Behavioral Health and Service Usage During the COVID-19 Pandemic Among Emerging Adults Currently or Recently Experiencing Homelessness.

PURPOSE: This study provides information on how the coronavirus disease 2019 (COVID-19) outbreak is affecting emerging adults currently or recently homeless in terms of engagement in protective behaviors, mental health, substance use, and access to services.
METHODS: Ninety participants in an ongoing clinical trial of a risk reduction program for homeless, aged 18-25 years, were administered items about COVID-19 between April 10 and July 9, 2020.
RESULTS: Most participants reported engaging in COVID-19 protective behaviors. Past week mental health symptoms were reported by 38%-48% of participants, depending on symptoms. Among those who used substances before the outbreak, 16%-28% reported increased use of alcohol, tobacco, and marijuana. More than half of the participants reported increased difficulty meeting basic needs (e.g., food), and approximately 32%-44% reported more difficulty getting behavioral health services since the outbreak.
CONCLUSIONS: Innovative strategies are needed to address the increased behavioral health needs of young people experiencing homelessness during events such as the COVID-19 outbreak.

Many emerging adults who are currently or recently homeless reported increased behavioral health problems due to coronavirus disease 2019, combined with greater difficulty accessing services and meeting basic needs (e.g., getting enough food). Innovative strategies are needed to address the increased service needs of this population during events such as the coronavirus disease 2019 outbreak.

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There are more than 35,000 unaccompanied youth experiencing homelessness (YEH) on any given night in the U.S. [1]. Because of harsh living conditions and already compromised health [2], YEH may be particularly vulnerable to getting coronavirus disease 2019 (COVID-19). Furthermore, the YEH population has high rates of psychiatric disorders and substance use [[3], [4], [5]], issues that may be exacerbated by the pandemic [6,7]. Under the best of circumstances, YEH have an acute need for both basic services (e.g., food, shelter, and hygiene) and higher level services (e.g., case management and behavioral health services) [8]. Yet, there are numerous existing barriers to service use among YEH [9,10], which are likely further compounded by COVID-19 restrictions on how services must be delivered to protect clients and staff [11]. The present study surveyed 18- to 25-year-olds currently or recently homeless to understand their sources of information about COVID-19, perceived susceptibility, engagement in protective strategies, and effects of the outbreak on their mental health, substance use, and ability to meet their basic needs and access services.

Methods

Participants and procedures

Participants were 90 individuals enrolled in an ongoing evaluation of AWARE, a substance use and sexual risk reduction intervention for 18- to 25-year-olds experiencing homelessness [12,13]. Participants were initially enrolled from three drop-in centers serving YEH in the Los Angeles area. COVID-19 items were added to the follow-up surveys and fielded between April 10 and July 9, 2020. The sample was 72% male and 28% female, 21% Hispanic, 22% non-Hispanic white, 43% non-Hispanic black, and 13% multiethnic/other. The mean age was 21.9 years. Seventy-five percent indicated that they had spent at least one night in the past week in one of the following settings: someone else's place, shelter/transitional housing program, outdoors, hotel/motel, vehicle, and abandoned building. All procedures were approved by the study's institutional review board.

Measures

Knowledge and perceived susceptibility

Participants were asked whether they knew about “COVID-19 (also known as the coronavirus).” Those who did were asked where they get their information about COVID-19, how worried they are about getting it (1 = not at all to 4 = extremely), whether they think they have contracted COVID-19 (No, I have not had any symptoms; No, I have been tested and was told that I did not have it; Yes, I have had symptoms, but I have not been tested; and Yes, I have been tested and told that I had it), and whether they know anyone else diagnosed with COVID-19.

Protective strategies

Fifteen items primarily drawn from the Johns Hopkins Bloomberg School of Public Health [14] asked whether, in the past 7 days, participants had engaged in behaviors such as social distancing, wearing a face mask, and handwashing (Yes, I did this; No, because I was not interested in doing this; No, because my current financial or living situation prevented me from doing this).

Mental health and substance use

Six items primarily drawn from the Johns Hopkins Bloomberg School of Public Health [14] asked how often, in the past 7 days, they felt the following when thinking about their experience with the COVID-19 outbreak (Not at all or less than one day, 1–2 days, 3–4 days, and 5–7 days): nervous, anxious, or on edge; depressed; lonely; hopeless about the future; physical reactions, such as sweating, trouble breathing, nausea, or pounding heart; and trouble sleeping. Separate items asked how the COVID-19 outbreak had affected their use of alcohol, tobacco, and marijuana (N/A, I did not use this before; A lot more now; A little more now; About the same; A little less now; A lot less now).

Ability to address needs

Nine items asked how the COVID-19 outbreak affected participants' ability to address their basic needs (e.g., food and hygiene) and access various higher level services (A lot easier, A little easier, No change, A little harder, and A lot harder).

Results

Nearly all participants (n = 85; 94%) knew about COVID-19 and went on to answer the remaining items. Most got their information from social media (71%), followed by TV/radio (59%), news websites (60%), friends or family (52%), service providers or health professionals (45%), and newspapers (42%). Approximately half (53%) were not at all worried about getting COVID-19 (32% were “a little,” 8% “very,” and 7% “extremely”). Six percent thought that they had contracted COVID-19, and 16% reported knowing someone with a positive diagnosis.

Most participants reported engaging in COVID-19 protective strategies during the past week, and there appeared to be few barriers because of their current financial or living situation (Table 1 ). However, it is worth noting that 19% reported not avoiding people at high risk for COVID-19, 22% were not avoiding public places, and 21% were not avoiding sharing cigarettes or drugs with others that could spread COVID-19.

Table 1

Engagement in COVID-19 protective strategies in the past 7 days

Strategy	Yes, I did this	No—I was not interested in doing this	No—my financial or living situation prevented me
Avoided shaking hands or other physical contact when greeting others	92%	7%	1%
Wore a face mask	92%	5%	4%
Kept your distance from others (6 feet)	87%	6%	7%
Washed hands with soap or used hand sanitizer several times per day	86%	7%	7%
Avoided crowded places	84%	9%	7%
Avoided contact with people who could be high risk of having COVID-19	81%	11%	8%
Canceled or postponed personal or social activities	80%	15%	5%
Avoided sharing cigarettes or drugs (e.g., joints, pipes, needles)	79%	16%	5%
Quarantined yourself, even if you did not have symptoms	78%	14%	8%
Avoided public places	78%	11%	12%
Changed school or work arrangements	67%	20%	13%
Stockpiled food or water	58%	26%	16%

COVID-19 = coronavirus disease 2019.

Participants reported numerous mental health symptoms from the COVID-19 outbreak during the past 7 days, including hopelessness (48%), anxiety (44%), loneliness (38%), sleep problems (34%), and depression (36%). Among those who had used substances before the outbreak, 16% reported increased alcohol use, 20% increased tobacco use, and 28% increased marijuana use.

Most participants indicated it was now harder to meet one or more of their basic needs, particularly getting enough food to eat (54%), and nearly half (42%) indicated that it was harder to get case management (Table 2 ). Given the extent of increased mental health symptoms and substance use because of COVID-19, it is worth highlighting that many indicated that it was now harder to get mental health (44%) and substance use (32%) services.

Table 2

Perceived effects of COVID-19 outbreak on ability to meet basic needs and obtain services

Item	A little or a lot easier	No change	A little or a lot harder	A lot hardera
Basic needs
Getting enough food to eat	18%	28%	54%	32%
Getting clean clothes or a shower	21%	46%	33%	26%
Finding a safe place to spend the night	24%	47%	29%	20%
Services
Finding or keeping a job	9%	39%	52%	48%
Mental health counseling (e.g., for depression, anxiety)	14%	42%	44%	34%
Case management	18%	40%	42%	32%
Finding or keeping stable housing	13%	45%	42%	31%
STD-related services (e.g., condoms, testing, PrEP)	14%	59%	27%	25%
Substance use services for alcohol or drugs	13%	55%	32%	25%

COVID-19 = coronavirus disease 2019; PrEP = pre-exposure prophylaxis; STD = sexually transmitted disease.

This is a subset of those in the “a little or a lot harder” category.

Discussion

Overall, the results are encouraging in suggesting that knowledge of COVID-19 and engagement in protective strategies is widespread among emerging adults with experiences of homelessness. However, many report increased behavioral health problems, combined with greater difficulty in accessing services. Many are also having difficulty meeting their basic needs for food, safe shelter, and hygiene. The results should be interpreted with caution, given that they are based on self-report data from a small sample of YEH in the Los Angeles area who participated in a clinical trial at a drop-in center. Nonetheless, the results emphasize the need for innovative strategies to address the increased behavioral health service needs of this population during events such as the COVID-19 outbreak.