Risk of death among homeless women: a cohort study and review of the literature

Abstract

Background: 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.

Methods: 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).

Results: 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.

Interpretation: 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.

Fig. 1: Rate ratios comparing mortality rates among homeless women with those among women in the general public. Younger and older age groups were defined, respectively, as 18–44 and 45–64 years for the Toronto and Boston studies, 15–44 and 45–64 years for the Copenhagen study, 20–44 and 45–64 years for the New York study, and 15–54 and 55–74 years for the Philadelphia study. Younger age group was defined as 14–25 years for the Montreal study. Bars indicate the 95% confidence intervals (when available). NA = not available.

Fig. 2: Rate ratios comparing mortality rates among homeless women and homeless men. Younger and older age groups were defined, respectively, as 16–44 and 45–64 years for the Brighton study; age groups for the other studies are defined in the caption to Fig. 1. Bars indicate the 95% confidence intervals (when available), and open diamonds represent rate ratios comparing mortality rates among women and men in the general population.