Mortality Among Unsheltered Homeless Adults in Boston, Massachusetts, 2000-2009

Abstract

IMPORTANCE Previous studies have shown high mortality rates among homeless people in general, but little is known about the patterns of mortality among "rough sleepers," the subgroup of unsheltered urban homeless people who avoid emergency shelters and primarily sleep outside. OBJECTIVES To assess the mortality rates and causes of death for a cohort of unsheltered homeless adults from Boston, Massachusetts. DESIGN, SETTING, AND PARTICIPANTS A 10-year prospective cohort study (2000-2009) of 445 unsheltered homeless adults in Boston, Massachusetts, who were seen during daytime street and overnight van clinical visits performed by the Boston Health Care for the Homeless Program's Street Team during 2000. Data used to describe the unsheltered homeless cohort and to document causes of death were gathered from clinical encounters, medical records, the National Death Index, and the Massachusetts Department of Public Health death occurrence files. The study data set was linked to the death occurrence files by using a probabilistic record linkage program to confirm the deaths. Data analysis was performed from May 1, 2015, to September 6, 2016. EXPOSURE Being unsheltered in an urban setting. MAIN OUTCOMES AND MEASURES Age-standardized all-cause and cause-specific mortality rates and age-stratified incident rate ratios that were calculated for the unsheltered adult cohort using 2 comparison groups: the nonhomeless Massachusetts adult population and an adult homeless cohort from Boston who slept primarily in shelters. RESULTS Of 445 unsheltered adults in the study cohort, the mean (SD) age at enrollment was 44 (11.4) years, 299 participants (67.2%) were non-Hispanic white, and 72.4% were men. Among the 134 individuals who died, the mean (SD) age at death was 53 (11.4) years. The all-cause mortality rate for the unsheltered cohort was almost 10 times higher than that of the Massachusetts population (standardized mortality rate, 9.8; 95% CI, 8.2-11.5) and nearly 3 times higher than that of the adult homeless cohort (standardized mortality rate, 2.7; 95% CI, 2.3-3.2). Non-Hispanic black individuals had more than half the rate of death compared with non-Hispanic white individuals, with a rate ratio of 0.4 (95% CI, 0.2-0.7; P < .001). The most common causes of death were noncommunicable diseases (eg, cancer and heart disease), alcohol use disorder, and chronic liver disease. CONCLUSIONS AND RELEVANCE Mortality rates for unsheltered homeless adults in this study were higher than those for the Massachusetts adult population and a sheltered adult homeless cohort with equivalent services. This study suggests that this distinct subpopulation of homeless people merits special attention to meet their unique clinical and psychosocial needs.

Health Literacy and Self-Rated Health among Homeless Adults

“…As hypothesized, individuals who were health literate reported better selfrated health compared to those who were only somewhat/a little bit/not at all confident completing medical forms by themselves. Results are consistent with previous studies conducted amongst domiciled samples linking health literacy with self-rated health (Fernandez, Larson, & Zikmund-Fisher, 2016;Marques et al, 2018) and extend these findings to a group with a (Baggett, Liauw, & Hwang, 2018;Chang et al, 2015;Roncarati et al, 2018). Based on our current results, we propose that special attention and intervention is needed among homeless individuals with poor health literacy levels to improve their ability to understand and process health information, which may ultimately impact their self-rated health.…”

Surviving versus living life: Capabilities and service use among adults with mental health problems and histories of homelessness

“…People with mental health problems are overrepresented in the homeless population (Fazel, Khosla, Doll, & Geddes, ), which experiences pervasive impairments of capabilities. For example, homelessness is associated with a heightened risk of dying prematurely ( life ; Fazel, Geddes, & Kushel, ; Nicholls, ; Roncarati et al, ), developing chronic medical conditions ( bodily health ; Beijer, Wolf, & Fazel, ; Fazel et al, ), having poor nutrition ( bodily health ; O’Campo et al, ), being assaulted ( bodily integrity ; Kushel, Evans, Perry, Robertson, & Moss, ; Nicholls, ), experiencing stigmatisation and discrimination ( affiliation ; Phelan, Link, Moore, & Stueve, ; Skosireva et al, ), and being unemployed and encountering barriers in returning to the workforce ( practical reason ; Poremski, Distasio, Hwang, & Latimer, ; Poremski, Whitley, & Latimer, ). Moreover, mental health problems compounds the negative effects that poverty has on capabilities.…”

Is precariousness the blind spot of prevention and treatment of the use of psychoactive substances?

“…Its impact will have been particularly important among the oldest DU who started their injections in the 1980s and paid a high toll to HIV before the introduction of HAART (42) and, until 1996, to overdoses before the liberalization of OST prescription as evidenced by the rst cohort study of the OFDT conducted from 1992 to 2002, which was already too late to measure the real impact of the HIV epidemic (36). A higher death-rate related to precariousness could participate in this decline (43,44).…”