Canadian Journal of Public Health

, Volume 93, Issue 6, pp 407–410 | Cite as

Is Homelessness Hazardous to Your Health?

Obstacles to the Demonstration of a Causal Relationship
  • Stephen W. Hwang


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.


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.


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Copyright information

© The Canadian Public Health Association 2002

Authors and Affiliations

  1. 1.Inner City Health Research Unit, St. Michael’s HospitalUniversity of TorontoTorontoCanada

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