The elimination of health and health care disparities for vulnerable populations is a major health policy objective in the U.S. (U.S. Department of Health and Human Services, 2000
). The extent of these disparities is quite well-documented for vulnerable populations typically defined by their low income and minority status (Agency for Healthcare Research and Quality, 2008
; Hebert, Sisk, & Howell, 2008
; Kilbourne et al., 2006
; Morales & Ortega, 2007
; Yancey, Bastani, & Glen, 2007
). Of special concern are vulnerable population subgroups in the United States today defined by the punishing environments in which they live, their risky and unhealthy life styles and the illnesses and injuries that afflict them (Aday, 2001
). These subpopulations include refugees and immigrants, people living with acquired immunodeficiency syndrome (AIDS), alcohol and substance abusers, high-risk mothers and infants, victims of family or other violence, and the chronically or mentally ill. Among these vulnerable sub populations, one with some of the greatest health and health care disparities, is the homeless.
Health and health care disparities for the homeless are particularly distressing for homeless women. Compared to the general population of women, homeless women's health disparities include higher rates of mortality, poor health status, mental illness, substance abuse, victimization, and poor birth outcomes (Arangua & Gelberg, 2007
; Schanzer et al., 2007
). Regarding health care, homeless women are less likely to have a regular source of care, health insurance, cancer screening, adequate prenatal care, appropriate ambulatory care, and specialty care for specific disorders (Arangua & Gelberg, 2007
; Gelberg et al., 2009
; Kim et al., 2006
; Weinreb et al., 2006
While all homeless women are vulnerable and experience health and health care disparities, they are diverse in many ways. Early on, Milburn and D'Ercole (1991)
documented their diversity in race/ethnicity, age, and circumstances that may have led them into or out of homelessness. More recently, some studies have been conducted that shed light on how these differences might be related to health and health behavior. For example, being partnered or married has been associated with greater distress among African American and white homeless women, and experiencing competing needs (difficulty finding a place to sleep at night, enough food to eat, a place to wash, or a place to go to the bathroom) has been observed to predict mental distress for African American and Hispanic homeless women (Austin, Andersen & Gelberg, 2008
). In other studies of homeless women, family closeness was found to be a significant protective factor against daily alcohol use for African Americans and high-acculturated Latinas and for daily drug use among low-acculturated Latinas, and negative peer influence in adolescence predicted daily drug use among high-acculturated Latinas (Nyamathi et al., 2001
). Active coping was observed to be associated with fewer general (sexual) AIDS risk behaviors for both African American and Latina women, and less drug use behavior among African American women (Nyamathi, Stein & Brecht, 1995).
Prior literature on racial/ethnic disparities in unmet need for health care among homeless women exists, but leaves unclear answers to important questions about disparities that should be considered in the identification and provision of services and care for different subgroups of these women. For example, some measures of health and health care disparities among homeless women indicate non-Hispanic whites are actually worse off than minority groups. One study of homeless women in Los Angeles suggested that whites appear to be the most vulnerable racial/ethnic subgroup compared to African Americans and Hispanics. Whites were most likely to report sexual abuse in childhood, physical abuse recently and in childhood, lifetime mental health hospitalization, serious medical symptoms, and lack of a regular source of care (Gelberg et al. 2009
). Further, in unadjusted analyses, the study showed that compared to whites, African Americans were less likely to have unmet need for medical care, Hispanics had similar unmet need, and other racial/ethnic groups had more unmet need. However, in adjusted analyses, no effects were observed according to race/ethnicity in an earlier publication (Lewis et al., 2003
). While unadjusted hospitalization rates were higher for homeless white women than for minorities, race/ethnicity showed no effect in multivariable regression analysis on the number of ambulatory care visits, hospitalization, and number of health screens (Gelberg, et al., 2009
; Lim et al., 2002). Thus, previous research demonstrates the importance of adjusted analyses in identifying differing needs among diverse racial/ethnic groups of homeless women.
The present study sought to provide data to increase our understanding of racial/ethnic disparities among homeless women by comparing African Americans, Latinas and whites according to a broad range of population, health and health care measures. In addition, we selected one health care measure (not seeing a doctor when perceived necessary), for further multivariable analyses to examine because it is generally considered a key measure of access to and disparities in health care (Aday & Andersen, 1975
; Andersen & Davidson, 2007
; Institute of Medicine, 1993
). The specific objectives of this study were to answer the following questions: (1) What were the background characteristics of the homeless women in the sample according to their race/ethnicity? (2) What were the health and health care disparities of the homeless women according to their race/ethnicity? (3) How were race/ethnicity and other background and health characteristics related in a multivariable analysis to the unmet need of homeless women for health care?
This study contributes new information and deepens our understanding of disparities among homeless women by examining and identifying areas of health and health care needs where racial/ethnic groups may differ. Further, while a limited number of studies have investigated racial/ethnic disparities in unmet need among homeless women, this study extends the findings on unmet need and also contributes new information on the effect of race/ethnicity on a range of health and health care disparity measures. The findings are essential in developing a more targeted, rather than a one-size-fits-all approach, to meet the specific health and health care needs of different subgroups of homeless women, including racial/ethnic subgroups.