An investigation of racial/ethnic disparities in service use among severely mentally ill homeless adults, US 1994-1997

Background. It is unknown whether disparities also encumber the care of severely mentally ill and homeless (SMIH) adults. Methods. Baseline self-reports of utilization of health and social services by participants in the Access to Community Care and Effective Services and Support (ACCESS) study were used to assess disparities in usual care. Models only controlled for clinical and/or social need differences. Analyses properly accounted for the skewed utilization distribution and for missing data. Results. The 3-group ACCESS sample (n = 6,829) consisted of 50% African-American and 6% Latino SMIH persons. Latinos were highly concentrated geographically and only 16% of them (n = 59) preferred Spanish. Unadjusted results suggested that relative to whites, Latinos used more substance use services and African-Americans received more public supports. However, adjusted analyses only confirmed the latter finding (OR =1.42, 95% CI 1.27 -1.54). The finding of a greater utilization of case management by African-Americans (OR =1.38, 95% CI 1.25 -1.51) and Latinos (OR =1.30, 95% CI 1.05 -1.60) evaporated upon controlling for state. The higher utilization of vocational services by Latinos (OR =1.38, 95% CI 1.02 -1.86) also evaporated after controlling for state. Latinos had lower odds of utilization of the remaining health and social services, yet neither achieved significance perhaps due to insufficient power. Conclusions. Although we found little evidence of inequity, this finding appeared to be confounded by the unequal geographic distribution of the groups. Moreover, Latinos may have a lower utilization of services, particularly health services. Clinical and policy implications are discussed.