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A cross-sectional observational study of unmet health needs among homeless and vulnerably housed adults… Argintaru, Niran; Chambers, Catharine; Gogosis, Evie; Farrell, Susan; Palepu, Anita; Klodawsky, Fran; Hwang, Stephen W Jun 13, 2013

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RESEARCH ARTICLE Open AccessA cross-sectional observational study of unmethealth needs among homeless and vulnerablyhoused adults in three Canadian citiesNiran Argintaru1*, Catharine Chambers1†, Evie Gogosis1†, Susan Farrell2†, Anita Palepu3†, Fran Klodawsky4†and Stephen W Hwang1†AbstractBackground: Homeless persons experience a high burden of health problems; yet, they face significant barriers inaccessing health care. Less is known about unmet needs for care among vulnerably housed persons who live inpoor-quality or temporary housing and are at high risk of becoming homeless. The objectives of this study were toexamine the prevalence of and factors associated with unmet needs for health care in a population-based sampleof homeless and vulnerably housed adults in three major cities within a universal health insurance system.Methods: Participants were recruited at shelters, meal programs, community health centers, drop-in centers,rooming houses, and single room occupancy hotels in Vancouver, Toronto, and Ottawa, Canada, throughout 2009.Baseline interviews elicited demographic characteristics, health status, and barriers to health care. Logistic regressionwas used to identify factors associated with self-reported unmet needs for health care in the past 12 months.Results: Of the 1,181 participants included in the analysis, 445 (37%) reported unmet needs. In adjusted analyses,factors associated with a greater odds of reporting unmet needs were having employment in the past 12 months(AOR = 1.40, 95% CI = 1.03–1.91) and having ≥3 chronic health conditions (AOR = 2.17, 95% CI = 1.24–3.79). Havinghigher health-related quality of life (AOR = 0.21, 95% CI = 0.09–0.53), improved mental (AOR = 0.97, 95% CI = 0.96–0.98)or physical health (AOR = 0.98, 95% CI = 0.96–0.99), and having a primary care provider (AOR = 0.63, 95% CI = 0.46–0.85)decreased the odds of reporting unmet needs.Conclusions: Homeless and vulnerably housed adults have a similar likelihood of experiencing unmet health careneeds. Strategies to improve access to primary care and reduce barriers to accessing care in these populations areneeded.Keywords: Access to care, Homelessness, Housing, Primary care, Public health policyBackgroundApproximately 150,000 Canadians and up to 3.5 millionAmericans experience homelessness in a year [1,2]. Formany, homelessness is a dynamic state characterized byshifts between unstable housing and homelessness.Homeless individuals who obtain housing often havedifficulty maintaining it due to factors such as financialhardship, physical or mental health problems, substanceuse, and lack of social support [3,4]. And so, as many as400,000 individuals in Canada are classified as “vulnerablyhoused,” referring to persons living in poor-quality,temporary or precarious housing such as single roomoccupancy (SRO) hotels or rooming houses [5]. Homelessand vulnerably housed individuals suffer from numerousthreats to their health [4], high rates of substance abuseand mental illness, and increased mortality compared tolow-income individuals in the general population [6-8].Housing has a substantial impact on mental and physicalhealth; hence, it is an important social determinant ofhealth [9,10]. Higher rates of substance abuse, seriousmedical issues, and trauma exist among unsheltered* Correspondence: nargintaru2014@meds.uwo.ca†Equal contributors1Centre for Research on Inner City Health, Keenan Research Centre in the LiKa Shing Knowledge Institute, St. Michael’s Hospital, Toronto, ON, CanadaFull list of author information is available at the end of the article© 2013 Argintaru et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the CreativeCommons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, andreproduction in any medium, provided the original work is properly cited.Argintaru et al. BMC Public Health 2013, 13:577http://www.biomedcentral.com/1471-2458/13/577homeless adults compared to the general population [11].Good quality housing would be expected to provide socialand personal stability, protection from the elements,privacy and sanitation, and more reliable contact withhealth care providers, factors which should contributeto improved health and access to care [11]. However,homeless and vulnerably housed individuals may fail toexperience these benefits.Homeless individuals are known to experience pooraccess to health care [12-15], and, as a result, mayexperience deterioration in health status, prolongedhomelessness, and increased mortality [16]. Barriers toaccessing services include financial difficulties, lack ofknowledge about where to obtain care, lack of transpor-tation, lack of child care, long waiting times, perceiveddiscrimination in health care settings, and competingpriorities for subsistence needs [13,17]. In a 1996 U.S.national survey of nearly 3,000 homeless adults, 24.6%reported being unable to access the health care theyneeded, and not having health insurance was noted as asignificant barrier [13]. A 2006 study of homeless andvulnerably housed individuals noted over 40% of partici-pants visited the emergency department at least once ayear, compared with under 30% of people living under thepoverty line and approximately 20% of the United Statesgeneral population [17,18]. Frequent emergency departmentvisits were associated with unstable housing and werepartly attributed to food and housing insecurity [17].However, because up to half of homeless adults in theUnited States do not have health insurance [13], thesefindings may not be applicable to countries such asCanada which have publicly funded systems of universalhealth insurance and significant differences in socialservices, housing availability, economy and climate.This study examines factors associated with unmethealth needs among homeless and vulnerably housedindividuals across three major Canadian cities and whetherbeing vulnerably housed is associated with a lower likeli-hood of unmet needs for health care compared to beinghomeless.MethodsThis study used baseline data from the Health and Housingin Transition (HHiT) study, an ongoing longitudinal studyexamining housing and health care utilization of homelessand vulnerably housed individuals over a four year period.Study settingIndividuals were recruited from Toronto, Ontario (popu-lation 2.62 million); Ottawa, Ontario (population 883,391);and Vancouver, British Columbia (population 603,502)[19]. On any given night there are approximately 2,600homeless individuals in Vancouver, over 900 in Ottawa,and as many as 4,400 in Toronto [20-22]. Low-costhousing alternatives consist largely of licensed andunlicensed rooming houses in Toronto and Ottawa andSRO hotels in Vancouver.In Canada, publicly funded universal health insurance isprovided for all citizens, landed immigrants, and refugeeswho meet residency requirements. Under these provinciallyadministered health insurance plans, individuals havecoverage for all medically necessary health services withoutpatient co-payments [23,24]. These include inpatienthospital services, emergency department visits, outpatientservices and some homecare.ParticipantsA total of 1,191 single adults (aged 18 or older who do notlive with a partner or dependent child) were recruitedthroughout 2009. Participants were recruited as part oftwo discrete samples: homeless adults and vulnerablyhoused adults. Homelessness was defined as living in ashelter, public space, vehicle, abandoned building, orsomeone else’s home, and not living one’s own homewithin the last seven days. Vulnerably housed status wasdefined as living in one’s own room, apartment, or place,but having been or having two or more moves over thepast 12 months. The two-stage sampling method, whererecruitment locations were first sampled and then par-ticipants were sampled within the individual locationswas adapted from Ardilly and Le Blanc (2001) and wasfurther validated in Marpsat and Razafindratsima (2010)[25,26]. Detailed sampling and recruitment methodsused for this study have been published previously andare briefly described here [6].Homeless individuals were recruited at shelters and mealprograms. At meal programs, recruitment of homelesspeople was limited to those who did not use shelters, withtheir numbers proportionate to the number of homelesspersons estimated to sleep on the street in each city [27].Shelters were randomly selected proportionate to theirnumber of beds, while meal programs were selectedrandomly based on location and estimated number ofindividuals who were served weekly. Vulnerably housedindividuals were recruited from SRO hotels in Vancouverand rooming houses in Toronto and Ottawa as well asfrom meal programs, drop-in centers, and communityhealth centers in all three cities. Although recruitment ofsome homeless and vulnerably housed participantstook place in meal programs, participants were classi-fied into the two groups based on the above defini-tions. Participants provided written informed consentand received $20 CDN for completing the interview.Ethics approval was obtained from the ResearchEthics Boards at St. Michael’s Hospital (Toronto), theUniversity of Ottawa, and the University of BritishColumbia (Vancouver).Argintaru et al. BMC Public Health 2013, 13:577 Page 2 of 9http://www.biomedcentral.com/1471-2458/13/577SurveyStructured in-person interviews lasting 60 to 90 minuteswere conducted immediately after recruitment. Informationwas obtained about demographic characteristics, healthstatus, health conditions, and barriers to accessing healthcare by self-report. The primary outcome measure for thisanalysis was unmet need for health care, based on thequestion “During the past 12 months, was there ever atime when you felt that you needed health care but youdidn’t receive it?”Participants self-identified their ethnic background fromcategories adapted from the Statistics Canada EthnicDiversity Survey [28]. Individuals were asked whetherthey had a regular medical doctor/nurse practitionerin the past 12 months. Individuals were also askedwhether they had a provincial health insurance number,which is issued to all persons covered by the universalhealth insurance system.Health status was assessed using the Short Form12-item health survey (SF-12), a health status instrumentthat provides reliable physical and mental health summarymeasures [29]. Physical component summary (PCS) andmental component summary (MCS) scores were calculatedaccording to the publisher’s specifications, and standardizedto the US general population (mean score = 50; SD = 10),with higher scores representing better overall health[6,29]. Individuals were also asked to identify any chronichealth conditions lasting six months or more and werediagnosed by a health professional using items adaptedfrom the Canadian Community Health Survey [30]. In anexploratory analysis, self-reported mental health diagnoseswere aggregated into three categories: mood disorders(including bipolar disorder, depression, and manic disorder);anxiety disorders (including generalized anxiety disorders,obsessive compulsive disorder, panic disorder, phobias,and posttraumatic stress disorder); and schizophrenia andother psychotic disorders.Health-related quality of life was measured using theEuroQol (EQ-5D) instrument that scores quality of lifebased on five dimensions (mobility, usual activity, self-care,pain/discomfort, and anxiety/depression) and provides aglobal rating of current health using a visual analog scale(VAS) ranging from 0–100 [31,32]. Weighted compositescores were calculated using weights for the United Statesgeneral population; scores theoretically range between −0.11and 1.00 on a scale where 0 represents death and 1represents perfect health [32].Statistical analysisOf 1,191 participants, 10 (0.8%) responded “don’t know,”refused to answer, or had missing data for having unmethealth care needs and were excluded from all analyses.Bivariate comparisons were made between participantswho reported having unmet needs for health care andthose who did not using Student’s t-test for continuousvariables and chi-square tests or Fisher’s Exact test(where appropriate) for categorical variables. Logisticregression was used to identify factors associated withreporting unmet needs.An analysis for gender-specific interactions with age,city, housing status at recruitment, SF-12 scores,self-reported mental health diagnoses, employmentover the past 12 months, and having been a victim of asexual assault revealed no significant interactions. Hence,stratified analyses by gender were not performed.The multivariate regression model included all factorsthat could plausibly contribute to unmet needs for healthcare. Results were considered significant at the alpha = 0.05level. A total of 142 (11.9%) participants were not includedin the final multivariate model due to missing valuesfor any of the 18 variables in the model. Final analysescollapsed data from all three cities into a single population,as stratified analyses by city did not yield significantdifferences. Analysis was performed using SPSS 19.0 forWindows (SPSS Inc., Chicago IL).ResultsIn total, 445 participants (37.7%) reported an unmet needfor health care in the past 12 months. Table 1 summarizesthe characteristics of participants with and without unmetneeds for health care. The average lifetime duration ofhomelessness reported was 5.1 years (SD = 6.0 years), andthere were no significant demographic differences betweenthe groups with and without unmet needs based onhousing status, age, gender, city, education, or employmentstatus (Table 1). However, significant differences werenoted for immigrant status, racial/cultural group, and life-time duration of homelessness.Participants who reported unmet needs for healthcare also had a significantly lower mean EQ-VAS scores(55.5 vs. 65.0, p < 0.01) and mean EQ-5D index score(0.7 vs. 0.8, p < 0.01) compared to those without unmetneeds. They were significantly more likely to report havingthree or more chronic health conditions than thosewithout unmet needs (63.1% vs. 41.7%, p < 0.01). Addition-ally, a history of a previous mental health diagnosis wassignificantly more common among participants withunmet needs for health care (59.2% vs. 46.9%, p < 0.01).Not surprisingly, participants with unmet needs for carewere more likely to report also having an unmet need formental health care (41.4% vs. 12.6%, p < 0.01).Of the 736 participants without unmet needs forhealth care, 92 (12.5%) reported having unmet needs formental health care in the same time period while 183(66.5%) of those who indicated having unmet needs formental health care also reported unmet needs for care.Overall, 23.4% of participants reported unmet mentalhealth care needs.Argintaru et al. BMC Public Health 2013, 13:577 Page 3 of 9http://www.biomedcentral.com/1471-2458/13/577Table 1 Characteristics of participants with and without self-reported unmet needs for care in Vancouver, Toronto,and Ottawa, Canada, 2009All participants(n = 1181)Participants withunmet needs (n = 445)Participants withoutunmet needs (n = 736)pDemographics, n (%) 0.71Homeless 592 (50.1) 220 (49.4) 372 (50.5)Vulnerably housed 589 (49.9) 225 (50.6) 364 (49.5)Age group, n (%) 0.52<30 years 159 (13.5) 62 (14.0) 97 (13.2)30–39 years 291 (24.7) 116 (26.2) 175 (23.8)40–49 years 439 (37.2) 166 (37.5) 273 (37.1)≥50 years 290 (24.6) 99 (22.3) 191 (26.0)Gender, n (%) 0.25Male 773 (65.7) 286 (64.4) 487 (66.4)Female 386 (32.8) 154 (34.7) 232 (31.7)Transgender 18 (1.5) 4 (0.9) 14 (1.9)City, n (%) 0.16Vancouver 391 (33.1) 160 (36.0) 231 (31.4)Toronto 396 (33.5) 136 (30.6) 260 (35.3)Ottawa 394 (33.4) 149 (33.5) 245 (33.3)Born in Canada, n (%) 992 (84.5) 386 (87.1) 606 (82.9) 0.05Racial/cultural group, n (%) <0.01White 712 (62.2) 282 (65.0) 430 (60.5)Black/African-Canadian 106 (9.3) 33 (7.6) 73 (10.3)First Nations/Aboriginal 204 (17.8) 79 (18.2) 125 (17.6)Mixed ethnicity 64 (5.6) 30 (6.9) 34 (4.8)Other 59 (5.2) 10 (2.3) 49 (6.9)Highest level of education, n (%) 0.38Some post-secondary education or more 375 (32.0) 148 (33.4) 227 (31.1)Completed high school or equivalent 274 (23.4) 94 (21.2) 180 (24.7)Some high school 523 (44.6) 201 (45.4) 322 (44.2)Employed past 12 months, n (%) 468 (39.7) 186 (41.9) 282 (38.4) 0.23Lifetime duration of homelessness (yrs), mean (SD) 5.1 (6.0) 5.5 (6.3) 4.9 (5.8) 0.07EQ-VAS score (perceived state of health), mean (SD) 61.5 (21.8) 55.5 (22.2) 65.0 (20.8) <0.01EQ-5D index score, mean (SD) 0.7 (0.2) 0.7 (0.2) 0.8 (0.2) <0.01Been victim of sexual assault over past 12 months, n (%) 104 (8.9) 55 (12.4) 49 (6.7) <0.01Has a provincial health card number, n (%) 991 (86.9) 365 (85.5) 626 (87.7) 0.29Has unmet needs for mental care, n (%) 275 (23.4) 183 (41.4) 92 (12.6) <0.01Has primary care provider, n (%) 713 (60.5) 252 (56.8) 461 (62.7) 0.04SF-12 PCS, 1 mean (SD) 44.5 (11.3) 41.4 (10.9) 46.4 (11.1) <0.01SF-12 MCS, mean (SD) 39.1 (13.1) 34.9 (12.2) 41.6 (12.9) <0.01Number of chronic health conditions, 2 n (%) <0.010 150 (12.7) 30 (6.7) 120 (16.3)1 248 (21.0) 69 (15.5) 179 (24.3)2 195 (16.5) 65 (14.6) 130 (17.7)≥ 3 588 (49.8) 281 (63.1) 307 (41.7)Diagnosed with a mental health disorder, n (%) 600 (51.5) 260 (59.2) 340 (46.9) <0.011On a scale where 50 is the mean and 10 is the standard deviation in the US general population.2Chronic health conditions include: high blood pressure; heart disease; asthma; COPD (includes emphysema and chronic bronchitis); cirrhosis; Hepatitis B or C;intestinal or stomach ulcers; urinary incontinence; bowel disorders; arthritis; problems walking, lost limb, or other physical handicap; HIV/AIDS; epilepsy; fetalalcohol syndrome or fetal alcohol spectrum disorder; head injury; glaucoma; cataracts; cancer, diabetes; or anemia.Argintaru et al. BMC Public Health 2013, 13:577 Page 4 of 9http://www.biomedcentral.com/1471-2458/13/577Table 2 summarizes the results of bivariate and multi-variate logistic regression models identifying factorsassociated with reporting unmet needs. Seven characteristicswere significantly associated with increased likelihoodof reporting unmet needs for health care in unadjustedregression models: being a victim of sexual assault inthe past 12 months, having been diagnosed with a mentalhealth disorder, having lower EQ-5D index or VAS scores,having lower SF-12 PCS and MCS scores, and havingmore than one chronic health condition.In the multivariate logistic regression model, housingstatus did not significantly alter the likelihood of reportingunmet needs for health care. Factors that increased thelikelihood of unmet needs for health care in adjustedmodels included being employed in the past 12 months(AOR= 1.41, 95% CI = 1.03, 1.91) and having three or morechronic health conditions (AOR= 2.17, 95% CI = 1.24, 3.79).Factors that decreased the likelihood of unmet needsfor health care include having a higher EQ-5D score(AOR = 0.21, 95% CI = 0.09, 0.53), having a higher SF-12PCS score (AOR = 0.98, 95% CI = 0.96, 0.99) or MCS score(AOR = 0.97, 95% CI = 0.96, 0.98), completing high schoolor equivalent (AOR = 0.67, 95% CI = 0.46, 1.00) andhaving a primary health care provider (AOR = 0.63, 95%CI = 0.46, 0.85).An exploratory bivariate analysis of participants reportingone or more previous mental health diagnoses issummarized in Table 3 and identifies significantly in-creased likelihood of reporting unmet need for healthcare in participants with mood disorders (OR = 1.73,95% CI = 1.36, 2.20) and anxiety disorders (OR = 1.96,95% CI = 1.48, 2.57). Schizophrenia or other psychoticdisorders were not associated with increased likelihood ofreporting unmet needs (OR = 0.82, 95% CI = 0.50, 1.33).DiscussionIn this study of homeless and vulnerably housed adults inthree Canadian cities, over one-third (37%) of participantsreported unmet needs for health care in the past12 months. This is a higher proportion than a similarToronto study of homeless people that noted a prevalenceof unmet needs for health care of 22% among single adultwomen and 14% among single adult males [33]. Thisdiscrepancy may be due to the previous study focusingspecifically on care from a doctor or nurse in the past12 months, while the current study investigated perceivedhealth care needs more generally. The prevalence ofunmet needs in our sample is, however, similar to otherstudies that have investigated unmet needs among homelesspopulations in the United States [13,15,34].An important finding of our analysis was that beingvulnerably housed was not associated with a lowerlikelihood of having unmet needs for health care whencompared to being homeless. This finding is supportedby prior research on housing and health status, whichsuggests that homeless and vulnerably housed individualsare intersecting and dynamic populations with equallypoor health status and similar barriers to accessing care[34]. This study suggests that provision of housing is notsufficient in and of itself to ensure health care access. Ourfindings highlight the importance of access to stable,secure, not overcrowded, affordable housing with appro-priate supports to both homeless and vulnerably housedpopulations.Having worse mental or physical health and having agreater number of chronic health conditions were sig-nificantly associated with an increased likelihood ofhaving unmet needs for health care. This association isnot surprising, since a greater need for health care wouldbe expected to increase the risk of having unmet needs forcare, especially given the numerous barriers to accessinghealth care that homeless and vulnerably housed peopleexperience [34,35].Our exploratory findings suggest that the ability or per-ceived ability to access care effectively may be particularlyproblematic for individuals with certain mental healthconditions, such as mood and anxiety disorders. Alterna-tively, individuals with schizophrenia or other psychoticdisorders may have a tendency to underestimate theirneed for care and thus report fewer unmet needs.Further research will be required to better delineate thesedifferences.The majority (86.9%) of participants in our studyreported having a provincial health number, either intheir possession or on record at a health care site (e.g.,doctor’s office, hospital). Having a provincial healthinsurance number is essential to accessing most medicallynecessary services in Canada. Although there was atendency for participants without a provincial healthnumber to report unmet needs for care, the trend wasnot statistically significant. It is also possible that partici-pants may be accessing health care through low-barriersites such as shelter-based clinics or community healthcenters, which may not require clients to present proof ofhealth insurance.In the adjusted analyses, as with the bivariate models,being vulnerably housed as opposed to homeless atrecruitment was not associated with having unmet needsfor care; therefore, the two samples were combined intoa single analytic group. Having a primary care providersignificantly reduced the likelihood of having unmet needsfor care, even when adjusting for potential confoundersand covariates, highlighting the role of a primary careprovider as a gateway to accessing healthcare services.There was no independent association between being avictim of sexual assault and unmet needs for health care,which differs from a previously identified associationbetween unmet health care needs and sexual victimization;Argintaru et al. BMC Public Health 2013, 13:577 Page 5 of 9http://www.biomedcentral.com/1471-2458/13/577Table 2 Factors associated with unmet needs for health care among homeless and vulnerably housed participants inToronto, Ottawa and Vancouver, Canada, 2009Bivariate models Multivariate modelOR (95% CI) p AOR (95% CI) pDemographics, n (%)Homeless (Ref) 1.00 1.00Vulnerably housed 1.05 (0.83, 1.32) 0.71 1.09 (0.82, 1.45) 0.56Age group, n (%)<30 years (Ref) 1.00 1.0030-39 years 1.04 (0.70, 1.54) 0.86 0.87 (0.54, 1.40) 0.5640–49 years 0.95 (0.66, 1.38) 0.79 0.74 (0.46, 1.18) 0.20≥50 years 0.81 (0.54, 1.21) 0.31 0.63 (0.37, 1.05) 0.07Gender, n (%)Male (Ref) 1.00 1.00Female 1.13 (0.88, 1.45) 0.34 0.84 (0.60, 1.19) 0.32Transgender 0.49 (0.16, 1.49) 0.21 0.24 (0.04, 1.05) 0.06City, n (%)Vancouver (Ref) 1.00 1.00Toronto 0.76 (0.57, 1.01) 0.06 1.10 (0.77, 1.59) 0.60Ottawa 0.88 (0.66, 1.17) 0.37 0.90 (0.63, 1.27) 0.55Born in Canada, n (%) 1.40 (1.00, 1.96) 0.05 0.89 (0.53, 1.49) 0.65Racial/cultural group, n (%)White (Ref) 1.00 1.00Black/African-Canadian 0.69 (0.45, 1.07) 0.10 0.76 (0.41, 1.39) 0.37First Nations/Aboriginal 0.96 (0.70, 1.33) 0.82 0.80 (0.54, 1.17) 0.24Mixed ethnicity 1.35 (0.81, 2.25) 0.26 1.34 (0.68, 2.25) 0.49Other 0.31 (0.15, 0.62) <0.01 0.28 (0.11, 0.69) <0.01Highest level of education, n (%)Some post-secondary education or higher (Ref) 1.00 1.00Completed high school or equivalent 0.80 (0.58, 1.11) 0.18 0.67 (0.46, 1.00) 0.05Some high school 0.96 (0.73, 1.26) 0.75 0.93 (0.67, 1.29) 0.66Employed in past 12 months, n (%) 1.16 (0.91, 1.47) 0.23 1.40 (1.03, 1.91) 0.03Lifetime duration of homelessness (years), mean (SD) 1.02 (0.99, 1.04) 0.07 1.01 (0.98, 1.03) 0.59VAS score (perceived state of health), mean (SD) 0.98 (0.97, 0.99) <0.01 1.00 (0.99, 1.01) 0.51EQ_5D, mean (SD) 0.06 (0.03, 0.11) <0.01 0.21 (0.09, 0.53) <0.01Been victim of a sexual assault over past 12 months, n (%) 1.95 (1.30, 2.93) <0.01 1.23 (0.73, 2.08) 0.44Has a provincial health card number, n (%) 0.83 (0.58, 1.17) 0.29 0.68 (0.44, 1.04) 0.08Has a primary care provider, n (%) 0.78 (0.61, 0.99) 0.04 0.63 (0.46, 0.85) <0.01SF-12 PCS, mean (SD) 0.96 (0.95, 0.97) <0.01 0.98 (0.96, 0.99) <0.01SF-12 MCS, mean (SD) 0.96 (0.95, 0.97) <0.01 0.97 (0.96, 0.98) <0.01Number of chronic health conditions, n (%)0 (Ref) 1.00 1.001 1.54 (0.95, 2.51) 0.08 1.26 (0.71, 2.22) 0.432 2.00 (1.22, 3.29) <0.01 1.50 (0.83, 2.69) 0.18≥ 3 3.66 (2.38, 5.64) <0.01 2.17 (1.24, 3.79) <0.01Ever diagnosed with a mental health disorder, n (%) 1.65 (1.29, 2.09) <0.01 1.13 (0.84, 1.53) 0.41Argintaru et al. BMC Public Health 2013, 13:577 Page 6 of 9http://www.biomedcentral.com/1471-2458/13/577however, gender differences were not explored in eitheranalysis [33]. Interestingly, participants who were employedin the previous 12 months were more likely to have unmetneeds for health care, possibly due to competing prioritiesbetween health and employment, incompatibility betweenthe hours of employment and hours of care, difficultykeeping appointments, or decreased exposure to commu-nity and shelter-based health care programs [35].Participants’ health status remained a key factor in thelikelihood of reporting unmet needs for health care,particularly when identified by the SF-12 mental andphysical summary measures and self-reported chronichealth conditions. A lower health-related quality of life,identified by the EQ-5D instrument, was also significantlyassociated with a higher likelihood of reporting unmetneeds for care.Taken together, our findings suggest that, despite theuniversal provision of health insurance, barriers still existto accessing health services, particularly among thoseindividuals who have extremely poor health status and aremost in need of health care. These barriers may be relatedto non-financial factors such as lack of knowledge aboutwhere to obtain care, lack of transportation, lack ofchild care, long waiting times, perceived discrimin-ation in health care settings, and competing prioritiesfor subsistence needs [13,15,36,37]. Addressing poten-tial barriers to accessing health care in Canada willalso require the creation of policies that acknowledgethe social determinants of health, in particular theprovision of stable housing [36].LimitationsHealth status and health care access were assessed on thebasis of self-report. Although self-reported needs for careare a recognized indicator of health care access, theypresent a subjective participant viewpoint. Previous re-search has shown homeless populations tend to under-report health issues [38]. Additionally, when reportingunmet needs for health care, individuals may not be awareof what care that is in fact available to them or may expecttherapy that is not necessarily appropriate. Recruitment ofsome vulnerably housed participants from sites that pro-vide health services (e.g., community health centres) mayhave resulted in a slight over-representation in our sampleof vulnerably housed individuals who are better able toaccess care.The criteria used to enrol study participants resulted insignificant similarities between the groups of homelessand vulnerably housed participants. However, this resulthighlights the dynamic nature of homelessness and theconsiderable overlap between individuals who reside inlow quality housing, in shelters or on the streets [6].Geographic factors and differences in health careprovision across cities were not specifically addressed inthis study. Gender-specific analyses, which may shedlight on the unique health care needs of women versusmen, were not performed. Self-reported chronic healthconditions were required to be diagnosed by a healthprofessional, which may result in a under-reporting ofchronic health conditions in participants who were unableto access care. Further studies and analysis is required toeffectively assess the role of mental health and specificmental health disorders in unmet needs for health care.Lastly, the study’s cross-sectional design is unable toexplore the casual association between changes in housingstatus and quality of housing on an individual’s ability toaccess care. Further research by our group will investigatechanges in health status as well as health care access andassociations with housing status using longitudinal datafrom the HHiT study.ConclusionsThis study identified no differences in the likelihood ofunmet health care needs between homeless and vulnerablyhoused adults, highlighting that both populations facesignificant challenges in accessing health care. Homelessand vulnerably housed individuals with multiple chronichealth conditions, worse health status, or no primary careprovider were more likely to report unmet needs for healthcare. It is therefore important to develop policies andprograms that are accessible, available, and appropriate forhomeless and vulnerably housed individuals in order tomeet their health care needs. Despite Canada’s universalhealth insurance system, homeless and vulnerably housedpopulations face barriers to meeting health care needs.Future studies should identify the types of health care thatare lacking and effective strategies to reduce barriers toaccessing care.Table 3 Unmet needs for health care in participants diagnosed with mental health conditionsMental health disorder All participants(n = 600)3Unmet needs forcare (n = 260)No unmet needsfor care (n = 340)Bivariate ModelOR (95% CI)pMood disorder (including bipolar disorder, depression,manic disorder)453 (38.6%) 207 (46.5%) 246 (33.5%) 1.73 (1.36, 2.20) <0.01Anxiety disorder (including generalized anxiety disorder,OCD, panic disorder, phobia, PTSD)256 (21.7%) 129 (29.0%) 127 (17.3%) 1.96 (1.48, 2.57) <0.01Schizophrenia and other psychotic disorders 78 (6.6%) 26 (5.8%) 52 (7.1%) 0.82 (0.50, 1.33) 0.413Participants were allowed to report more than one mental health diagnosis, therefore total does not equal sum of column.Argintaru et al. BMC Public Health 2013, 13:577 Page 7 of 9http://www.biomedcentral.com/1471-2458/13/577Competing interestsThe authors declare that they have no competing interests.Authors’ contributionsAll of the authors contributed to the study concept and design. SH, SF, AP,FK and EG acquired the data. NA and CC performed the statistical analysis.SF, AP, FK and EG contributed to the analysis. They, along with SH and CCand interpreted the data. NA drafted the manuscript, and all of the authorscritically revised it for important intellectual content and approved the finalversion submitted for publication.AcknowledgementsThe Centre for Research on Inner City Health in the Li Ka Shing KnowledgeInstitute at St. Michael’s Hospital gratefully acknowledges the support of theOntario Ministry of Health and Long-Term Care. The authors thank RosaneNisenbaum and Ying Di, Centre for Research on Inner City Health, for expertprogramming and analyses. We would like to acknowledge the followingindividuals from our community partner organizations: Laura Cowan, LizEvans, Sarah Evans, Stephanie Gee, Clare Haskel, Erika Khandor, and WendyMuckle. The authors also thank the shelter, drop-in, and municipal andprovincial staff for their assistance with participant recruitment andfollow-up. The views expressed here are the views of the authors and do notnecessarily reflect the views of the Ontario Ministry of Health and Long-TermCare or any of the other named individuals or organizations.Author details1Centre for Research on Inner City Health, Keenan Research Centre in the LiKa Shing Knowledge Institute, St. Michael’s Hospital, Toronto, ON, Canada.2Institute of Mental Health Research, University of Ottawa, Ottawa, ON,Canada. 3Department of Medicine, University of British Columbia, Vancouver,BC, Canada. 4School of Geography and Environmental studies, CarltonUniversity, Ottawa, ON, Canada.Received: 14 September 2012 Accepted: 28 May 2013Published: 13 June 2013Reference1. Gordon L: Shelter - Homelessness in a growth economy. In Foundation forEthics in Leadership. Calgary: Sheldon Chumir Foundation; 2007.2. Burt M, Aron L, Lee E, Valente J: Helping America’s Homeless: EmergencyShelter or Affordable Housing?. Washington DC: Urban Institute Press; 2001.3. 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Weinreb L, Perloff J, Goldberg R, Lessard D, Hosmer DW:Factors associated with health service utilization patterns inlow-income women. J Health Care Poor Underserved 2006,17:180–199.38. Gelberg L, Linn LS: Demographic differences in health status of homelessadults. J Gen Intern Med 1992, 7:601–608.doi:10.1186/1471-2458-13-577Cite this article as: Argintaru et al.: A cross-sectional observational studyof unmet health needs among homeless and vulnerably housed adultsin three Canadian cities. BMC Public Health 2013 13:577.Submit your next manuscript to BioMed Centraland take full advantage of: • Convenient online submission• Thorough peer review• No space constraints or color figure charges• Immediate publication on acceptance• Inclusion in PubMed, CAS, Scopus and Google Scholar• Research which is freely available for redistributionSubmit your manuscript at www.biomedcentral.com/submitArgintaru et al. 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