Risk of death among homeless women
From the Women\'s Health Program, University Health Network (Cheung), the Inner City Health Research Unit, St. Michael\'s Hospital (Hwang), and the Department of Medicine, University of Toronto (Cheung, Hwang), Toronto, Ont.
Homeless people are at high risk for illness and have higher death rates than the general population. Patterns of mortality among homeless men have been investigated, but less attention has been given to mortality rates among homeless women.
We report mortality rates and causes of death in a cohort of women who used homeless shelters in Toronto. We also compare our results with those of other published studies of homeless women and with data for women in the general population.
A cohort of 1981 women not accompanied by dependent children who used homeless shelters in Toronto in 1995 was observed for death over a mean of 2.6 years. In addition, we analyzed data from published studies of mortality rates among homeless women in 6 other cities (Montreal, Copenhagen, Boston, New York, Philadelphia and Brighton, UK).
In Toronto, mortality rates were 515 per 100 000 person-years among homeless women 18?44 years of age and 438 per 100 000 person-years among those 45?64 years of age. Homeless women 18?44 years of age were 10 times more likely to die than women in the general population of Toronto.
In studies from a total of 7 cities, the risk of death among homeless women was greater than that among women in the general population by a factor of 4.6 to 31.2 in the younger age group and 1.0 to 2.0 in the older age group. In 6 of the 7 cities, the mortality rates among younger homeless women and younger homeless men were not significantly different.
In contrast, in 4 of the 6 cities, the mortality rates were significantly lower among older homeless women than among older homeless men.
Excess mortality is far greater among homeless women under age 45 years than among older homeless women. Mortality rates among younger homeless women often approach or equal those of younger homeless men. Efforts to reduce deaths of homeless women should focus on those under age 45.
Homelessness is an important problem in the United States, Canada and the United Kingdom. Earlier studies have documented the high burden of illness among homeless people due to mental illness and addictions, medical conditions, tuberculosis and HIV infection, and traumatic injuries. These illnesses, in conjunction with severe poverty and often inadequate access to health care, lead to high mortality rates among homeless people.
Previous studies have focused on excess mortality observed among homeless people relative to their counterparts in the general population.
In Philadelphia, the mortality rate among homeless adults was 3.5 times higher than the rate in the general population. In a study of homeless people in Boston, mortality rates among men were 5.9, 3.0 and 1.6 times higher than those in the general population for people 18?24, 25?44 and 45?64 years of age respectively.
A study of people using homeless shelters in New York found age-adjusted death rates 2 to 3 times higher than those in the city\'s general population. Among men using homeless shelters in Toronto, mortality rates were 8.3, 3.7 and 2.3 times higher than rates among men in the general population aged 18?24, 25?44 and 45?64 years respectively.
Although a significant proportion of homeless people are women, relatively little attention has been focused on patterns of mortality in this subgroup. Among homeless people, single men, single women and women accompanied by children tend to have different health problems.
For example, the prevalence of substance abuse is lower among homeless single women than among homeless single men, but the rate of major depression is higher.
Such differences may have an effect on mortality rates. In this study, we focus on homeless single women, who tend to have more health problems than homeless women accompanied by children.
In the general population, mortality rates among younger women are one-third to one-half those among younger men. Low socioeconomic status is strongly associated with shorter life expectancy, but within every socioeconomic stratum women have a longer life expectancy than men do.
Whether this survival advantage is attenuated or lost altogether among homeless women is an important question, because the underlying mechanisms (e.g., addictions leading to drug overdose, or depression leading to suicide) might be amenable to targeted intervention.
We therefore conducted this study to determine whether homeless women lose the survival advantage associated with being female.
Our first objective was to determine mortality rates among women who use homeless shelters in Toronto. Our second objective was to analyze published data on mortality rates among homeless women compared with those among women in the general population and among homeless men.
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