear directive to replace
them with a minoritized representative to begin the process of healing the inadvertent racial
injustice.
Part of the problem in not having racial diversity represented in leadership is the lack of
empathy and understanding for the unique challenges minoritized populations face daily. Aubrey
elucidates that management does not understand
that constant level of adrenaline and fear and checking your back all the time and making
sure you know what’s going on, yeah, how exhausting it is. Like, why you’re like, “Oh,
that’s why we [people of color] die earlier.” Yeah, we’re stressed half the time, half our
lives.
Then Aubrey pointed out the disparities in treatment and representation in management are
“really difficult when we are working for Black, Brown people. That’s who we serve.”
Therefore, Aubrey believes racial representation in management as well as to HPWs adds layers
of understanding and connection to the organization as well as the people they serve. Supporting
this, Cameron’s experience with their minoritized adopted son helped them better comprehend
the true depth of racism and injustice faced daily. Just being White and declaring “Yeah, that’s
my kid” changes responses of people immediately which is something they had not realized
before their child came into their life (Cameron). They were also previously unaware of how
prevalent racism is in society. With this new understanding, Cameron is better able to empathize
with HPWs of minoritized races and recognizes instances of systemic racism when it occurs.
Understanding the power of safety that non-marginalized racial presentation offers can help
leadership check their advantages before making decisions.
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Covering Others on Team
Of the DSP’s interviewed, seven mentioned covering their coworker’s responsibilities
with two supporting their team member’s absence during our interview. Employers expected
DSPs to fulfill both roles when a coworker was sick, out for personal days, in the field, at a
conference, in meetings, touring the property, and for other scenarios. The team members they
covered did not always fill the same role as the individual. For example, the front office staff was
out during our interview, so Riley “covered both her job position and mine, too, which I’m used
to doing anyway.” Thus, a social worker might cover for a receptionist, managers and
subordinates might cover for each other, or an intake clerk might cover for a person on the
outreach team. This indicates that cross-training is prevalent and a common practice when
working directly with HPWs at an organization. Therefore, communication within DSP teams is
essential for fulfilling this expectation. This expectation to know other roles and duties coupled
with filling them ad hoc adds to the workload of DSPs.
Off-site Roles
Part of these interviews focused on juggling on-site and off-site activities with so few
team members. Jessie, Skyler, Cameron, Casey, Jamie, Jalen, and Riley recognized the efficacy
of meeting HPWs who do not have readily available transportation at their homes. It is so
important, in fact, that the biggest initiatives they spoke about revolved around mobile outreach
programs. Another time-consuming element for DSPs is their role in driving clients to and from
various meetings, appointments, and errands such as “taking [clients] to the doctor’s or to job
interviews, orientations, shopping… working in one of [the other] sites or going over there for a
meeting and something like that (Riley).” These off-site excursions include everything from
visiting government offices to confirm identity and benefits, to driving to job interviews and the
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shopping preceding for interview clothing, to attending weekly counseling or therapy meetings,
to even more personal things like meeting with family or friends.
In non-client related off-site excursions, DSPs frequent government meetings for training
on policy and laws as well as other relevant conferences and classes. However, whenever a DSP
attends a training, another employee must cover their work on site which further impacts the
stress and responsibility load of the team. While the work is substantial, the added emotional
load from building rapport and being available to support clients’ interpersonal needs adds to
their encumbrance. Beside covering others on the team and numerous off-site duties, DSPs
already fill large workloads.
Large Workloads
Building rapport, supporting co-workers, and fulfilling job duties are typical expectations
placed by DSP employers. As recounted by Riley, Cameron, Casey, Jessie, Skyler, Aubrey, and
Jalen, these multiple roles DSPs fill may include but are not limited to intake evaluator, needs
assessor, identity confirmation and registration coordinator, external service coordinator, internal
service provider, social and emotional supporter, goal-tracker, daily behavior mitigator, and
under-resourced resource provider (such as access to the internet or cell phone). Meanwhile, they
must maintain all paperwork encompassing each of these tasks.
Expectations are unique to every client, and the caseloads for DSPs are often very large.
For instance, Aubrey is responsible for sharing the caseload of 500 residents with two coworkers,
which means they each must continuously track and coordinate all those clients for those days
when one is out of the office, sick, or on vacation. Cameron and Casey support and maintain
monthly contact with over 5,000 individuals who are eligible for rationed supplies along with
service coordination. Skyler distributed over 15,000 diapers alone. DSPs’ willingness to maintain
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so many simultaneous and consistent connections to their clients indicates their dedication to
their jobs.
Since all these responsibilities would be a considerable load to maintain for any
individual, the feelings of being overworked and misunderstood by management are logical
reactions to most DSP positions. For example, Riley is one of two people in her department and
described the numerous tasks to complete and track for a typical intake as captured in Figure 2.
The time and energy required by both the SP and the HPW to complete these steps is
considerable. While this does not nearly capture all the processes required to begin servicing
HPWs, it helps illustrate the thinking process and complicated interconnectivity of procuring
services for HPWs. This litany of tasks is merely the process for a single client. Moreover, it is
noteworthy that during our interview, Riley was asked to hand over their personal cell phone to
facilitate a sheltered youth client’s communication with another SP. People stopping by the
office and two direct phone calls requiring immediate answers also interrupted our interview.
Every interviewee, including the FHPWs, validated the nature of DSPs having numerous and
simultaneous responsibilities representing a similar scope. Essentially, DSPs undertake every
aspect of every client’s life by navigating paperwork, outreach, eligibility, follow-up, goal
setting, and progress tracking. To be effective at all these tasks and levels of care, knowing the
clients and their needs well is imperative.

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Figure 2
A Sample of Tasks Required to Begin Service Provisioning

Emotional Load
Knowing HPWs’ needs takes an emotional toll. All DSPs and FHPWs reflected on the
importance of personal rapport and taking time to talk with the HPWs regularly to establish trust.
Skyler described “this space [as] stressful and emotionally tormenting at times.” While Rene
recognized her own reliance on Jamie as she texted numerous concerns about her pregnancy.
Five participants noted the importance of hugs to support their clients, which Aubrey described
as “you feel them go (sigh) that release, like I make myself cry, but it’s like, it’s a big deal
because that could be the difference between them being okay with life and not being okay with
life.” The expectation that DSPs can adequately serve these emotional needs for all the people
they serve may indicate that management is out-of-touch with their team’s workloads.
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Summary of Findings for Research Question 1
Throughout the exploration of what challenges are faced in procuring services for HPWs,
themes emerged including: communication, coordination, collaboration, representation and
adaptation. Shelter insufficiencies due to restrictions on who shelters will serve limits HPW’s
options. Communication and coordinated efforts prove challenging for organizations through
misunderstandings about roles, lack of training, and insufficient exposure to and knowledge of
smaller organizations to match HPWs’ to more personalized services. This extends to situations
where funders create environments that are more competitive than collaborative with current
paradigms. The responsibility of funding extends to social movements that do not coordinate
their efforts when protesting to ensure they mitigate for any interruptions of key public services.
Additionally, at an intraorganizational level, the workload of DSPs is exceptional. Between
covering their own responsibilities, covering peers’ roles, and continuing personal and
organizational growth, DSPs are overburdened. Compounding this, the emotional load requiring
personalized care for each HPW they encounter is substantial.
Research Question 2: What are Effective Programs and Practices that Support HPWs?
Four themes emerged when analyzing the data exploring the effective programs that are
currently in place for HPWs: (a) large government organizations effectively provide basic needs
such as money, food, and healthcare (b) smaller organizations provide niche services not covered
by larger organizations, (c) trust between SPs and HPWs positively influences the outcomes of
HPWs and their children, and (d) MDSP roles better support and understand DSPs’ needs and
requirements. The following sections will evaluate these themes and their effects on the
provisioning process of services for HPWs.
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The Role of Large Government Organizations
Large government organizations effectively provide basic needs such as money, food,
healthcare, and shelter. While none of the interviewees mentioned the government as being a
reliable resource, of the effective organizations they recalled outside of their own employers,
large government organizations represented 26 of the total 35 resources.
The 26 government organizations identified provide basic needs for HPWs. It is
important to recognize that almost all the organizations and programs cited in Figure 3 provide
more services than captured in this data which only represents the services and programs
advertised on the most prominent website page regardless of whether they coordinated with
another agency or were part of their own. I chose this parameter because HPWs and SPs would
find specific services by evaluating the advertised services, and not necessarily be aware of
additional services not listed.
To evaluate a wide variety of services, I consolidated them into larger categories: basic,
mental health, shelter, and autonomy. Basic services constitute food, healthcare, parenting
supplies (diapers, formula, feminine products, clothing, furniture), and money. Mental health
includes therapy, substance use mitigation, and IPV support. Shelter stands alone. Because
employment and education support often require concurrent childcare, and phones, these are all
consolidated into autonomy along with legal services that support individual choice. The results
show 75% of government managed programs in this study supply basic needs for HPWs; just
more than half (54%) support mental health; 40% provide tools for autonomy while 30% offer
shelter (see Figure 2).

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Figure 3
Services Recalled by SPs Offered by Government Programs

Note: The x-axis represents the number of services of each type that the organizations provide.

In particular, substance use treatment can be effective with HPWs. Over the course of all
the interviews, 10 of the 14 interviewees recognized the efficacy of substance rehabilitation
programs for HPWs, which suggests this is an important factor of HPWs’ interventions.
Cameron acknowledged “most of [their] moms are addicted to something.” The three who did
not mention this aspect of care were all in strictly non-direct-service management roles. To
convey the impact substance use has on procuring services, I will review the process from
0 1 2 3 4 5 6 7 8 9
Healthcare for Homeless (aka HCH)
Youth Services Bureau
Unemployment
Temporary Assistance for Needy Families (aka TANF)
Spectrum Internet and Phone Service (via CA Lifeline via CPUC)
Special Supplemental Nutrition Program for Women, Infants, and…
Rapid Rehousing Program
Project Roomkey
Police Homeless Liason Officers
John George Psychiatric Hopsital
HUD
Highland Hospital
Healthy Start
Health Clinics
General Assistance (aka General Relief)
Food Stamps (aka S.N.A.P.)
Family Justice Center
Emergency Rental Assistance Program (aka ERA)
Coordinated Outreach Referral, Engagement program
Contra Costa County Hospital
Choosing Change
Casa Ujima
CalWORKS
Calli House
CA Law Facilitators
Alameda Family Services
Alameda County Health System
Autonomy Basic Needs Mental Health Shelter
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identification as a substance-using HPW, to finding services, to the services rendered, and
ultimate outcomes.
From the very beginning of the process of procuring substance treatment services for
HPWs, the police, service coordinators, medical professionals, and service providers interviewed
escalate their intervention efforts. Supporting this, Jalen emphasized HPWs “go on my radar a
little bit higher because I know the importance of prenatal care and the effects of drug and
alcohol abuse— what that could do to a fetus.” It appears from the two interviews with FHPWs,
that some HPWs seek rehabilitation services when they find out they are pregnant with Tracy
simply stating, “I know that I needed rehab.” Similarly, Rene “sought out prenatal care, you
know, independently right away.” Both FHPWs and Jamie highly recommended rehabilitation
programs while reflecting on the most impactful services for HPWs.
However, while substance use interventions are effective, availability of appropriate
programs for this population are not as robust or easy to secure. For example, the advantage of
government run programs is their affordability whereas private programs are much more
expensive which Tracy described in her experience of finding these services:
Well, this is also sad, but I was actually in a rehab before [during her first pregnancy]. So
I was there for 20 whatever days, um, and I knew from being that rehab in Oakland, that
there were several different ways to get recovery. So, there's many, like, inpatient and
outpatient programs, and outpatient, so I was looking for outpatient programs. I also
knew that from, you know, going to AA [sic, NA] meetings I had heard around of
different [programs] like, county based. So because I was looking for affordable, it’s
really affordable and had to be flexible enough for me to, you know, [to] make it there
and stuff. Yeah. And this one worked out, and it was longer. So normally they do like
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one-month, two-month outpatient programs, or one- month inpatient, two-months, three-
months outpatient. This was a full six-months of outpatient once a week. And so I
thought it was like, comprehensive enough, and, you know, kept me accountable every
week.
In this case, the HPW needed to have experience, knowledge, and initiative to join a program
that fit her situation. Additionally, because all services are voluntary, the HPW needed to also be
willing to participate. When they do choose to participate, however, Jamie noted, HPWs are far
more intrinsically motivated than typical substance users, and the government offers the fathers
substance treatment as well.
Once the HPW decides to attend treatment, that internal motivation of being pregnant
helps them commit to the program. For example, despite a heroin addiction, Tracy attended
weekly outpatient treatments to ensure her baby would be healthy. Affirming similar comments
by Aubrey and Skyler, Jamie reflected, HPWs “get medical, so a lot of things sort of fall into
place that make it actually pretty, you know, easy to work with them…. you can’t ask for a better
motivation other than, you know, housing your baby.”
Consequently, after an HPW has committed to substance use treatment, their prognosis
appears promising. Jamie and both FHPWs confirm this anecdotally. An additional benefit for
residential programs that accept HPWs includes shelter throughout treatment. As Tracy pointed
out, the most affordable of these programs are government managed.
Interactions between Large Organizations
At some capacity, the government ran, administered, funded, contracted, or coordinated
26 of the 35 large organizations serving HPWs mentioned by participants in this study (see
Figure 4). The remaining 9 organizations worked closely with the government to provide
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services, while maintaining more autonomy through more versatile and variable types of
funding.
Figure 4
Large Organizations Recalled by Participants by Primary Funding Source

Government
Alameda County Health System
Alameda Family Services
C.O.R.E. Homeless Outreach (Coordinated Outreach
Referral, Engagement program)
CA Law Facilitators
Calli House
CalWORKS
Casa Ujima
Choosing Change (County, not state)
Contra Costa County Hospital
ERA Program (Emergency Rental Assistance
Program)
Family Justice Center
Food Stamps (SNAP/TANFF food benefits)
General Assistance (aka General Relief)
Health Clinics
Healthcare for Homeless (HCH)
Healthy Start
Highland Hospital
Housing and Urban Development (HUD)
Police Homeless Liason Officers
Project Roomkey
Rapid Rehousing Program
Spectrum Internet and Phone Service (via CA
Lifeline via CPUC)
TANF (Temporary Assistance for Needy Families)
Unemployment
WIC (Special Supplemental Nutrition Program for
Women, Infants, and Children)
Youth Services Bureau (county cc)
Non-government
211.org
Alameda County Community Food Bank
Alameda Food Bank
Building Futures
Love a Child Missions
PACT
St. Vincent de Paul
Uplift Family Services
Village of Love
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Note: These are the organizations that participants recalled, separated into government-
funded versus otherwise-funded groups.
This commonality exposes the efficiencies and inefficiencies of government run programs.
Regardless of benefit type, apart from procuring housing, the fluidity of moving through the
system once an SP registered the HPW seemed so efficient, participants barely acknowledged it
compared to other topics. For example, Jalen was comfortable reaching out to 211.org,
government shelters, food banks, county hospitals, and other officers on their team to help
respond to HPWs’ needs. Likewise, Kennedy, Jessie, Jamie, and Alex were quick to reference
large programs such as the General Fund, Food Stamps, WIC, and others. Ryan notes “our main
building sites and other resources are really easy to partner [HPWs] up with.” Similarly, Jamie
perceives the same ease in procuring medical care saying, “I find it pretty easy to get someone in
if they want to get in.” From these examples, it appears the interagency and intra-agency
coordination is well integrated for basic needs. Another effective aspect of service provisioning
is private organizations.
The Role of Private Organizations
Private organizations provide essential niche services not covered by government and
large organizations. These private programs fill roles that government operations often overlook,
and they frequently offer longer-term support, often spanning many years after initial
intervention. Cameron and Casey frequently referenced individuals they had worked with for as
long as 18 years. Similarly, when each Tracy and Rene were unable to find government help
with adoption, they both turned to small private organizations for help. More than five years
have passed, and they continue to keep in touch with those organizations. Whether faith-based,
mission-based, or practicality-based, the non-government, nonprofit organizations not only
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provide additional resources for the overcrowded government programs, but they also offer it in
ways that cater to the unique needs and beliefs of various HPWs. The organizations with which
Skyler and Cameron work both offer extensive adoption services to which none of the large
organizations initially referred Tracy or Rene.
Between the 2 FHPWs, the 4 interviewees representing private organizations, and the 9
nonprofit institutions recalled by participants, the distinctive features of nonprofit organizations
filled gaps and/or supplemented under-resourced government programs (see Figure 5).
Specifically, there are more private programs actively advertising their capacity to provide
adoption services, education, hygiene products, safe parking, food, and feminine supplies than
government organizations despite the large difference between representation in this sample
(Figure 5).
Figure 5
Types of Services Provided by Entity Type

Note: The y-axis represents the number of organizations that offer this type of service. Each of
these services represents a category of services that were counted as a single unit for each
0
2
4
6
8
10
12
Adoption
Childcare
Coordination
Education
Families
Food
Healthcare
Hygiene
Insurance
IPV
Job Help
Legal
Mental Health
Mobile Clinic
Money
Phones/Internet
Postnatal Care
Safe Parking
Shelter
Substance Treatment
Supplies
Transportation
Government provided services Nonprofit Organization Provided Services
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organization. If an organization provided shelter as well as residential substance treatment, it
shows as one unit for substance treatment and one unit for shelter.
Not shown in this chart, is the very ubiquitous role of United Way’s 211.org which is one of the
most robust systems of coordinated care efforts in the nation. 211.org provides access to local
listings of all registered SPs in a database. Without this program, both government and nonprofit
programs would suffer decreased exposure to HPWs.
The Importance of Individual Connection in Service Provisioning
One factor that helps private organizations fill governmental agency gaps is their ability
to provide more individualized care for HPWs. Establishing rapport, especially as a single point
of contact, is the best practice for HPWs. Jalen attributed their success to “building some level of
trust and rapport.” Similarly, Riley acknowledges “Trust is so important when we’re dealing
with these issues [of trauma].” Meanwhile Jamie “just want[s] that first visit [to] establish trust”
because as Aubrey states, “you want them to trust you back.” A single point of contact with
regular interaction appears to positively influence the outcomes of HPWs and their children. Ten
of the 14 interviewees, two of which were the FHPWs themselves, recognized the significance of
a single vested SP providing many levels of support at regular, frequent intervals.
Personal Connection at Intake
There is anecdotal evidence that trusting an SP will result in earlier requests for help and
access to services. Skyler, Ryan, Cameron, Casey, Jamie, Jalen, Aubrey, and Riley all reference
the importance of personal connection to HPWs in order to help them. Jamie’s primary goal at a
medical intake meeting is for “that first visit- I want to establish trust to come back, if that makes
sense.” From another perspective, Tracy imagines:
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When the girl comes in, and she is homeless, and she finds out she’s pregnant, maybe
having, like, a counselor there on site, somebody like an advocate or a support person to
bring her in and to love on her and to show her exactly what is available for her would be
optimal.
With so much stress on an HPW, that initial contact can either encourage or deter her from
seeking essential services.
Trust between SP and HPW
After the introductions, it is also important to build on trust. For instance, Rene
reminisced about how two DSPs each continued to build trust by inviting her to communicate
with them regularly. Building on that trust further, one DSP even invited Rene to their home for
holidays, meals, and days of relaxation. Meanwhile Skyler and Riley both recognize the
importance of helping HPWs build plans to fulfill long-term goals to further build rapport. While
there are certainly more methods of building a relationship with HPWs, both the SP and the
HPW feel the impact.
Genuine Connection and Consistent Interactions
The key component of developing trust and rapport with HPWs is consistent
communication. Cameron and Casey laud their program’s consistency in “touch(ing) these
women every 30 days” while Jalen also noted the consistent visits decreased fear and increased
rapport. Similarly desiring more personal interactions, Jessie imagined a better program that
would provide “a case manager by my side with some, I think, nurses, my staff that they can do
other medical, but there’s somebody that could really have more touches with these patients.”
Those consistent interactions with HPWs create an environment of access to essential services.
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The more frequent touches also result in SPs spending substantial portions of their time calling
and emailing on HPWs’ behalf which is the most crucial step in procuring services.
DSPs Benefit from Having MDSPs
MDSPs exhibit more connection to the work of DSPs and better understand and support
their needs and requirements. For example, Skyler, Cameron, and Jamie fervently described the
need they were addressing with statistics and holistic understanding. Managing operations while
simultaneously serving as DSPs creates a very empathetic environment both for employees as
well as clients. Riley understands their role as one where “if I can make a difference, it means a
lot to me.” All MDSPs gave the impression that there was no task too small for them to roll up
their sleeves and do themselves. The MDSPs also lauded their teams as essential employees with
job related stress. There was no aspect of their team’s work that they did not know intimately, so
they shared the frustrations of their teammates and celebrated every success alongside them as
well. The dynamic between Cameron and Casey was particularly striking in their complete
choreography of movement, decisions, and even speech. One would begin answering a question
only for the other to elucidate with an affirmation of the previous response and then their own
additional commentary. For instance, one exchange shows their cohesion:
Casey: Yeah, so as far as pregnant and homeless,
Cameron, simultaneously with Casey: there is no help.
Casey: There is no assistance.
Cameron: They live on my couch.
The sense of a flat structured organization dominated the interview experience, and their
comingled replies as they completed each other’s sentences accentuated this dynamic. MDSPs
appeared to have a far better grasp of the daily work of their teams than MSPs. This connection
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to the work further encouraged strong team mentality and coordinated efforts. MDSPs relate to
and sympathize with DSPs more effectively than MSPs. Decreasing the burden of DSPs may
improve service provisioning outcomes.
Summary of Research Question 2 Findings
Both government and private organizations provide essential support to HPWs. While
government entities are successful at coordinating and supplying basic needs for HPWs, they are
unable to provide niche and personalized services like private organizations offer. One of the
most important factors in successful outcomes for HPWs is a personalized connection to a single
individual to provide support, connection, help, advice, and consistency. Similarly, one of the
most important factors in DSP support is connection with an MDSP who shares their challenges.
Research Question 3: What Resources do HPWs Require?
The third research question aimed to determine the resources that would improve overall
outcomes for HPWs. These outcomes include a healthy pregnancy, long-term stability, optimal
environments for SPs to provide services, and post-natal care that will benefit both mother and
child. In general, government sponsored programs are supportive and available within their
capacities. Indeed, HPWs generally perceived all currently available services as having positive
impacts when available. The overarching theme of which resources would improve outcomes
directly or indirectly involve the challenges posed around accessing available resources. The
most prominent concerns included: (a) shelter availability, (b) a need for parenting classes and/or
mentors, (c) fully funded cell phones with internet access, and (d) sufficient adoption materials
during intake meetings. For each of these concerns, the following themes emerged as represented
in Table 3.

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Table 3
Research Question 3 Findings
Concerns Themes
Safe Shelter Spaces
Participants recognized the lack of available shelter spaces
for HPW in general.

Safety from others is important for HPW seeking shelter.

Shelter spaces that offer consistent space throughout
pregnancy would be ideal.
Parenting Classes or Mentorships
Having additional parenting classes or mentors would
help HPW navigate their experience.

Adding this role to the HPW services would help with
coordinating important resources.

Mentors would help decrease SP loads.

Mentors would provide consistent rapport throughout the
process.
Cell Phone and Internet Access
Access to services rely heavily on cell phone and internet
access.

Cell phone and internet service will help maintain
essential social support roles that family and friends fulfill
for HPW.

Access will decrease reliance on SPs.
Adoption as Option
Large SPs do not present adoption as an option to HPW’s
sufficiently.

Materials marketed to HPS are not readily available at
intake.

Adoption can decrease reliance on government programs.

Adoption is promising option for HPW who hold pro-life
or similar values.

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Shelter Requirements
It is no surprise that shelter is a primary concern for HPWs, however there are unique
subtleties underlying the HPW’s experience that further complicate their experiences with the
current shelter system. The three most prominent concerns amongst SPs and HPWs included: (a)
the lack of shelters set up to serve the unique needs of HPWs, (b) the types of safety required for
sheltering HPWs, and (c) the importance of long-term shelter to last the duration of the
pregnancy.
The Need for Shelters with Resources to Support Pregnancies
The shelter spaces available are insufficient for the need. Between the limitations
imposed by shelters that exclude HPWs and a lack of shelter resources in general, HPWs face
considerable challenges in finding shelter despite their heightened safety needs. For example, it
is challenging to find a shelter that accepts pregnant women’s unique characteristics which can
range from a full family, a child already born, substance use while pregnant, and IPV issues.
Casey stated, “We have 371 beds and 6000 homeless women with their kids,” that being the
case, if women with children are that underserved with shelter resources, pregnant women are
even more so. Shelters have strict guidelines for whom they will serve. Riley noted that their
organization will accept HPWs up to month 7 though do not have the system to support HPWs in
their last trimester. Fortunately, Riley’s particular program, which is government-based, ensures
continued housing of HPWs when discharged from their shelter by coordinating with other
shelters in the area.
Safety from Others is Important for HPW Seeking Shelter
In the context of a HPW’s shelter, safety from others can take numerous forms. As Rene
acknowledged, the primary reason she initially went to the homeless shelter was “to get away
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from [the father].” Similarly, Tracy relayed concern surrounding the child’s father and the
importance of removing the father from her life for the sake of her own sobriety and the child.
However, SPs must address safety issues beyond shelter.
Because of the connection many mothers have with their unborn child’s fathers, and the
high likelihood of IPV or substance misuse playing a role in that relationship, safety from the
HPW’s own tendencies to go back to that scenario are just as important as safety within the
shelter. After relying on the father’s connections to secure housing and having everything stolen
followed by a period of intimidating captivity by the thieves, Tracy explained with a sincere look
in her eyes, “I think that one thing I do know is that I think we need more resources for women
with domestic violence.” Being inaccessible to this man who encouraged substance misuse and
surrounded himself with others willing to take advantage of an HPW, provided a sense of relief
and safety to this participant. Rene echoed this sentiment regarding her own child’s abusive
father acknowledging she “kind of didn’t want him to know where [she] was living. So, you
know, going to the shelter, which was anonymous as well, was kind of, that was appealing to
[her].” While safe shelter is important, consistent shelter develops a sense of belonging and
facilitates logistical ease of accessing other important services for HPWs.
Consistent Housing Need
Being able to settle into a single housing facility reduces stress and develops social
connections. Perhaps the interviewee who best captured the importance of consistent housing for
HPWs is Jessie who “encourage[s] women to go to inpatient rehabilitation in pregnancy, because
that’s the housing resource.” Inpatient rehabilitation offers sobriety, psychological support, a
community, medical care access, and stable housing. Concerns Jamie posed for HPWs included,
“What if they relapse? What if they’re at risk for overdose? What if they have unstable
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housing?” Thus, the importance of medical access for HPWs who have stable housing arises.
Supporting this is Jalen who remembered a case where a 40-year-old woman with substance use
issues recurringly created interpersonal issues at her housing sites to the point where a shelter
banned her from the premises with a restraining order. Instead of checking into rehabilitation,
she returned to her car and was pregnant within a year. With stable housing, HPWs can maintain
contact with SPs, and equally importantly, SPs can keep in touch and encourage positive
behaviors more easily by knowing where to find their clients. The stability housing provides can
lead to a sense of supportive community essential for mental health.
Stable housing improves the experience for HPWs. Rene shared her reality of when she
“found [she] was pregnant. [She] lost [her] job, and therefore [her] housing,” both events of
which decrease the probability of sustaining a healthy child and mother. She also appeared
empathetic to a substance misusing mother at one of the shelters who, despite having multiple
children taken from her, still returned to the shelter with the intention to raise her baby there. In
that case, the shelter fulfilled the role of “home” completely for the other mother and her child.
Another aspect that made the shelter feel like home was when Rene described receiving her first
piece of mail at the shelter, and it felt “empowering” to have an address to receive mail at which
symbolized a place of belonging. In contrast, Rene found the requirement some of the shelters
she stayed in had for staying out during the day as less stable because “you’re kind of out
wandering anyways.” In contrast, the shelter that provided tiny houses and all-day access
provided a sense of “community” that she “remembered those some of those little [interactions]
being so important.” Therefore, consistent housing not only benefits health and regular services,
but also can provide a sense of empowerment and community for HPWs.
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Parenting Classes and/or Mentors
Both FHPWs and four of the SPs discussed a need for parenting classes or women
mentors who could provide emotional support as well as parenting wisdom. To support this,
Ryan reflected that “they need to have mentors in their life that can help teach them” while
Aubrey suggested parenting courses or workshops. Meanwhile, Cameron recognizes much of her
role in HPWs lives is to “teach[] them how to keep [their children] with responsible parenting.”
From another perspective, Rene believes, “just having someone that’s, you know, simple and just
kind of making it easy for [HPWs]. That. I would have benefited from someone like that.”
Likewise, Alex explained that CFS must provide education to fulfill their mandate to protect
children while also making efforts to maintain family units when appropriate. Each of these
participants agreed that adding a mentor to HPWs’ pregnancy and parenting experiences would
provide consistent support otherwise not available. Importantly, HPWs must have ways to access
those mentors and classes which cell phones and internet service would provide.
Cell Phones with Internet Access
While CA Lifeline offers a discount off cell phones and service, it is insufficient for
HPWs’ needs. Consequently, HPWs need more and better access to cell phones and internet. Ten
of the interviewees mentioned the importance of cell phones and internet access for HPWs. As
Tracy explained:
It's not easy to get help or get into places because they're so full right now…. You'd have
to call every day to show you wanted it kind of thing. You know, when you're on the
streets and you're homeless, and you don't have like a phone. It's so hard to get in.
Because, you know, how are you going to call every day when it's so hard to even survive
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or find, you know, people won't, like, let you use their phone and stuff. So it was really
tough.
Thus, the reason cell phones are essential is because they provide a way to create and manage
critical appointments, access services, contact case workers, evaluate options, and communicate
with others who can provide support.
Organizations rely heavily on HPWs’ phone and internet access. For instance, 211.org
requires access by phone or internet, and only provides phone numbers for their referrals. To
elucidate, Rene noticed that when she inquired about obtaining services, she was “just referred to
a calling list” which required a phone. Supporting this, Jalen mentioned that most of the
homeless they liaison with are “encouraged…to call [them], text [them] or email [them]” for any
help they may need. Similarly, Ryan acknowledged the role of calling other SPs together to
procure appropriate support. However, the only way to access a drug and alcohol program, or a
social work referral, according to Jessie, is by calling a phone number. Summing up the need,
Jamie clearly stated that “one thing [they] would change is, [they] would just give them phones.”
Unfortunately, as Ryan recognizes, society in general assumes people have access to phones, and
does not recognize the importance of the tool for accessing services while homeless. When those
phones are only subsidized instead of fully funded, Ryan noted that a problem SPs face is the
likelihood that the contact phone number will frequently change without notice because of
failure to pay bills (both the cell phone service bill as well as electrical to charge the phone) on-
time, effectively rendering follow-up impossible unless the individual initiates it. HPWs require
both, a consistent cell phone number and internet access for optimal service utilization.
Another key benefit of cell phones is access to the internet. Internet coverage can make
the process of filling out paperwork, researching options, and contacting SPs much easier for
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HPWs. For instance, Rene noted that going online to file for unemployment was significantly
easier than her previous experiences filing through the paper system. Additionally, Rene
recognizes that “any type of advancements [in technology] are good, like, technology wise,
making things much more simple whether that’s like, take a picture of your ID or something like
that, or whatever.” Considering this in the context of Jalen “encourage[ing] [the homeless people
they encountered] to call me, or text me, or to email me,” the assumption of access and
requirement for homeless people to obtain full cell phone services becomes clear. One issue the
FHPWs encountered was the need to use the internet to research adoption options, because DSPs
did not proffer or have materials explaining adoption during their intake interviews with HPWs.
Adoption Option
Brochures and access to adoption options are not readily available or sufficient for
HPWs. Though SPs verbally acknowledge adoption as a viable option, none of them had
brochures on hand to give HPWs when inquiring about it. Instead, they referred the individuals
to 211.org or recommended searching the internet (which would require internet access).
Explaining further, Rene noted when she went in for her initial intake interview with county
health,
I kind of said I was considering adoption, and what are some kind of resources for that?
And she didn’t have any, and I was like, ‘Wait, what? What? I mean, it’s an option right
there.’ So, I mean, [they] did kind of have like a resource for [adoptive] parents, you
know from the other end, but nothing really for birth moms or women…considering
[putting their child up for adoption]…. So [they’re], like, I have abortion stuff…. So
[they] told me [they] would do some research and then get back to me.
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While ultimately county health was able to connect Rene to an adoption facilitator, it added
burden to the intake process as well as at least a week of processing time during which a mother
could plausibly lose the option to choose an abortion. As challenges to abortion access in the
judicial system of the United States rises, this concern increases even further.
Summary of Research Question 3’s Findings
In evaluating requirements to improve outcomes for HPWs, four factors emerged as
significant: (a) safe, consistent shelter with pregnancy support, (b) mentors and parenting classes,
(c) cell phones with unlimited minutes and internet connection, and (d) adoption options. Cell
phones with unlimited internet, mentors, and parenting classes would all decrease workloads for
DSPs. Cell phones would allow autonomy and direct access to services and support networks for
HPWs, while mentors and parenting classes would offer HPWs community support, help, advice,
and people to access other than DSPs. Complete technology access would also ease DSP’s
workloads by not requiring they find new phone numbers for clients whose provider
disconnected services due to bill payment challenges. Additionally, full access phones would
allow HPWs to call shelters that require multiple calls per day without worrying about a lack of
minutes available. This would improve HPWs access to shelters. However, more shelters should
offer pregnancy support and longer term stays for HPWs to ensure stability necessary for healthy
pregnancy outcomes. While pregnant and navigating these systems, HPWs may also benefit from
more access to adoption options for the child they are carrying. These factors impacting
outcomes are interrelated with complete cell phone access having a fundamental and large
impact.
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Summary of Results
Access and coordination for both SPs and HPWs are the key thematic takeaways from
this research. When access is inhibited, the burden rises for both SPs and HPWs. As a result,
HPWs must reach out to multiple places through what means they can find, and repeatedly
contact places and explain their situation, potentially retraumatizing themselves by experiencing
another night on the streets when shelter availability is low. This means oftentimes multiple SPs
must answer extra phone calls multiple times a day while tracking and prioritizing unique
situations as vacancies arise. Finally, since access is only as good as capacity, and the capacity
for shelter and mental health support are insufficient, access is not well distributed.
One keyway in which to improve access and capacity is to increase coordinated efforts
between organizations and with HPWs. By improving interoffice communications and equitably
distributing funding, organizations will be better able to respond immediately with relevant,
oftentimes more suitable, alternatives which will better serve their clients. This will require
creating a funding strategy that recognizes the added value of smaller organizations’ work to
larger organizations’, and requiring coordinated efforts as well as funding redistribution is likely
to create an ecological system that better serves HPWs.
These inter-organizational coordinated efforts may yield faster, more catered access to
HPWs. To aid this process, providing unlimited cell phone and internet access, mentors and
classes for HPWs will support autonomy while decreasing SPs’ workloads. Part of inter-
organizational coordination are best practices, laws, and regulations that influence how SPs
interface with HPWs. Addressing the oversights in these realms is necessary for optimal results.
To optimally serve HPWs, the ecological mesosystem of regulations, best practice
guidelines, laws, and funding parameters must effectively support more coordinated efforts by
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the exosystem of SP organizations while they also encourage autonomy in the microsystem of an
HPW. To successfully do this, the mesosystem must regard an HPW’s autonomy, small
organizations’ unique contributions, and DSPs workloads when creating policies, procedures,
qualifiers, assessments, evaluations, oversight objectives, and outcomes goals.
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Chapter Five: Discussion and Recommendations
This research aimed to develop a more integrated understanding of the multiple levels of
experience of procuring services for HPWs. The research questions it explored were:
1. What are the challenges to care provision for HPWs?
2. What are effective programs and practices to support HPWs?
3. What resources do HPWs require?
Through targeted snowball sampling 14 interviewees participated in the research. Twelve of the
interviewees represented various levels of service provisioning while two were women who
formerly experienced pregnancy while homeless. Different interview protocols were used for
each of those subsets, and facts were triangulated with information obtainable through websites.
A lack of resources, collaboration, and connection emerged as the three relevant themes for
procuring services for HPWs. Government programs were reported as efficient and effective
while private organizations appeared to supply niche and overflow services that government
programs were unable to provide. This holistic perspective of the provisioning process created an
optimal environment for evaluating processes and services for recommendations for practice and
future research. This chapter will begin with discussion of the research followed by those
findings’ implications for practice. It will then address its limitations and delimitations, and close
with recommendations for future research.
Discussion
In tandem with general insufficiencies of resources for HPWs, communication and
collaboration are the two key takeaways from this research project. Because it occurred during
COVID-19, SPs provided additional insights to this unique environment. The following
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discussion will begin with lack of resources, then discuss findings surrounding collaboration of
resources. From there, it will explore the role of connection in service provisioning.
Lack of Resources
Resources are lacking for HPWs. The most obvious need is shelter, but mental health
support and cell phones with internet access are essential as well. Additionally, more support for
DSPs who could better educate around adoption options would improve service provisioning for
HPWs.
Currently, shelters have policies and procedures that are not conducive for HPWs’ needs.
They either restrict against HPWs altogether (Dworsky, 2010), shorten lengths of stays (Feinberg
et al., 2014), or are insufficient in the areas where HPWs live (Mast, 2014; Alameda County,
2020). By having shelter spaces accommodate “pregnancy education, access/transportation, baby
care, advocacy, and material necessities” (Ake et al., 2018, abstract ) along with mental
healthcare, HPWs’ needs will be better met. Without consistent housing, access to the HPWs is
difficult for DSPs. One way to improve access is through a robust cell phone plan that include
unlimited internet.
Though California Lifeline offers significant discounts for cell phone use through various
providers, it is insufficient for HPWs’ needs because of the structure of phone cost and service
access. In fact, Calvo et al. (2019) evaluated 50 articles to confirm that technology access “offers
promising opportunities to explore new ways of intervention in prevention, harm reduction, and
health treatment of IEH (individuals experiencing homelessness)” (p. 2). Cell phones support the
autonomy of HPWs as well as decrease the workload of DSPs.
DSPs face heavy workloads and numerous stressors. While DSPs are creating systems for
referrals and processes, DSPs are also required to cover others on their team in similar or
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disparate roles, and travel off-site for numerous duties. Concurring with Wirth et al., (2019),
“common job demands identified were working in a bureaucratic system, high caseloads, the
exposure to client’s suffering and little experience of success in their work” (p. e266). This
indicates that the challenges Degarmo et al. discovered in 1993, that “the lack of clear
responsibility within the context of delivering services contributed to the likelihood of burnout”
(p. 53) are still occurring today. Between DSPs’ cohesive coverage of others on their team and
large caseloads, the complicated processes in conjunction with the necessary individualization
required for optimal rapport lead to both, job satisfaction and stress. Part of this stress is due to
bureaucratic and excessive paperwork (Sutton-Brock, 2013) while another portion is due to the
emotional load which leads to exhaustion (Guhan & Liebling-Kalifani, 2011). Because this
research happened during a pandemic, it is important to recognize DSPs “go beyond service
provision agreements to meet the needs of clients so that safety and wellbeing is maintained”
(Osborn et al., 2019, p. 63) when supplying services during a public emergency. In addition to
the already extensive workloads, lack of initial training, (Salem et al., 2018) and emotional strain
from racial inequity in the workplace add stress to DSPs’ lives (Lenzi et al., 2021). Interestingly,
I found no research regarding race demographics in management versus DSP representation in
this sector. Furthermore, stress expands beyond the workplace, and can be derived from sources
in the exosystem such as politically trending agendas like the current Defund the Police
movement which impacts choices and the performance of DSPs. Saunders et al. (2019) support
this finding with their research that concluded, “the current state of the socio-political climate is
generating an increase in fear and stress in police officers” (p.47). When any one of the SP’s
performance diminishes, the impact can be felt across the system and may decrease the efficacy
of service provisioning for HPWs.
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Adoption would relieve some of the stress of DSPs. Firstly, adoption provides a source of
housing and basic needs for HPWs (CDSS, Adoption Assistance Program, 2022). With
approximately 20% of adoptees coming from homeless women (Sisson, 2022, p. 46), creating an
environment conducive to HPW’s preferences could yield supported, housed, fed, and otherwise
healthy pregnancies in HPWs. Additionally, in providing housing, adoption arrangements can
shorten an HPW’s duration of homelessness which Zabkiewicz et al. (2014) found improves
mental health if the mother has been homeless for more than 2 years.
However, mental health support proves difficult to obtain for many HPWs who would
benefit. An episode of mental instability including psychotic breaks increases the stress
responses of the victim as well as witnesses such as DSPs (Petrovich et al., 2021). Additionally,
failure to detect a major psychotic break early can lengthen the duration of the episode (Joa et al.,
2008) which may compromise the mother’s ability to care for herself sufficiently while pregnant.
With the additional burden of pregnancy, any shelter that does not serve the HPWs long enough
to stabilize their mental health and housing situation is not optimizing her or her child’s chances
for success (Steinbock, 1995). Additionally, better systems designed around procuring mental
health services for HPWs would likely result in better pregnancy outcomes. Government
organizations provide strong mental health support, but do not coordinate well with non-
government organizations coordinating care for HPWs.
Collaboration
Collaboration within and between organizations is a central theme throughout the
exploration of challenges in procuring services for HPWs. Cross-sector collaboration between
government entities and nonprofit providers is thought to promote more holistic solutions,
support innovation, and better coordinate services (Page et al., 2015). Similarly, sharing more
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resources between small and large organizations would expand personalized services and
decrease burden on SPs if done effectively. This is particularly true for mental health support. In
the cases of psychological services and substance misuse programs, government organizations
provide exceptional access. Unfortunately, smaller organizations are unable to refer HPWs to
these programs and are left without a vital resource required for best outcomes. Unfortunately,
these residential programs do not accept families which adds a limitation to access. Mental
health support is not the only difficulty to permeate the realm of large organizations. Importantly,
as difficult as it is for smaller organizations to refer to government programs, there is opportunity
for larger programs to better utilize small, community-based healthcare referrals (Varda et al.,
2020). One possibility is for larger organizations to better coordinate with smaller organizations
earlier in the process: during funding.
Large and government organizations significantly impact which private organizations and
support services get funded. This often leads to bigger private organizations, with larger teams
for grant writing, negotiations, and contract management, receiving the funding and controlling
the processes of procuring services for HPWs. “Nonprofit providers and government do not
always see themselves as partners when it comes to addressing homelessness” (Mosley, 2021, p.
250). These larger organizations do not provide customized and niche services that many HPWs
would prefer such as adoption coordination and mentorships.
Some of the highest performing organizations are small and niche. These smaller
organizations offer “unique expertise but [Continuum of Care programs] have difficulty ensuring
that these providers succeed, serve consumers in their regions, and remain engaged” due to
difficulties accessing funds, the burden of sharing data, and integration challenges (Mosley,
2021, p. 257). However, contracting out or referring to these smaller organizations could
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decrease the burden on the support system overall. Because most homeless services are meeting
or exceeding capacity, this narrowed referral process results in high-demand services such as
psychological or rehabilitation having very few referral sources yielding all their clients. In turn,
that practice makes it difficult for organizations outside the close referral relationship to provide
access to these services. As Greenberg and Rosenheck (2022) explain “system integration can be
defined broadly as the provision of services with high levels of coordination, communication,
trust, and respect among service agencies so that they are better able to work together to achieve
common objectives” (p. 185). They then extrapolate from their data that collaborative efforts do
not appear to be easily sustainable which suggests more than just collaboration is required if the
goal is to improve the system permanently.
Connection
Connection with HPWs appear to have long term effects and be a sustainable practice.
Personal connections between SPs and both, other SPs and HPWs, are important for optimizing
results in the micro and meso systems of this ecological model. The key to successful
intervention for both SPs and HPWs, is the personal relationships developed in the microsystem
of the HPWs with SPs, which involve trust, support, and multiple interactions to develop.
Connection between SPs and HPWs is essential for trust which improves the service
provisioning process. Gomez et al. (2016) highlight the importance of relational care that focuses
on treatment for individuals who have experienced trauma which Goodman et al. (1991)
recognize includes the experience of homelessness independently. When people interact with
others who are in crisis, SPs’ “empathy soothes [HPWs] and makes [them] feel safe” (Fishbane,
2007, p. 403). All the participants except two supervisor SPs emphasized the importance of
creating and sustaining connection with HPWs.
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Just as important for service provisioning is rapport between organizations through SPs’
connections. While Greenberg and Rosenheck (2010) discovered additional funding did not
improve collaborations between organizations, the anecdotal evidence from this research
suggests new funding through organizational relationships has potential to do so. More
organizations participating in CoC programs will result in more people available to develop
personal relationships with HPWs. By more cohesively integrating more organizations into the
process, more HPWs will benefit from services with options to choose programs that support
individuality, autonomy, and unique circumstances.
Recommendations for Practice
The following section will explore six recommendations for practice, why they may be
effective, and how to implement them. To better support HPWs, findings from this research
suggest the following to improve service provisioning: (a) increase access by increasing cell
phone with internet coverage; (b) increase communications between public safety organizations
such as the police and CFS with HPWs and SPs; (c) recognize and utilize smaller service
organizations; (d) consider rehabilitation and adoption programs as alternative housing options;
(e) confer with HPWs in making policies and procedures, and (f) provide better support to DSPs.
They will be presented from the most distal to most proximal recommendations.
Recommendation 1: Increase Access by Increasing Cell Phone with Internet Coverage
Federal and State governments should expand the Lifeline Program for Low Income
Consumers to expand hotspot requirements for internet accessibility so HPWs can make all the
necessary calls and online applications to procure services. Governments should also consider
HPWs’ and single mothers’ unique expenses like health and childcare that may exceed the 135%
Federal poverty income qualification currently in place. Additionally, governments should
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provide some level of free cell phone connectivity to guarantee uninterrupted service. Supporting
this is Reitzes et al., (2017) conclusion that “providing the homeless with better access to cell
phones, the internet, and email may enable social service agencies to maintain closer ties to the
homeless and to improve outreach services” (p. 157). These connections with SPs result in
personal relationships that improve advocacy on an HPW’s behalf (Mayberry, 2016).
Additionally, cell phones offer connection to social supports that impact outcomes positively
(Glasser & Bridgeman, 1999).
Recommendation 2: Increase Communications and Early Interventions by Public Safety
Providers Such as the Police and CFS with HPWs
Public safety providers would benefit from improving their external communication,
especially directly with HPWs. While California funds a homeless liaison position for every
police department, not every police department chooses to have one. Every police department
should have an active homeless liaison. By having a familiar face to interact with, HPWs are
more likely to ask for help in finding services. In contrast, CFS has the opportunity to develop a
liaison position with the new Family First Prevention Services Act who could help educate
mandated reporters on what is actionable while also intervening before a child is born to help
HPWs adjust their situations so they are more amenable to parenting and keeping their child after
it is born. Familiarity through communication and coordination develops better service
provisioning across all realms. Myers and Carpenter (2019) capture the precarious nature of
HPWs in their encounters with public safety providers who can remove custody of their children
in their concluding remarks by emphasizing how each decision made by law enforcement can
change an HPW’s trajectory for the long term. By interacting sooner, public safety providers can
more effectively encourage and coordinate services that may result in better outcomes for the
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HPW and her child. Both CFS’s and homeless liaisons’ intentions can be misinterpreted as
punitive rather than helpful, however, with more communication and interactions, both can allay
those fears.
CFS and homeless liaisons refer clients to a wide variety of SPs, but most HPWs and
some SPs understand their roles as legal enforcers rather than safety advocates. Part of this
confusion is due to lack of communication by CFS and police liaisons with organizations, and
another part of it is attributable to insufficient initial training of DSPs. SPs and HPWs do not
understand the role of CFS which can be detrimental. SPs and HPWs tend to believe more
situations are actionable by CFS and police than actually are. In evaluating misunderstandings
surrounding Child Welfare Programs, Barth et al. (2022) acknowledge: “Misunderstandings can
arise when what is being written in commentaries and social media does not reflect actual
practice” (p. 492). Additional reports by SPs add workload to CFS and police teams in making
determinations about the reports filed. Meanwhile, the fear of being reported may cause HPWs to
avoid medical care in fear of CFS when in fact, CFS is not mandated to intervene before a child
is born. These misunderstandings are due to a lack of proper training of SPs and a lack of
communication by public safety providers. CFS and police departments should fully utilize
liaison roles to educate and develop rapport with other SPs and HPWs.
Recommendation 3: Recognize and Utilize Smaller Service Organizations
Individualized, consistent care is important in larger, more expansive government programs
as well as private organizations which target specialized needs and help compensate for overflow
(Brookfield & Fitzgerald, 2018). Within this study’s conceptual framework, government entities
in the exosystem offer adequate care for an HPW’s basic needs, and their capacity to serve this
population is limited to government funding and policies which pose “challenges for
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organizations whose missions do not neatly align with collaborative goals” (Mosley, 2021, p.
247) of CoC groups. Thus, many nonprofit organizations are funded by government
organizations to provide additional capacity, which creates a mesosystem still bound to
government ideals that set the parameters of services to be provided (Mosley, 2021, p. 248).
Increased inter-agency collaboration will benefit organizations, DSPs, and HPWs. 211.org
should set up a system where shelters could report vacancies in real-time. Additionally,
organizations funding services for HPWs could adapt their strategy to include set-asides in
specific amounts per person served toward an individual to eliminate the incentive to underpay
smaller organizations for niche support. Part of adapting includes coordinating and collaborating
with other organizations to ensure a variety of ideas are considered in the process. Organizations
would likely improve service provisioning for HPWs by applying Martin et al.’s (2016) 4 C’s
approach toward organizing Haitian relief organizations, which is developing systems and
cultures around collaboration, communication, cooperation, and coordination. These tactics will
help communication within, as well as between, agencies. Another way to improve these aspects
of service provisioning is by having MSPs create two positions: an intermediary DSP position
that serves as a floater to support other DSPs and a mentorship program for HPWs. These will
decrease the burden of labor of DSPs and improve services to HPWs.
Recommendation 4: Consider Rehabilitation and Adoption Programs as Alternative
Housing Options
Long-term rehabilitation programs should use Canada’s PRISM (Projet Réaffiliation
Itinérance Santé Mentale [Homelessness Mental Health Reaffiliation Project]) project as a model
for serving HPWs who may develop significant long-term autonomy from such programs that
focus on long-term services and housing after 2-3 month rehabilitation residency (Laliberté et al.,
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2022). Though PRISM is focused on severe mental illnesses, its premise and practices are
generalizable to HPWs. These facilities should include in their designs the means to support a
pregnant woman with basic needs, like food, shelter, and safety, as well as therapy, a
community, and medical support. Because of a pregnancy’s outcome is inherently inversely
correlated with substance misuse, rehabilitation centers should prioritize HPWs for treatment
which may provide almost all available services sooner than other avenues of procuring support.
Additionally, SPs should evaluate and consider inclusive systems like substance treatment
inhouse facilities when designing their own programs. Similarly, adoption provides housing and
basic needs to HPWs who are interested. DSPs should have adoption materials targeted toward
mothers available at intake sessions to increase HPWs’ autonomy and options. While both of
these supportive structures serve specific profiles, their contributions are important.
Recommendation 5: Confer with FHPWS in Making Policies and Procedures
Researchers and SPs should involve FHPWs when designing studies, programs, facilities,
plans, and policies. As evidenced by the insights presented by Tracy and Rene, FHPWs can add
substantial understanding and depth to SPs’ policies and procedures. One useful tool for
understanding HPWs’ needs and perceived potential is through self-determination theory based
focus groups. Importantly, van der Laan et al. (2017) highlight:
It is important for service providers to realize that individual program[] plans for
homeless people are not only a means of attaining stable housing, income, work and
contact with service providers. They should also provide an opportunity to explore the
personal values and goals of the client, as this in itself can promote an increased
satisfaction with life (Shern et al. 2000) (p. 209)
This involvement will improve motivation and outcomes for HPWs.
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Recommendation 6: Provide Additional Support to DSPs
MSPs should provide additional support to the DSPs with whom they work. Grimm et al.,
(2017) found training in recognizing and intervening with mental health problems are perceived
as more valuable to DSPs than psychosocial support. This training would help DSPs make more
effective referrals as well as cope with situations when they encounter them. Additional training
in available resources and coordination with other SPs would also benefit DSPs. Similarly to the
findings of Guhan and Liebling-Kalifani (2011) in housing services for UK refugees, there is a
need for “training on benefits, housing, managing violence and aggression…[along with] the
need for regular updates on new policies and procedures relating to their work” (p. 222).
One effective mitigation is having MDSPs on site who work alongside DSPs, know the
challenges, and interact regularly with the teams. While MDSPs appreciate the substantial
expectations and directly support their SPs, MSPs are less knowledgeable of their teams’
stressors. Quinn et al., (2017) noted the disparities of concerns as MSPs blamed challenges on
funding and DSPs perceived a lack of utilization of available services as the primary problem in
homeless services. Burt et al., (2010) highlighted the importance of organizations that
“significantly increased the degree of coordination and collaboration among homeless assistance
providers, among mainstream agencies, and between the two groups” (p. iv). For effective
coordination and collaboration to happen, MSPs must know the needs of their DSPs and the
organization as a whole which MDSPs exhibited in this research.
Limitations and Delimitations
Focusing on FHPWs and current SPs had limitations. The multiple layers of ecological
impacts on both SPs and HPWs create an exponentially complex system of interactions that are
beyond a single study’s reach. Limitations include time, lack of funding, self-reporting factors,
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reliance on memories, and lack of physical access to participants. Specifically, both FHPWs
decided to have their children adopted, which is not representative of the majority of their
population. Additionally, while the research may shed light on a few specific experiences, the
number of factors influencing outcomes will not be generalizable because it is a small,
qualitative study. Access to this population required FHPWs actively deciding to contribute to
the research for minimal personal gain which may have skewed results toward a certain
personality type. By deeply understanding individuals within this context, dynamics that
influence both experiences surface, but only as they relate to these very specific sets of
characteristics. This data is only as reliable as the sources who may or may not be reliable due to
memory integrity or ulterior motives such as trying to impress or hiding embarrassment. The
research was dependent upon participants' willingness to share very personal experiences, so
rapport was essential. Additionally, as with any qualitative research, every probing question and
interpretation relies on objectivity of the researcher. Empathizing too much with the SP or the
FHPW could create a scenario where a person describing something or somebody as difficult
elicits understanding instead of clarity, and a lost opportunity to find the root cause. What is easy
or challenging with one person at one organization may not generalize to another person at that
organization, with the same person at another organization, or with others at other organizations.
However, this study may add to the conversation in the realm of public policies and grant
limitations that impact these processes. One example is how COVID-19 affected some public
policies during this research which may have changed the dynamics and retrospective thoughts
of participants. This clearer understanding of what is included in the study also influences what
is not part of the research.
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Delimitations of the study include the retrospective nature of the interviews which only
provide insight to previous times influenced by different policies, procedures, funding, options,
and laws. Because the research took place in the East Bay region of the San Francisco Bay Area,
findings may not be generalizable to other regions. Additionally, the chosen population did not
include women who were still homeless after having a child which may eliminate an important
group for whom service provisioning processes have failed. Negative outcomes for interviewing
anybody who is pregnant while homeless include potential intervention by Child Protective
Services or even possible imprisonment which is the reason for the FHPW requirement. While
currently HPWs actively seeking services could provide more accurate, timely, and verifiable
recounts of their experiences, the access to and any potential anticipated negative outcomes of
including currently HPWs in the research did not outweigh the benefits of interviewing FHPWs.
Recommendations for Future Research
Five topics for future research will add to our understanding of HPWs’ and SPs’
experiences procuring services and will be explored from most proximal to HPWs to most distal.
Research surrounding the long-term outcomes of HPWs who have mentors in comparison to
those who do not may provide insight to the value mentors add to the service provisioning
process. Having an additional person to support DSPs may impact the number of dead-end phone
calls made by DSPs and HPWs when trying to procure services, which is another area for
scientific review. Mentors also add a layer of social network to HPWs experience, however,
more research to understand the impact of social networks developed by HPWs in rehabilitation,
shelters, and educational programs may inform future programming decisions. Whether those
programs are run by small or large organizations, research regarding the impact of large
grantees’ control over funding, and how it impacts sub-contracting partners’ growth as well as
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how small organizations that are not included in the contract fare over the long term would add
valuable insight to the literature surrounding funding policies. Lastly, a retrospective review of
how the Defund the Police movement impacted social services may help SPs negotiate with
organizations that may respond to social or political agendas in ways that may harm HPWs in the
future.
Conclusion
The experience of procuring services for HPWs is complicated and layered. Policies in
the exosystem drive who gets funded and what services are prioritized. Funding in the
mesosystem determines which organizations thrive and which are overburdened. This leads to
DSPs who must fulfill multiple roles for large caseloads under policies that may not align with
their clients’ needs. That dynamic diminishes their ability to develop the close interpersonal
connections they need to effectively procure services for HPWs. Ultimately, HPWs are a
symptom of failure to collaborate, communicate, and coordinate between the theoretical
framework’s systems, organizations, and intra-organizationally. Improving those three facets of
any or all levels of the system will substantially improve the experience of procuring services for
HPWs.

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156

APPENDIX A: Interview Protocol
Formerly Homeless Pregnant Women
(Before starting the recording, the interviewer will confirm the name of the participant
and then tell them they are beginning recording.)
Thank you so much for spending your time with me today. For the record, after
confirming your name, I started recording this conversation. I am going to begin with some basic
questions, and then we will move into your specific experiences while you were pregnant. You
will remain anonymous so your personal information is protected. If you do not want to answer
any question or feel uncomfortable at any point, you can say you would rather not answer or ask
me to turn off the recorder. Do you have any questions before we start?
First I need to get some basic information about you.
1. How old are you?
2. What race do you consider yourself?
3. How many children do you have?
4. How old are they?
5. How old were you the first time you had a child?
Okay, before we begin, I want to make sure we are using the word “homeless” in the same
way. When I ask you about “homelessness” I mean any time when you stayed in a shelter,
temporary housing, a friend’s house, the streets, a motel, or other place that you could not
declare your home address.
A. Can you tell me one or two scenarios from your own life that fit this definition of
homelessness while you were pregnant?
B. Are you currently homeless?
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That is the time period we are researching. The goal of this interview is to understand your
personal experience in trying to get support for your pregnancy. Let’s get started.
A. Will you please tell me about a (the first) time you were pregnant and homeless? What
was that like? RQ 3
1. Were you pregnant before you became homeless or did you become pregnant
while you were homeless? RQ 3
a. Were you under 18 when you were pregnant? RQ 3
b. What was your reaction when you found out you were pregnant? RQ 1
c. How did you feel about being pregnant at that time? RQ 3
2. Thinking back to when you first found out you needed pregnancy services
while homeless, who did you turn to for your questions? RQ 2
a. What questions did you have? RQ 3
b. What services did you know you needed? RQ 3
c. What services did you not think of? RQ 3
d. Is there any other person who is involved during this pregnancy? Is
there a friend, relative, or social worker who has been helpful to you
socially, emotionally, financially, or in any other way? Who helps
you? RQ 3
e. In what ways did they support you? RQ 2
3. Were you raising or helping raise any other children while you were pregnant?
RQ 3
a. (If so) How many? RQ 3

158

Now, I’m going to ask you about some services. You don’t need to give me any names, the
purpose is for me to understand if you are aware of who should go to for help, and not to get
anyone into trouble.
B. When you think back to that time when you were first pregnant while homeless, what
was your process in accessing services? What happened? RQ 2
1. Who did you go to find support services for your pregnancy? RQ 2
a. (if multiple) Do they work together or did you have to communicate
between the organizations? RQ 1
b. What is the title (I don’t need names) of the person who coordinates
these services? RQ 2
i. What organization do they work with? RQ 2
2. Tell me about the resources that are available to pregnant homeless moms?
RQ 2
3. What types of services did you receive? RQ 2
a. From whom? RQ 2
b. What requirements did you have to fulfill- in other words, what did
you need to do to keep services? RQ 1
c. How long were you eligible for these services? Why? RQ 1
4. How soon after you found out you were pregnant, did you request services?
RQ 1
a. After your initial request, how long did it take to receive services? RQ
1
b. What was that process like? RQ 2
159

5. Did you ever request specific service providers- nonprofits, doctors, or
otherwise? RQ 3
a. What happened? RQ 1
6. Have you ever stopped receiving any services at any point while you were
pregnant? RQ 1
a. Which ones? RQ 1
b. When did that happen? RQ 1
c. What do you think caused that change in services? RQ 1
d. If you had not received services, what alternatives would have been
available to you? RQ 2
7. What was your experience in accessing the services you were eligible for? RQ
1
a. How did you navigate getting to the appointments or resources? RQ 1
8. What services do you wish you had been able to get that you did not receive
while pregnant? RQ 3
i. Do you know anybody who lost services while underage? RQ
3
ii. Will you share their story with me so I can understand the
differences between you and them? RQ 1
C. What would you tell a homeless pregnant mother to help her along her path? RQ 2
D. What do you want me to know about the process of getting services? RQ 3
1. Is there anything more you would like to tell me? RQ 1

160

APPENDIX B: Interview Protocol
Service Providers
Thank you so much for spending your time with me today. I am going to start out with
some basic questions and then we will move into your specific experiences about helping
procure services for homeless women who are pregnant. You will remain anonymous so your
personal information is protected. If you do not want to answer any question or feel
uncomfortable at any point, you can say you would rather not answer or turn off the recorder. Do
you have any questions before we start?
1. Just for the record, will you please tell me a little about your job as it relates to homeless
pregnant women? RQ 2
a. When you first started this job, how was your experience finding services for
homeless pregnant women? RQ 1
b. How is it now compared to then? RQ 3
2. Where do you get your major sources of funding? RQ 2
3. Will you please tell me what services are available to women who are pregnant while
homeless? RQ 2
a. Which organizations provide these services? RQ 2
b. What other services you have heard of but are not including? RQ 2
4. Who sets parameters for services? RQ 1
a. What laws must you follow? RQ 1
5. Can you walk me through the process a HPWs would go through the first time they come
in to explore services. RQ 3
a. What do they typically ask for? RQ 3
161

b. What do they not typically ask for but probably should? RQ 3
c. How do you decide which services to recommend? RQ 1
d. Which services are easy to procure? RQ 2
e. Which services are more difficult to procure? RQ 3
i. And to get people to go to? RQ 1
ii. Why? RQ 3
iii. What keeps people from getting services? RQ 1
f. What helps you predict whether a person will be eligible for services? RQ 1
i. What requirements must homeless pregnant women meet to get
services? RQ 1
g. How long are they eligible for services? RQ 2
i. What happens then? RQ 1
b. Have clients ever abruptly stopped receiving any services at any point? RQ 1
i. Which services? RQ 1
ii. When? RQ 3
iii. Is there any reason you would stop offering services? RQ 1
iv. What causes a change in services? RQ 1
v. Do you know anybody who lost services while underage? RQ1
vi. Will you share their story with me so I can understand the differences
between adult experiences and them? RQ 1
6. How far along in the pregnancy is a typical client when they first contact you about the
pregnancy? RQ 3
a. After their initial request, how long did it take to receive services? RQ 2
162

b. How long would it take to be seen by a doctor? Therapist? RQ 2
c. What was that process like? RQ 1
7. Do they ever request specific service providers- nonprofits, doctors, or otherwise? RQ 3
a. What happens? RQ 3
Thank you for this clearer picture of how services are procured. Now I would like to discuss your
interactions with other agencies.
8. Can you tell me how you coordinate with other agencies? RQ 1
a. By what methods do you communicate? RQ 1
b. How are your conversations and decisions conveyed to the homeless pregnant
women? RQ 1
b. Tell me some highlights about this communication process that can shed some
light on how things flow between agencies. RQ 1
9. Can you think of any agencies you feel you should work with more frequently? RQ 1
10. How has COVID-19 affected your processes. RQ 1
11. What do you believe the homeless pregnant women experience in accessing the services
they were eligible for? RQ 1
12. What services do you wish you could provide that are not currently available? RQ 3
13. What would you tell a homeless pregnant mother to help her along her path? RQ 2
14. Is there anything more you would like to tell me? RQ 2

Abstract (if available)

Abstract This study aimed to better understand the experience of provisioning services for women who experience homelessness while being pregnant from both service providers’ as well as homeless pregnant women’s perspectives. In 2021, during the COVID-19 pandemic, I conducted 14 qualitative interviews with people representing multiple phases of the service provisioning process from initial intake to post-natal care. By analyzing the data utilizing an inductive thematic coding process, numerous challenges and successful operations were uncovered. Challenges primarily revolved around the themes of lack of resources, collaboration, and communication. The most effective systems were run by large government organizations but did not cater to individualized needs like the smaller, niche organizations did. Findings provide broad understandings of the microsystem, mesosystem, and exosystem as presented in the conceptual framework and are based on the qualitative insights into the challenges service providers and homeless, pregnant women face while accessing services.

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Asset Metadata

Creator Chiu, Heather (author)

Core Title The experience of service provisioning for homeless pregnant women

School Rossier School of Education

Degree Doctor of Education

Degree Program Organizational Change and Leadership (On Line)

Degree Conferral Date 2022-12

Publication Date 01/17/2023

Defense Date 12/09/2022

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag bronfenbrenners,ecological,homeless,homeless pregnant women,homeless services,Homeless women,Housing,housing services,OAI-PMH Harvest,pregnancy services,pregnant,Pregnant women,process,qualitative,service recommendations,services,support services,Women

Format theses (aat)

Language English

Contributor Electronically uploaded by the author (provenance)

Advisor Hirabayashi, Kimberly (committee chair), Andres, Mary (committee member), Singh, Melissa (committee member)

Creator Email heatherchiu@comcast.net,heatherlchiu@gmail.com

Permanent Link (DOI) https://doi.org/10.25549/usctheses-oUC112715906

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