title: Examining the relationship between health-related need and the receipt of care by participants experiencing homelessness and mental illness.
abstract: BACKGROUND
  People experiencing homelessness and mental illness face multiple barriers to care. The goal of this study was to examine the association between health service use and indicators of need among individuals experiencing homelessness and mental illness in Vancouver, Canada. We hypothesized that those with more severe mental illness would access greater levels of primary and specialist health services than those with less severe mental illness.
  
  
  METHODS
  Participants met criteria for homelessness and current mental disorder using standardized criteria (n = 497). Interviews assessed current health status and involvement with a variety of health services including specialist, general practice, and emergency services. The 80th percentile was used to differentiate 'low health service use' and 'high health service use'. Using multivariate logistic regression analysis, we analyzed associations between predisposing, enabling and need-related factors with levels of primary and specialist health service use.
  
  
  RESULTS
  Twenty-one percent of participants had high primary care use, and 12% had high use of specialist services. Factors significantly (p ≤ 0.05) associated with high primary care use were: multiple physical illnesses [AOR 2.74 (1.12, 6.70]; poor general health [AOR 1.68 (1.01, 2.81)]; having a regular family physician [AOR 2.27 (1.27, 4.07)]; and negative social relationships [AOR 1.74 (1.01, 2.99)]. Conversely, having a more severe mental disorder (e.g. psychotic disorder) was significantly associated with lower odds of high service use [AOR 0.59 (0.35, 0.97)]. For specialist care, recent history of psychiatric hospitalization [AOR 2.53 (1.35, 4.75)] and major depressive episode [AOR 1.98 (1.11, 3.56)] were associated with high use, while having a blood borne infectious disease (i.e., HIV, HCV, HBV) was associated with lower odds of high service use.
  
  
  CONCLUSIONS
  Contrary to our hypotheses, we found that individuals with greater assessed need, including more severe mental disorders, and blood-borne infectious diseases had significantly lower odds of being high health service users than those with lower assessed needs. Our findings reveal an important gap between levels of need and service involvement for individuals who are both homeless and mentally ill and have implications for health service reform in relation to the unmet and complex needs of a marginalized sub-population. (
  
  
  BACKGROUND
  ISRCTN57595077 and ISRCTN66721740).
authors.affiliation: Faculty of Health Sciences, Simon Fraser University, 8888 University Drive, Burnaby V5A 1S6, BC, Canada. clauren@sfu.ca.
authors.forename: Lauren B
authors.initials: LB
authors.lastname: Currie
authors.forename: Michelle L
authors.initials: ML
authors.lastname: Patterson
authors.forename: Akm
authors.initials: A
authors.lastname: Moniruzzaman
authors.forename: Lawrence C
authors.initials: LC
authors.lastname: McCandless
authors.forename: Julian M
authors.initials: JM
authors.lastname: Somers
mesh_terms: D000328:Adult; D001955:British Columbia; D005260:Female; D006296:Health Services / Q000706:statistics & numerical data*; D006297:Health Services Accessibility; D006301:Health Services Needs and Demand; D006703:Ill-Housed Persons; D006801:Humans; D007407:Interviews as Topic; D016015:Logistic Models; D008297:Male; D028642:Persons with Psychiatric Disorders; D008875:Middle Aged; D017060:Patient Satisfaction; D036301:Qualitative Research