Abstract
Background: Homeless people suffer from high levels of morbidity and mortality, but there is surprisingly little empiric evidence that homelessness has a direct adverse effect on health.
Methods: This study examined the relationship between shelter use and risk of death using longitudinal data in a cohort of 8,769 homeless men in Toronto, Ontario. Shelter use was modelled as a time-dependent covariate in a Cox regression analysis.
Results: In a model adjusted for age and previous pattern of homelessness, the risk of death during months in which homeless shelters were used was significantly increased (hazard ratio, 1.84; 95% confidence interval, 1.27–2.67).
Conclusions: Among men, periods of homeless shelter use are associated with higher mortality. There are three reasons why this finding does not necessarily mean that homelessness itself increases the risk of death. First, the hazard of death associated with shelter use compared to non-shelter use may be significantly different from that associated with homelessness compared to non-homelessness. Second, the association between shelter use and risk of death may be confounded by other variables such as alcohol and drug use. Finally, because the mechanism and time-course of the putative effect of homelessness on health is uncertain, appropriate modelling of the time-dependent covariate is difficult to ensure. Further research into the possible adverse effects of homelessness on health is needed and would have important implications for public policy.
Résumé
Contexte: Les sans-abri présentent des taux de morbidité et de mortalité élevés, mais les preuves empiriques des effets indésirables de la clochardise sur la santé sont étonnamment rares.
Méthode: À l’aide de données longitudinales, nous avons étudié le lien entre l’hébergement en maison pour sans-abri et le risque de décès dans une cohorte de 8 769 hommes sans abri à Toronto (Ontario). L’hébergement en maison pour sans-abri a été modélisé comme covariable chronologique d’une analyse de régression de type Cox.
Résultats: Selon notre modèle, ajusté selon l’âge et les épisodes antérieurs de clochardise, le risque de décès durant les mois d’hébergement en maison pour sans-abri présentait une hausse significative (coefficient de risque: 1,84; intervalle de confiance de 95% = 1,27–2,67).
Conclusions: Chez les hommes, les périodes d’hébergement en maison pour sans-abri sont associées à un taux de mortalité supérieur. Mais pour trois raisons, cette constatation ne signifie pas nécessairement que la clochardise accroît en soi le risque de décès. Premièrement, le risque associé à l’hébergement en maison pour sans-abri, par comparaison avec le non-hébergement dans ces maisons, peut différer de manière significative du risque associé à la clochardise par comparaison avec la non-clochardise. Deuxièmement, d’autres variables, comme la consommation d’alcool et de drogues, peuvent brouiller l’association entre l’hébergement en maison pour sansabri et le risque de décès. Troisièmement, comme on ignore le mécanisme et l’évolution dans le temps de l’effet présumé de la clochardise sur la santé, il est difficile de modéliser convenablement la covariable chronologique. Il faudrait pousser la recherche sur les éventuels effets indésirables de la clochardise sur la santé, ce qui aurait d’importantes incidences sur les politiques gouvernementales.
References
- 1.Breakey WR, Fischer PJ, Kramer M, Nestadt G, Romanoski AJ, Ross A, et al. Health and mental health problems of homeless men and women in Baltimore. JAMA. 1989;262:1352–57. doi: 10.1001/jama.1989.03430100086034. [DOI] [PubMed] [Google Scholar]
- 2.Koegel P, Burnam A, Farr RK. The prevalence of specific psychiatric disorders among homeless individuals in the inner city of Los Angeles. Arch Gen Psychiatry. 1988;45:1085–92. doi: 10.1001/archpsyc.1988.01800360033005. [DOI] [PubMed] [Google Scholar]
- 3.Susser E, Struening EL, Conomver S. Psychiatric problems in homeless men: Lifetime psychosis, substance use, and current distress in new arrivals at New York City shelters. Arch Gen Psychiatry. 1989;46:845–50. doi: 10.1001/archpsyc.1989.01810090087012. [DOI] [PubMed] [Google Scholar]
- 4.Gelberg L, Linn LS, Usatine RP, Smith MH. Health, homelessness, and poverty. A study of clinic users. Arch Intern Med. 1990;150:2325–30. doi: 10.1001/archinte.1990.00390220069014. [DOI] [PubMed] [Google Scholar]
- 5.Ferenchick GS. Medical problems of homeless and nonhomeless persons attending an inner-city health clinic: A comparative study. Am J Med Sci. 1991;301:379–82. doi: 10.1097/00000441-199106000-00004. [DOI] [PubMed] [Google Scholar]
- 6.Fischer PJ, Breakey WR. The epidemiology of alcohol, drug, and mental disorders among homeless persons. Am Psychologist. 1991;46:1115–28. doi: 10.1037/0003-066X.46.11.1115. [DOI] [PubMed] [Google Scholar]
- 7.Gelberg L, Linn LS. Demographic differences in health status of homeless adults. J Gen Intern Med. 1992;7:601–8. doi: 10.1007/BF02599198. [DOI] [PubMed] [Google Scholar]
- 8.Power R, French R, Connelly J, George S, Hawes D, Hinton T, et al. Health, health promotion, and homelessness. BMJ. 1999;318:590–92. doi: 10.1136/bmj.318.7183.590. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9.Johnson TP, Freels SA, Parsons JA, Vangeest JB. Substance abuse and homelessness: Social selection or social adaptation? Addiction. 1997;92:437–45. doi: 10.1111/j.1360-0443.1997.tb03375.x. [DOI] [PubMed] [Google Scholar]
- 10.Susser E, Moore R, Link B. Risk factors for homelessness. Epidemiol Rev. 1993;15:546–56. doi: 10.1093/oxfordjournals.epirev.a036133. [DOI] [PubMed] [Google Scholar]
- 11.Brickner PW, Scharer LK, Conanan B, Elvy A, Savarese M, editors. Health Care of Homeless People. New York, NY: Springer Publishing Co.; 1985. [Google Scholar]
- 12.Stark LR. Barriers to health care for homeless people. In: Jahiel RI, editor. Homelessness: A Prevention-Oriented Approach. Baltimore, MD: Johns Hopkins University Press; 1992. pp. 151–64. [Google Scholar]
- 13.Hibbs JR, Benner L, Klugman L, Spencer R, Macchia I, Mellinger AK, et al. Mortality in a cohort of homeless adults in Philadelphia. N Engl J Med. 1994;331:304–9. doi: 10.1056/NEJM199408043310506. [DOI] [PubMed] [Google Scholar]
- 14.Hwang SW, Orav E O, Connell JJ, Lebow JM, Brennan TA. Causes of death in homeless adults in Boston. Ann Intern Med. 1997;126:625–28. doi: 10.7326/0003-4819-126-8-199704150-00007. [DOI] [PubMed] [Google Scholar]
- 15.Barrow SM, Herman DB, Cordova P, Struening EL. Mortality among homeless shelter residents in New York City. Am J Public Health. 1999;89:529–34. doi: 10.2105/AJPH.89.4.529. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 16.Hwang SW. Mortality among men using homeless shelters in Toronto, Ontario. JAMA. 2000;283:2152–57. doi: 10.1001/jama.283.16.2152. [DOI] [PubMed] [Google Scholar]
- 17.Roy E, Boivin JF, Haley N, Lemire N. Mortality among street youth. Lancet. 1998;352:32. doi: 10.1016/S0140-6736(05)79510-6. [DOI] [PubMed] [Google Scholar]
- 18.Shaw M, Dorling D. Mortality among street youth in the UK. Lancet. 1998;352:743. doi: 10.1016/S0140-6736(05)60868-9. [DOI] [PubMed] [Google Scholar]
- 19.Shaw M, Dorling D, Brimblecombe N. Life chances in Britain by housing wealth and for the homeless and vulnerably housed. Environment and Planning A. 1999;31:2239–48. doi: 10.1068/a312239. [DOI] [Google Scholar]
- 20.Babidge NC, Buhrich N, Butler T. Mortality among homeless people with schizophrenia in Sydney, Australia: A 10-year follow-up. Acta Psychiatr Scand. 2001;103:105–10. doi: 10.1034/j.1600-0447.2001.00192.x. [DOI] [PubMed] [Google Scholar]
- 21.Alstrom CH, Lindelius R, Salum I. Mortality among homeless men. Br J Addict. 1975;70:245–52. doi: 10.1111/j.1360-0443.1975.tb00034.x. [DOI] [PubMed] [Google Scholar]
- 22.Hwang SW, Lebow JM, Bierer M O, Connell JJ, Orav EJ, Brennan TA. Risk factors for death in homeless adults in Boston. Arch Intern Med. 1998;158:1454–60. doi: 10.1001/archinte.158.13.1454. [DOI] [PubMed] [Google Scholar]
- 23.Hwang SW. Homelessness and health. CMAJ. 2001;164:229–33. [PMC free article] [PubMed] [Google Scholar]
- 24.Kuhn R, Culhane DP. Applying cluster analysis to test a typology of homelessness by pattern of shelter utilization: Results from the analysis of administrative data. Am J Community Psychol. 1998;26:207–32. doi: 10.1023/A:1022176402357. [DOI] [PubMed] [Google Scholar]
- 25.Homelessness: Programsthe People they Serve. Findings of the National Survey of Homeless Assistance Providers and Clients. Washington, DC: U.S. Dept. of Housing and Urban Development; 1999. [Google Scholar]
- 26.Culhane DP, Dejowski EF, Ibanez J, Needham E, Macchia I. Public shelter admission rates in Philadelphia and New York City: The implications of turnover for sheltered population counts. Housing Policy Debate. 1994;5:107–40. doi: 10.1080/10511482.1994.9521155. [DOI] [Google Scholar]
- 27.Fisher LD, Lin DY. Time-dependent covariates in the Cox proportional-hazards regression model. Annu Rev Public Health. 1999;20:145–57. doi: 10.1146/annurev.publhealth.20.1.145. [DOI] [PubMed] [Google Scholar]
- 28.Epidemiology of alcohol usealcohol-related consequences. In . Ninth Special Report to the U.S. Congress on Alcohol and Health. Rockville, MD: National Institute on Alcohol Abuse and Alcoholism; 1997. [Google Scholar]
- 29.Rosner B. Fundamentals of Biostatistics. 4th edition. Belmont, CA: Wadsworth Publishing Co.; 1995. pp. 399–402. [Google Scholar]
- 30.Gelberg L, Gallagher TC, Andersen RM, Koegel P. Competing priorities as a barrier to medical care among homeless adults in Los Angeles. Am J Public Health. 1997;87:217–20. doi: 10.2105/AJPH.87.2.217. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 31.Fuller-Thomson E, Hulchanski JD, Hwang SW. The housing/health relationship: What do we know? Reviews on Environmental Health. 2000;15(1–2):109–33. doi: 10.1515/reveh.2000.15.1-2.109. [DOI] [PubMed] [Google Scholar]
- 32.Rossi PH, Wright JD. The determinants of homelessness. Health Aff. 1987;6:19–32. doi: 10.1377/hlthaff.6.1.19. [DOI] [PubMed] [Google Scholar]