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Original Investigation
September 2018

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

Author Affiliations
  • 1Department of Social and Behavioral Sciences, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
  • 2Center for Community-Based Research, Dana-Farber Cancer Institute, Boston, Massachusetts
  • 3Boston Health Care for the Homeless Program, Boston, Massachusetts
  • 4Division of General Internal Medicine, Massachusetts General Hospital, Boston
  • 5Centre for Urban Health Solutions, St Michael’s Hospital, Toronto, Ontario, Canada
  • 6Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
JAMA Intern Med. 2018;178(9):1242-1248. doi:10.1001/jamainternmed.2018.2924
Key Points

Question  What are the mortality patterns for unsheltered homeless adults who primarily sleep outdoors?

Findings  In this 10-year cohort study of 445 unsheltered homeless adults, the age-standardized all-cause mortality rate was almost 3-fold larger than that for a cohort of homeless adults primarily sleeping in shelters and nearly 10-fold larger than that for the adult population of Massachusetts; both represented significant differences. Common causes of death were cancer and heart disease.

Meaning  Interventions and models of care need to address the unique needs of the unsheltered homeless adult population to improve outcomes.


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.

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