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Mortality among residents of shelters, rooming houses, and hotels in Canada: 11 year follow-up study

BMJ 2009; 339 doi: (Published 27 October 2009) Cite this as: BMJ 2009;339:b4036
  1. Stephen W Hwang, research scientist1, associate professor2,
  2. Russell Wilkins, senior research analyst3, adjunct professor4,
  3. Michael Tjepkema, senior research analyst5, MHSc candidate6,
  4. Patricia J O’Campo, director1, professor67,
  5. James R Dunn, chair in applied public health1, associate professor68910
  1. 1Centre for Research on Inner City Health, Keenan Research Centre, Li Ka Shing Knowledge Institute, St Michael’s Hospital, Toronto, ON, Canada
  2. 2Division of General Internal Medicine, Department of Medicine, University of Toronto, Toronto
  3. 3Health Information and Research Division, Statistics Canada, Ottawa
  4. 4Department of Epidemiology and Community Medicine, University of Ottawa, Ottawa
  5. 5Health Information and Research Division, Statistics Canada, Toronto
  6. 6Dalla Lana School of Public Health, University of Toronto, Toronto
  7. 7Department of Population, Reproductive and Family Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
  8. 8Department of Geography and Programme in Planning, University of Toronto, Toronto
  9. 9Successful Societies Program, Canadian Institute for Advanced Research, Toronto
  10. 10Department of Health, Aging and Society, McMaster University, Hamilton, ON
  1. Correspondence to: S W Hwang, Centre for Research on Inner City Health, St. Michael’s Hospital, 30 Bond Street, Toronto, ON, Canada M5B 1W8 hwangs{at}
  • Accepted 8 June 2009


Objective To examine mortality in a representative nationwide sample of homeless and marginally housed people living in shelters, rooming houses, and hotels.

Design Follow-up study.

Setting Canada 1991-2001.

Participants 15 100 homeless and marginally housed people enumerated in 1991 census.

Main outcome measures Age specific and age standardised mortality rates, remaining life expectancies at age 25, and probabilities of survival from age 25 to 75. Data were compared with data from the poorest and richest income fifths as well as with data for the entire cohort

Results Of the homeless and marginally housed people, 3280 died. Mortality rates among these people were substantially higher than rates in the poorest income fifth, with the highest rate ratios seen at younger ages. Among those who were homeless or marginally housed, the probability of survival to age 75 was 32% (95% confidence interval 30% to 34%) in men and 60% (56% to 63%) in women. Remaining life expectancy at age 25 was 42 years (42 to 43) and 52 years (50 to 53), respectively. Compared with the entire cohort, mortality rate ratios for men and women, respectively, were 11.5 (8.8 to 15.0) and 9.2 (5.5 to 15.2) for drug related deaths, 6.4 (5.3 to 7.7) and 8.2 (5.0 to 13.4) for alcohol related deaths, 4.8 (3.9 to 5.9) and 3.8 (2.7 to 5.4) for mental disorders, and 2.3 (1.8 to 3.1) and 5.6 (3.2 to 9.6) for suicide. For both sexes, the largest differences in mortality rates were for smoking related diseases, ischaemic heart disease, and respiratory diseases.

Conclusions Living in shelters, rooming houses, and hotels is associated with much higher mortality than expected on the basis of low income alone. Reducing the excessively high rates of premature mortality in this population would require interventions to address deaths related to smoking, alcohol, and drugs, and mental disorders and suicide, among other causes.


  • Contributors: RW and MT conceived the study and conducted the analyses after revisions suggested by the other authors. SWH and RW drafted the manuscript with input from the other coauthors. All authors contributed in critically revising the article for important intellectual content, and approved the version submitted for publication. All authors had full access to the data (including statistical reports and tables) in the study and can take responsibility for the integrity of the data and the accuracy of the data analysis. SWH and RW are guarantors.

  • Funding: The Canadian census mortality follow-up study was funded by the Canadian Population Health Initiative, part of the Canadian Institute for Health Information. The Centre for Research on Inner City Health gratefully acknowledges the support of the Ontario Ministry of Health and Long-Term Care. JRD was supported by a Canadian Institutes of Health Research and Public Health Agency of Canada Chair in Applied Public Health. The authors’ work was independent of the funders. The views expressed in this article are those of the authors and do not necessarily reflect the views of the above-named organizations or of the institutions with which they are affiliated.

  • Competing interests: None declared.

  • Ethical approval: The Canadian census mortality follow-up study, of which this study is a part, was approved by the Statistics Canada Policy Committee and the research ethics committee of the University of Toronto.

  • Data sharing: No additional available.

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