We found a significant degree of perceived unmet need among the homeless women: 37% of our sample felt there was a time in the past 60 days when they wanted to see a doctor or nurse practitioner but did not. Our data indicate the homeless have significantly more perceived unmet need than do the housed. The 1993 National Health Interview Survey found 21% of working age adults reported a perceived unmet health care need.31
However, in that survey, unmet need included both a delay in obtaining services and not receiving care; therefore the 21% is a high estimate for not obtaining care at all. This suggests the gap between the unmet need in the homeless and the unmet need in the housed is probably higher than these statistics indicate.
The limitations of this study include the dependence on self-report for barriers and unmet need. Research has shown the homeless underreport health problems; when their report is compared to objective measures, there may have been more unmet need than we found.32
Additionally, with a cross-sectional study, we were not able to demonstrate causation. The regressions demonstrate associations between the independent variables and unmet need. Furthermore, the women may have experienced specific barriers to care at an earlier point in time and thus the experience may not have been proximal to their unmet need. However, if the barriers were related to their prior experience they could still be problems, and the women's perception that these are problems still needs to be addressed. Although we did have a probability-based sample in LA County, we systematically excluded women who do not use shelters or meal programs. These are likely the most disaffiliated homeless women. Had we included them, we would have likely found more unmet need.
Similarly, our study was limited to women of reproductive age. Although women and families are the fastest growing segments of the homeless population, and reproductive age women constitute the majority of homeless women, we can not generalize our results to older homeless women. These older women would be less likely to have children with them and more likely to have chronic diseases which may alter their health care seeking behavior.33
Finally, our results may not be generalizable to homeless women in other cities.
We were surprised race was not significantly associated with perceived unmet need for health care. In studies of the housed population, blacks and other minorities are less likely than whites to obtain necessary health care services. In our study, all of the women were highly vulnerable. This could perhaps neutralize race as a proxy for unmet need. Previous research on the homeless has provided mixed results regarding race and the use of health services.32,34,35
The increased unadjusted odds of unmet need for those with a history of alcohol abuse and those with a history of drug abuse is not surprising. Drug use may increase the risk of trauma and is associated with increased risk of sexually transmitted disease, anemia, dental disease, heart disease, and breast disease.36,37
Substance abuse can both predispose the women to health care needs, and can complicate their ability to pursue care. When homeless women do have contact with the health care system, they should be screened for drug and alcohol problems.
The increased unadjusted odds of unmet need for those with a history of victimization was not surprising.25
However, when we controlled for other factors, neither a history of rape nor other physical abuse was a significant predictor of unmet need. While it is well documented victimization is related to increased health care needs,38
it was not found to be a major factor related to unmet needs for the homeless women in our study.
Another interesting finding is the trend toward higher odds of unmet need for women living in limited housing — staying in an indoor place not intended for shelter such as a car compared to women in emergency shelters. Previous research on homeless women has found spending time “unsheltered” was associated with increased needs and increased unmet need for gynecologic care.39
This mode of housing results in greater daily uncertainty. This could also be a marker for other problems making woman ineligible for a homeless shelter or to stay with family or friends. Others have suggested more research is needed to determine a link between housing and health.40
Our findings show a clear association. Programs targeting homeless shelters exclusively could miss homeless women with the highest odds of unmet need for medical care. These findings support the need for greater outreach to remote and hidden sites such as abandoned buildings or cars.
Another group of homeless women to target for health services is women who have children with them. While only a quarter of the women surveyed who had children with them perceived a lack of a babysitter as a barrier to obtaining care, women who reported having children with them had higher odds of unmet needs when controlling for other factors. Further, we found 81% of the women who had children with them felt that obtaining health care at the same time that their children got health care would be very helpful to them. Interventions might target families by providing childcare services or outreach to the mother when services are provided to homeless children.
The 2 factors associated with lower odds of perceived unmet need in the multiple variable analyses were being homeless for 1 year or more and having a regular source of care. Women who were homeless for longer may have learned more about available services and may be better able to cope with their survival demands. It is encouraging that women with a regular source of care had less perceived unmet need. The regular source of care—a “medical home”—was found to be more important than health insurance.
The lack of association between having health insurance and perceived unmet need provides valuable insight into the problems of the homeless. Previous research supports the conclusion that insurance coverage is not sufficient to ensure the needs of the homeless are met.41
Rather, nonfinancial barriers to care are greater factors.
We have provided evidence that a list of homeless women's perceived barriers to care can be used to help identify women with higher unmet need for medical care. The most important perceived barriers to care identified are not knowing where to go, long waiting times, and being too sick to seek care. When women visit meal programs and shelters they should be educated regarding available health services. Additionally, clinics serving the homeless must decrease waiting times. Because waiting times may be difficult to decrease (even the housed who utilize the County system or emergency departments face long waiting times), perhaps the perception of waiting can be changed.42,43
This could be accomplished by providing something valuable to do while waiting for health care — showers, laundry, health promotion education, social services, or vocational counseling. Finally, the problem of being too sick to seek care is difficult to address. Perhaps, if obtaining care was easier or more convenient, being sick would be less of a deterrent. Alternatively, increased outreach and prevention to help homeless women stay well or to help them address problems could prevent them from deteriorating to the extent that seeking care is difficult.
Homeless women's perceptions of facilitators for obtaining health care are logical, given the significant barriers identified. The vast majority said free transportation, treatment for all health care problems at the same place, and obtaining health care and social services at the same place would be very helpful.
It is important to understand these perceived barriers and facilitators to improve access to care for the homeless. By talking to homeless women and obtaining information from their perspective, we were able to show how their feelings relate to unmet need for medical care. With more attention to the needs of the homeless and further work toward decreasing their perceived barriers to care, we may decrease their excess burden of disease.