Health Care for Homeless Women: Unmet Needs and Barriers to Care

Joy H. Lewis, DO; Ronald M. Andersen, PhD; Lillian Gelberg, MD, MSPH


J Gen Intern Med. 2003;18(11) 

In This Article

Abstract and Introduction

Objective: Homelessness is a significant and growing problem in the United States. Women and families are the fastest growing segments of the homeless population. Homelessness increases the risk of having health problems and encountering barriers to care. This study determines how much perceived unmet need for medical care there is among homeless women, what homeless women perceive to be barriers to health care, and how barriers and other factors are associated with unmet needs.
Design: Cross-sectional study of homeless women, utilizing structured interviews.
Setting and Participants: Community-based probability sample of 974 homeless women aged 15 to 44 years.
Main Outcome Measures: Perceived unmet need for medical care in the past 60 days. Relationship between unmet need and demographic variables, place of stay, source of health care, insurance, and perceived barriers to care.
Results: Of the 974 women, 37% reported unmet need for medical care. Controlling for other factors, the odds of unmet need were lower among those with a regular source of care (odds ratio [OR] to .35, 95% confidence interval [CI], .21 to 58), while having health insurance was not significantly associated. The odds of unmet need were higher among those who experienced the barriers: not knowing where to go (OR 2.27, 95% CI, 1.40 to 3.69), long office waiting times (OR 1.89, 95% CI 1.27 to 2.83) and being too sick to seek care (OR 2.03, 95% CI, 1.14 to 3.62).
Conclusions: There is significant unmet need for medical care among homeless women. Having a regular source of care was more important than health insurance in lowering the odds of unmet need. Homeless women must be educated regarding sources of care, and clinics serving the homeless must decrease waiting times.

Homelessness is a significant and growing problem in the United States. A recent study by the National Law Center on Homelessness and Poverty estimates that over 700,000 people are homeless on any given night and up to 2 million people experience homelessness during 1 year.[1] Furthermore, it is estimated that 14% of the U.S. housed population have been homeless in their lifetime.[2] While the majority of the homeless are still men, studies have found women and families are the fastest growing segments of the homeless population. In its 1998 survey of 30 American cities, the U.S. Conference of Mayors found families comprised 38% of the homeless population. This study also concluded that a disproportionate number of racial and ethnic minorities are homeless.[1]

Living without a home increases one's health risks. The homeless have more morbidity, as well as higher age-adjusted mortality rates than the general population.[3] A 1994 study of 6,308 homeless persons in Philadelphia found the age-adjusted mortality rate among the homeless was 3.5 times that of Philadelphia's general population.[3] Previous research has also shown the homeless have higher rates of hypertension, arthritis, mental illness, victimization, tuberculosis, and substance abuse.[4,5]

Despite the higher rates of health problems, the homeless are less likely to have a regular source of health care, health insurance, a steady income, or social support.[6] The homeless are less likely to obtain preventive medical services, even for children.[7] Additionally, they are more likely to have experienced barriers to health care, such as not knowing where to go for care, long waiting times, and high costs.[8]

Previous research on homeless women is limited. While studies have identified numerous potential "perceived barriers" to health care, the majority of studies are based on convenience samples of women in clinics or shelters.[6,8,9,10,11,12] Additionally, the studies that utilized probability samples did not determine the effect of multiple "perceived barriers" to care on unmet need for medical care.[4,13,14]  Table 1 details previous research study characteristics and barriers to care identified.

Our study, using data from the University of California Los Angeles (UCLA)/RAND Homeless Women's Health Project, is the first representative, probability sample of homeless women where perceived barriers to care are used to predict unmet need for health care. We address 5 research questions. How much unmet need for medical care is there among homeless women? How does unmet need vary by race, age, insurance, time homeless, usual place of stay, or health status? What do homeless women perceive to be their barriers to health care? How do perceived barriers relate to unmet need for medical care? What do homeless women believe would facilitate their access to health care?


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