Competing Priorities as a Barrier to
Medical Care among Homeless Adults
in Los Angeles
Lilliani Gelberg, MD, MSPH, Teresa C. Gallagher PhD,
Roniald M. Anidersen, PhD, and Palul Koegel, PhD
Introduction
'Competing priorities" are hypoth-
esized to be a major barrier to the
utilization of health services among home-
less adults.4NMuch of the social life of
homeless adults centers around meeting
their basic needs for food, shelter, and
safety, which they perceive as higher
priority needs than issues of health or
illness.8 Of those few studies that have
empirically examined the utilization of
health services among homeless adults,
however, none have explicitly explored
the role of competing priorities as a
bamrer to care.9-14
Data collected in the UCLA Home-
less Health Study. a community-based
survey of homeless adults conducted in
Los Angeles in 1991, afford us the
opportunity to empirically assess the role
of competing needs as a barrier to the
utilization of physical health services
among the homeless. (See reference 14
for an analysis of the utilization of mental
health and substance abuse treatment
services in a related homeless cohort.)
Consistent with Andersen's Behavioral
Model.,'56 we hypothesized that compet-
ing priorities would be most important in
predicting the utilization of health ser-
vices perceived as discretionary and less
important in predicting the utilization of
less discretionary health services.
Methods
Slubjects anid Procedutres
The sample for the UCLA Homeless
Health Study is a subset of the RAND
Course of Homelessness (COH) Study
sample collected in 1990/91. (The study
design and sampling procedures of the
COH Study are described in detail else-
where.'7 '8) The COH study was based on
a probability sample of 1563 homeless
adults in the two areas of Los Angeles
County having the largest concentrations
of homeless persons the urban down-
town area (Skid Row) and a Los Angeles
suburb (Westside). From the COH base-
line sample, a random stratified sub-
sample of 485 persons was drawn for
longitudinal follow-up. One year later, the
389 persons remaining in the panel were
asked to participate in the UCLA Home-
less Health Study, and 363 agreed to
participate. The Health Study consisted of
individual, in-person interviews con-
ducted by trained lay interviewers who
followed a structured protocol; a limited,
lay-administered physical examination;
and a tuberculosis skin test. Respondents
received $10 for completing the baseline
COH interview, $5 for completing the
health interview and physical examina-
tion, and $5 on their return for a reading of
the tuberculosis test.
Measures
Our dependent variables are four
self-reported measures of health services
utilization for physical illness or injury:
the likelihood of having a regular source
of care (current); having gone without
needed medical care (prior 12 months);
having made an outpatient physician visit
Lillian Gelberg is with the Division of Farmily
Medicine, and Ronald M. Andersen is with the
School of Public Health. University of Califor-
nia. Los Angeles (UCLA). At the time of the
study. Teresa C. Gallagher was with the UCLA
School of Public Health. Paul Koecel is with the
RAND Corporation. Santa Monica, Calif.
Requests for reprints should be sent to
Lillian Gelberg. MD. MSPH. UCLA Division of
Family Medicine, Room 50-071 Center for the
Health Sciences, Box 951683. Los Angeles. CA
90095-1683.
This paper was accepted October 24. 1996.
American Journal of Public Health 217
Gelberg et al.

adult homeless population in the two Los

TABLE 1-Demographic and TABLE 2-Unadjusted Odds Angeles sites studied. Using these weights,
Health Character- Ratios (ORs) of we describe the extent of subsistence
istics of UCLA Home- Selected Health difficulty in our sample, calculate the
less Health Study Services Utilization unadjusted odds of health services utiliza-
Sample (n = 363), Outcomes among tion for those with frequent (vs infre-
Los Angeles, 1991 Members of UCLA
Homeless Health quent) subsistence difficulty, and then
Characteristic % Study with Frequent adjust the odds for a range of predispos-
Subsistence Difficulty, ing, enabling, and need characteristics
Demographic Los Angeles, 1991 assumed to influence the utilization of
Male 80.2 physical health services among the home-
Age > 18-41 y
OR 95% Cl less.
62.2
Race
White 18.5 Regular source of 0.30 0.16, 0.53
Black 55.9 care Results
Hispanic 16.0 Went without 1.77 1.04, 3.00
Other 9.6 needed medical Eighty percent of our sample were
Less than high school 32.0 care in past year male, 63% were between the ages of 18
education Outpatient visit in 0.69 0.41,1.15
past year and 41, and slightly over half were Black
Veteran 26.1 (see Table 1). Only 7% were living with a
Hospitalized in 1.41 0.70, 2.82
past year spouse or partner, and 3% with one or
Homelessness-related
more children (not shown in table). Most
Frequent subsistence difficulty 20.4 Note. Of the 363 subjects, 74 (20.4%) had been homeless for 1 year or less (not
Skid Row residence 67.5 reported that they usually (vs some-
Unsheltered 53.8 times, rarely, or never) had difficulty shown), and 54% had spent most of their
New to Los Angeles 33.0 meeting their subsistence needs. Cl = nights in the previous month in a place not
5 or more years since last 20.6 confidence interval. meant for sleeping. Five percent of the
housed respondents suffered from chronic mental
illness (without chronic substance depen-
Health-related dence), 50% from chronic substance de-
Fair or poor health 36.8 Other determinants of health ser- pendence (without chronic mental illness),
One or more index conditions 67.1 vices utilization treated as control vari- and 21% from chronic mental illness and
Chronic major mental illness ables in these analyses are derived from
or substance usea
chronic substance dependence.
None 23.8 the expanded Behavioral Model.'9 In the Forty-seven percent of the respon-
Chronic major mental illness 5.1 predisposing domain, they include demo- dents "rarely or never" had a problem in
Chronic substance abuse or 49.9 graphic characteristics (gender, age, race, meeting their subsistence needs in the
dependence education, veteran status) and social struc- previous 30 days; 32% "sometimes" had
Dual diagnosis 21.2
ture characteristics (new to Los Angeles,
Health insurance 34.2 a problem; and 21% "usually" had a
Skid Row location, shelter status, long- problem. Thirty-seven percent rated them-
aCategories are mutually exclusive. term homelessness, social isolation, selves as in fair or poor health. Forty-four
Definitions are based on data gathered chronic major mental illness and/or chronic percent reported a regular source of care,
with the Diagnostic Interview Sched- substance use). Psychiatric measures are and 31% had gone without needed medi-
ule, Version III-R,20 and the use of a
predetermined algorithm.21 based on use of the Diagnostic Interview cal care in the previous 12 months. Fifty-
Schedule, with some modifications for a three percent had had an outpatient visit,
homeless population.20,21 and 14% had been hospitalized for a phys-
Enabling characteristics controlled ical illness or injury in the previous year.
for include financial (health insurance) Table 2 presents the unadjusted odds
(prior 12 months); and having been and nonfinancial (social support, ability to ratios for the likelihood of each of our
hospitalized (prior 12 months). Our key negotiate bureaucratic systems) character- utilization measures among those with
independent variable is an index of self- stics. Measures of need for physical health frequent subsistence difficulty. Those with
reported difficulty in meeting subsistence services include self-perceived health sta- frequent difficulty were about one third as
needs. It was created by averaging scores tus, restricted activity days, bodily pain, likely as those with infrequent difficulty to
on five separate markers of subsistence and presence of study index conditions have a regular source of care, and almost
difficulty: frequency of difficulty in find- (hypertension, vision, skin/leg/foot condi- twice as likely to have gone without
ing shelter, enough to eat, clothing, a place tions, tuberculosis). Presence of index needed medical care. There was no sta-
to wash, and a place to use the bathroom conditions was based on personal inter- tistically significant impact of frequent
in the past 30 days. While the original view, physical examination, and tubercu- subsistence difficulty on the likelihood of
variable ranged from 1 ("never" had losis skin test. having had an outpatient visit or having
difficulty in meeting subsistence needs in been hospitalized. After adjustment for
the prior 30 days) to 4 ("usually" had Data Analysis potential confounding factors, these con-
difficulty), we dichotomized this variable To adjust for oversampling of se- clusions remained the same. However,
into those with frequent subsistence diffi- lected subgroups and attrition, each respon- after adjustment, those with frequent
culty (score > 3) and those with infre- dent in the UCLA Homeless Health Study subsistence difficulty were even more
quent difficulty (score ' 3) in these analy- was assigned a weight so that our likely than those with less frequent
ses. estimates would be representative of the difficulty to report having gone without

218 American Journal of Public Health February 1997, Vol. 87, No. 2

needed medical care in the past year (odds
ratio = 2.77, 95% confidence interval =
1.29, 5.33).
Discussion
This study lends empirical support to
the notion of competing priorities as an
important nonfinancial barrier to the util-
ization of physical health services among
homeless adults. Our findings are consis-
tent with those of Schlossstein et al., who
found that competing priorities (finding
housing or employment, keeping welfare
appointments, and finding child care)
were a barrier to the keeping of medical
referral appointments in a sample of
homeless women.--
Consistent with predictions of the
Behavioral Model, however, subsistence
difficulty had an inhibiting effect only on
more discretionary measures of health
services utilization-having a regular
source of care and perception of having
gone without needed medical care. It
appears that frequent subsistence diffi-
culty may be contributing to the observed
pattem of health behavior whereby home-
less adults do not seek preventive care or
care in the early stages of illness, but
delay seeking care until their need is
acute.1623 This pattem, in tum, may be
contributing to the high rate of hospitaliza-
tion among homeless adults, which is
often for neglected illnesses that could
have been prevented or treated in ambula-
tory care settings if identified earlier in the
course of illness.24
An important limitation of this analy-
sis is that it is based on cross-sectional
data. A competing interpretation of our
results is the converse of our hypothesis-
namely, that homeless adults who are less
likely to use health services are more
likely to have difficulty meeting their
subsistence needs because they are in
poorer health. However, we attempted to
rule out this possibility by controlling for
functional limitations and other aspects of
health status. Our measure of competing
priorities is limited in that it looks only at
difficulty in meeting subsistence needs
and ignores other competing needs that
may be important to homeless adults, such
as working for pay, procuring and consum-
ing drugs or alcohol, applying for jobs or
benefits, and taking care of children.
A major strength of our study is that
it is not shelter based and includes
homeless persons who do not use food
and shelter services. In this regard, it is
less likely than a shelter-based study to
underestimate the extent of subsistence
February 1997, Vol. 87, No. 2
difficulty and its implications for access to
medical care among the homeless. How-
ever, our conclusions are limited in
generalizability because this study is
based in a major metropolis, where many
health and social welfare services de-
signed to meet the subsistence needs of
the homeless are available. One might
expect the level of subsistence difficulty
and its implications for the utilization of
health services to be greater in smaller
cities and towns where there may be fewer
social welfare services for the homeless.25
Also, our sample includes only a small
number of homeless families, whose
pattems of health care needs and utiliza-
tion may differ in important ways from
those of single homeless adults. (See
reference 14 for an analysis of the
utilization of mental health and substance
abuse treatment services among homeless
adults by gender and family status.)
Conclusion
Any attempt to address the health
care needs of the homeless must take into
consideration their unmet needs for food,
clothing, shelter, and bathroom facilities.
Locating walk-in clinics where the home-
less congregate to receive subsistence
services would help to reduce the role of
time and scheduling constraints as barri-
ers to care. We should ensure that some of
these programs are linked to food ser-
vices, which may be available on a more
equitable basis and may be more widely
used than shelter services.
In addition, as health policy contin-
ues to encourage the transfer of the
medical care of the poor (including the
homeless) into managed care systems, it
will be important to consider the compet-
ing priorities of vulnerable populations
in planning how they will access these
systems of care and to monitor their
access on an ongoing basis. Gatekeeping
mechanisms designed to ration care may
lead homeless adults to further avoid
seeking care in the early stages of illness if
the care-seeking process becomes more
arduous or time-consuming. El
Acknowledgments
This study was supported in part by grant
ROI HS06696 from the Agency for Health
Care Policy and Research to Dr Gelberg and
by National Research Service award I T32
HS00046-01. It was conducted in conjunction
with the RAND Course of Homelessness
Study, which was funded by National Institute
of Mental Health grant 1 RO1 MH64121 to
Dr Koegel.
Barriers to Care
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