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Cited by 1,568Homelessness and Social IssuesUrban and Rural Development ChallengesHIV, Drug Use, Sexual Risk

The health of homeless people in high-income countries: descriptive epidemiology, health consequences, and clinical and policy recommendations

Open access
Fazel, Seena, Geddes, John R, Kushel, Margot·2014·The Lancet
DOI 10.1016/s0140-6736(14)61132-6PMC PMC4520328
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Abstract

In the European Union, more than 400 000 individuals are homeless on any one night and more than 600 000 are homeless in the USA. The causes of homelessness are an interaction between individual and structural factors. Individual factors include poverty, family problems, and mental health and substance misuse problems. The availability of low-cost housing is thought to be the most important structural determinant for homelessness.

Integrity signals

Registry

Crossref · 10.1016/s0140-6736(14)61132-6

Cites

123 of 123 references verified0 citation errors · 0 not checkable

Statistics

Nothing to recompute.

Claims the paper makes

58 of 158 cited sources checked · 8 supported · 2 flagged · accuracy not yet measured

  • Premisecitation

    Drug and alcohol misuse are strongly associated with both the onset and continuation of homelessness.

    “Evidence suggests that drug and alcohol misuse have strong associations with both the initiation and persistence of homelessness.13”
    Quote in the paperNot a substantial claim1 of 1 sources checked
    • cites [13] source

      The Results (§3.2) report higher alcohol and illegal-drug use among LGB youths with a history of homelessness. But use generally began after the first homeless episode, and the Discussion (§4.1) suggests it may be a consequence rather than a cause of homelessness. The paper does not establish an association with the persistence of homelessness. (LLM, conf=0.84)

      Experimental — accuracy not yet measured
  • Premisecitation

    Roma gypsies and other minorities are over-represented among homeless people in the EU.

    “Roma gypsies and other minorities are over-represented.26”
    Quote in the paperNot a substantial claim1 of 1 sources checked
    • cites [26] source

      The Recruitment and Eligibility section describes a sample from Toronto, Canada, not the EU. The Results compare racial-minority proportions between two groups of homeless women, but do not compare homeless people with the general population or mention Roma people. Searches for Roma, EU homelessness, and minority over-representation found no supporting passage. (LLM, conf=0.76)

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  • Premisecitation

    Across the whole EU, an estimated 4.1 million people experience a homeless episode each year.

    “In the whole of the EU, an estimated 4·1 million people have a homeless episode in a year (panel 2).26”
    Quote in the paperNot a substantial claim1 of 1 sources checked
    • cites [26] source

      The Introduction discusses homelessness in Canada and gives Toronto shelter figures, while Recruitment and Eligibility describes a Toronto sample. Searches for the 4.1 million figure and an annual EU homelessness estimate found no passage addressing that claim in our copy. (LLM, conf=0.76)

      Experimental — accuracy not yet measured
  • Premisecitation

    Homeless individuals have worse physical and emotional health status than the general population, including people from deprived neighbourhoods.

    “Homeless individuals have worse physical and emotional health status than the general population, including those from deprived neighbourhoods.32,49-51”
    Quote in the paperSubstantial claim1 of 4 sources checked
    • cites [32]
    • cites [49] source
    • cites [50] source

      Table 1 reports serious emotional problems among the homeless adults studied, and the Covariates section describes a measure of general health status. The Discussion compares food insufficiency and health-service use with the US general population, but our copy does not compare physical and emotional health status with either the general population or people from deprived neighbourhoods. (LLM, conf=0.73)

      Experimental — accuracy not yet measured
    • cites [51] source
  • Premisecitation

    Crisis or transitional homelessness is often caused by a discrete event such as a natural or political crisis, an economic disruption, or a personal crisis.

    “Crisis or transitional homelessness is often caused by a discrete event: either an act of nature or political crisis that displaces individuals, an economic disruption (severe recession, foreclosure crisis), or a personal crisis (job loss, illness).28”
    Quote in the paperNot a substantial claim1 of 1 sources checked
    • cites [28] source

      The Subject Characteristics and Data Collection sections describe when and how long participants had been homeless, but not what caused their homelessness. Searches for crisis or transitional homelessness and for the proposed triggers—displacement, economic disruption, job loss, and illness—found no passage addressing the claim. Page numbers were not available in our copy. (LLM, conf=0.75)

      Experimental — accuracy not yet measured
  • May combine two claims. 51
  • Classified as probably not a substantial claim. 4

  • May combine two claims.

    Premisecitation

    Since a 2012 systematic review, two new tuberculosis studies reported prevalence between 4% and 8%, and one New York City HIV study reported a rate of 1.8%.

    “Since a 2012 systematic review,56 two new studies69,70 of tuberculosis that reported a prevalence of between 4% and 8%, and one study71 of HIV (from New York City) reporting rates of HIV of 1·8% have been published (appendix).”
    Quote in the paperNot a substantial claim3 of 4 sources checked
    • cites [56] source
    • cites [69] source

      The Study and Conclusions (page numbers unavailable) report hepatitis E findings among homeless persons in Marseille, not post-2012 tuberculosis studies or an HIV prevalence study in New York City. Searches for the tuberculosis prevalence range and the New York City HIV rate found no passage addressing either claim. (LLM, conf=0.78)

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    • cites [70] source

      The Methods section (page unavailable) says this paper surveyed homeless adults in Pittsburgh and Philadelphia in 1997, not New York City. Published in 2005, it also cannot be one of the studies published since the 2012 review. The passages do not report an HIV prevalence of 1.8%. (LLM, conf=0.88)

      Checked by a reasoning model — may be wrong.

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    • cites [71] source

  • May combine two claims.

    Premisecitation

    In a study of 500 homeless people in three British Columbia cities, three-quarters reported at least one form of abuse and more than half reported a history of sexual abuse.

    “Findings from a study of 500 homeless people in three cities in British Columbia, Canada, showed that three-quarters of homeless people reported one form of abuse, with more than half reporting a history of sexual abuse.95”
    Quote in the paperNot a substantial claim1 of 1 sources checked
    • cites [95] source

      The Methods and Results describe a study in inner-Sydney with 105 participants, not 500 people in three British Columbia cities. The Results report that 49 of 102 respondents (48%) experienced violence in the previous year; the cited paper does not report the claimed abuse or sexual-abuse figures. (LLM, conf=0.89)

      Checked by a reasoning model — may be wrong.

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  • May combine two claims.

    Premisecitation

    Mortality is substantially increased in homeless people, with the excess risk most evident in younger people and, in some studies, women.

    “Findings from several studies have shown that mortality is substantially increased in homeless people,35-45 with the excess risk most evident in younger people39,46 and, in some studies, women.”
    • Also stated in: § Mortality · plain
      “Findings from several studies have shown that mortality is substantially increased in homeless people,35-45 with the excess risk most evident in younger people39,46 and, in some studies, women.35,41,42”
    Quote in the paperSubstantial claim5 of 10 sources checked
    • cites [35] source
    • cites [36] source

      The Abstract reports substantially higher mortality among homeless and marginally housed people, with the highest rate ratios at younger ages; the Results confirm that rate ratios were higher at younger ages for both sexes. The Discussion reports excess mortality among women, but does not show that the overall excess risk was more pronounced in women than in men. (LLM, conf=0.83)

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    • cites [37] source
    • cites [38] source
    • cites [39] source
    • cites [40] source
    • cites [41] source
    • cites [42] source
    • cites [43] source
    • cites [44] source

      The Results (Mortality; page not provided) show elevated mortality among homeless children and adults aged 25–49 compared with NYC residents. But overall adult mortality among family-shelter users was similar to the comparison populations, and the female mortality estimate was not statistically conclusive. The paper therefore supports excess risk in some younger groups, not a substantial increase across homeless people generally or a clear excess among women. (LLM, conf=0.87)

      Experimental — accuracy not yet measured

  • May combine two claims.

    Premisecitation

    For young people aged 12-25, the main individual risk factors for homelessness are family conflict and victimisation, non-heterosexual sexual identity, and prior involvement with the child welfare system.

    “Primary individual risk factors for homelessness in young people (unaccompanied individuals aged 12–25 years) are family conflict and victimisation,14 non-heterosexual sexual identity,15,16 and having been in the child welfare system.17-19”
    Quote in the paperNot a substantial claim1 of 3 sources checked
    • cites [14] source
    • cites [15]

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

    • cites [16] source

  • May combine two claims.

    Premisecitation

    In homeless families in New York, overall mortality was not higher than among residents of low-income neighbourhoods, but excess mortality was still present in homeless children.

    “In homeless families in New York, the overall mortality was not higher than that in residents of low-income neighbourhoods, although the excess was still present in homeless children.48”
    Quote in the paperNot a substantial claim1 of 1 sources checked
    • cites [48] source

      The Abstract discusses adult homelessness and adverse childhood experiences, and the Discussion addresses adult mental and physical health outcomes. Searches for mortality in homeless families in New York and excess mortality in homeless children found no passage reporting the claimed comparison with low-income-neighbourhood residents. (LLM, conf=0.76)

      Experimental — accuracy not yet measured

  • May combine two claims.

    Premisecitation

    There are no consistent differences in mortality risk between homeless men and women, although most studies report that the proportionate excess of mortality in women is similar to men.

    “There are no consistent differences in mortality risks between homeless men and women, although most studies report that the proportionate excess of mortality in women is similar to men.40,45,47”
    Quote in the paperNot a substantial claim1 of 3 sources checked
    • cites [40] source
    • cites [45] source

      The paper’s background passage says homeless people have high rates of premature mortality compared with the general population, but it does not compare mortality risks for homeless men and women. Searches for sex-specific mortality risk and proportionate excess mortality found no passage addressing either claim; the paper instead analyzes health status and health care use. (LLM, conf=0.76)

      Experimental — accuracy not yet measured
    • cites [47] source

  • May combine two claims.

    Premisecitation

    In 2012-13, 53,540 UK households were eligible for homelessness assistance; 65% were white, 15% black, 8% Asian, and 3% mixed race, indicating over-representation of black and Asian people; 64% had dependent children.

    “In 2012–13, 53 540 UK households were eligible for homelessness assistance. Of these households, 65% were white, 15% black, 8% Asian, and 3% mixed race (indicating an over-representation of black and Asian people); 64% had dependent children.25”
    Quote in the paperNot a substantial claim1 of 1 sources checked
    • cites [25] source

      Split into 2 atoms — 0 confirmed, 0 partially supported, 0 disputed, 0 misattributed, 2 unverifiable. Expand the claim to see per-atom verdicts.

      Experimental — accuracy not yet measured

  • May combine two claims.

    Premisecitation

    Homelessness appears to have increased in the EU over the past 5 years, with only Finland and the Netherlands reporting reductions.

    “Homelessness seems to have increased in the past 5 years; only Finland and the Netherlands have reported reductions.26”
    Quote in the paperNot a substantial claim1 of 1 sources checked
    • cites [26] source

      The Introduction discusses a growing segment of the homeless population in Canada, while Recruitment and Eligibility describes a Toronto sample. Searches for Finland, the Netherlands, EU homelessness trends, and a five-year increase found no passage addressing the claim. (LLM, conf=0.78)

      Experimental — accuracy not yet measured

  • May combine two claims.

    Interpretationcitation

    The poor health of homeless people is multifactorial, including risk factors that increase homelessness risk and are associated with poor health outcomes, such as early life poverty and mental health and substance misuse disorders.

    “The reasons for this are multifactorial and include risk factors that increase individuals’ risk for homelessness and are associated with poor health outcomes, such as early life poverty52 and mental health and substance misuse disorders.49,53”
    Quote in the paperNot a substantial claim2 of 3 sources checked
    • cites [49] source
    • cites [52] source

      The Introduction reports substantially increased morbidity among homeless people and higher prevalence of mental disorders. The Discussion also identifies injection drug use as a risk factor worth further study for infectious diseases. Neither section establishes that mental health or substance misuse disorders increase the risk of becoming homeless; a search for early-life poverty found no relevant passage, though that example has a separate citation in the citing sentence. (LLM, conf=0.84)

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    • cites [53] source

      The Introduction reports elevated rates of mental illness and substance use disorders among homeless people and says psychiatric illness or substance abuse commonly precipitates hospital care. It does not establish that these disorders increase the risk of becoming homeless. Early-life poverty is attached to citation 52, not to this source. (LLM, conf=0.84)

      Experimental — accuracy not yet measured

  • May combine two claims.

    Premisecitation

    In Europe and Canada, homeless people have lower rates of obesity and hyperlipidaemia than the general population.

    “In Europe and Canada, compared with the general population, homeless people have higher rates of smoking, lower rates of obesity and hyperlipidaemia, and similar rates of diabetes and hypertension77-81 (table 3).”
    Quote in the paperNot a substantial claim2 of 5 sources checked
    • cites [77] source

      The Results compare obesity among shelter attendees with and without diabetes, not with the general population. The paper’s general-population comparison concerns diabetes prevalence; the passages found for obesity, cholesterol and hyperlipidaemia do not establish lower rates of obesity or hyperlipidaemia among homeless people in Europe or Canada. Page numbers were not available in our copy. (LLM, conf=0.77)

      Experimental — accuracy not yet measured
    • cites [78] source
    • cites [79] source
    • cites [80] source
    • cites [81] source

      In the section on homelessness and cardiovascular mortality (page unavailable), a Toronto study found that elevated body mass index was not more prevalent among homeless adults than in a matched Canadian population. That does not establish a lower obesity rate. The section provides no Europe-wide comparison or evidence of lower hyperlipidaemia rates; it says the direction of differences in most traditional risk factors remains unclear. (LLM, conf=0.76)

      Experimental — accuracy not yet measured

  • May combine two claims.

    Interpretationcitation

    The higher cardiovascular morbidity and mortality in homeless people is probably caused by more illicit drug and tobacco use, poorer control of hypertension, diabetes, and hyperlipidaemia, and poorer access to early cardiac care.

    “The increased risk of morbidity and mortality from cardiovascular disease is probably a result of high rates of behavioural risk factors (illicit drug use, tobacco use); poor control of hypertension, diabetes, and hyperlipidaemia; and poor access to care for early cardiac disease.80,85”
    Quote in the paperSubstantial claim1 of 2 sources checked
    • cites [80] source
    • cites [85] source

      The Results (Drug Dependence; page unavailable) report a high prevalence of drug dependence among homeless people, supporting one behavioural-risk component. The Introduction reports elevated overall mortality, but neither passage links cardiovascular morbidity or mortality to drug or tobacco use, control of hypertension, diabetes or hyperlipidaemia, or access to early cardiac care. (LLM, conf=0.78)

      Experimental — accuracy not yet measured

  • May combine two claims.

    Premisecitation

    Compared with low-income non-homeless people, homeless people are more likely to seek care for falls, cold-related injury, burns, poisonings, assaults, traumatic brain injuries, and self-harm, and less likely to seek care for transport-related injuries.

    “Results from these studies showed that homeless individuals (compared with low-income non-homeless individuals) are more likely to seek medical care for falls, cold-related injury (hypothermia, frostbite), burns, poisonings (from medication and illicit substances), assaults, traumatic brain injuries, and self-harm and are less likely to seek care for transport-related injuries.32,57,58,60,96”
    Quote in the paperNot a substantial claim1 of 5 sources checked
    • cites [32]

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

    • cites [57] source
    • cites [58] source
    • cites [60] source
    • cites [96] source

      Split into 2 atoms — 0 confirmed, 1 partially supported, 0 disputed, 0 misattributed, 1 unverifiable. Expand the claim to see per-atom verdicts.

      Experimental — accuracy not yet measured

  • May combine two claims.

    Premisecitation

    Heterogeneity between individual tuberculosis studies is partly explained by different diagnostic methods (higher rates with chest radiography vs sputum analysis) and differences in the underlying rate in the general population.

    “Heterogeneity between individual tuberculosis studies is partly explained by different diagnostic methods (higher rates when chest radiography was used vs sputum analysis) and differences in the underlying rate in the general population.56”
    Quote in the paperNot a substantial claim1 of 1 sources checked
    • cites [56] source

      The Abstract and Limitations of the evidence base discuss traumatic brain injury among people who are homeless, including variation in how TBI was assessed. Searches for tuberculosis, chest radiography, sputum analysis, and underlying population rates found no passage addressing the claimed explanation for heterogeneity between tuberculosis studies. (LLM, conf=0.78)

      Experimental — accuracy not yet measured

  • May combine two claims.

    Premisecitation

    In the USA, homeless people have higher hypertension rates than the general population but rates similar to the non-homeless low-income population.

    “Data from the USA are similar, with the exception that rates of hypertension in homeless people are higher than in the general population, but similar to the non-homeless, low-income population.82”
    Quote in the paperNot a substantial claim1 of 1 sources checked
    • cites [82] source

      The Background compares U.S. homeless, low-income, and general populations on emergency-department use, not hypertension rates. A search for “hypertension” found no passage in our copy addressing the claimed comparison. (LLM, conf=0.76)

      Experimental — accuracy not yet measured

  • May combine two claims.

    Premisecitation

    Few studies of hepatitis B in homeless people have been published, but they report high rates typically around 20-30%, and 3% have recent or ongoing hepatitis E.

    “Few studies of hepatitis B have been published, but they report high rates that are typically around 20–30%,68,72 and 3% have recent or ongoing hepatitis E.73”
    Quote in the paperNot a substantial claim1 of 3 sources checked
    • cites [68] source
    • cites [72] source
    • cites [73] source

      Citation 73 is attached to the claim that 3% of homeless people have recent or ongoing hepatitis E; the hepatitis B figures have separate citations. Our copy’s Results report diabetes, pre-diabetes and metabolic syndrome in a homeless population, but no passage addresses hepatitis E (searched for hepatitis E and viral infection). (LLM, conf=0.77)

      Experimental — accuracy not yet measured

  • May combine two claims.

    Premisecitation

    Other risk factors for poor health in homeless people are secondary to homelessness itself, such as poor nutrition, exposure to communicable diseases, harsh living environments, high rates of victimisation and unintentional injuries, and increased tobacco use.

    “Other risk factors are secondary to the conditions of homelessness itself, such as poor nutrition,54,55 exposure to communicable diseases,56 harsh living environments,57,58 high rates of victimisation59 and unintentional injuries,57,60 and increased rates of tobacco use.61,62”
    Quote in the paperNot a substantial claim1 of 3 sources checked
    • cites [54] source
    • cites [55] source
    • cites [56] source

      The Discussion reports high rates of traumatic brain injury among people who are homeless, supporting the injury-related part of the citation. It does not establish that these injuries were unintentional or caused by the conditions of homelessness; it says the first brain injury preceded homelessness for most participants in the studies that examined timing. (LLM, conf=0.86)

      Experimental — accuracy not yet measured

  • May combine two claims.

    Premisecitation

    Poor health status among homeless people is exacerbated by poor access to health care and challenges in adhering to medication.

    “Poor health status is exacerbated by poor access to health care63-65 and challenges in adherence to medication.66,67”
    Quote in the paperSubstantial claim5 of 5 sources checked
    • cites [63] source
    • cites [64] source
    • cites [65] source

      The Discussion reports a much higher incidence of TB among homeless people, but does not attribute poor health to limited health-care access or difficulty adhering to medication. The Methods describe free TB treatment for participants; they do not assess access barriers or adherence. Searches for both mechanisms found no passage addressing them. (LLM, conf=0.74)

      Experimental — accuracy not yet measured
    • cites [66] source

      The Background describes elevated TB risk and poor outcomes among homeless people, but attributes risk to factors such as nutrition and housing, not poor access to health care. Searches of our full-text copy for health-care access and medication adherence found no passage addressing either proposed explanation for poor health status. (LLM, conf=0.74)

      Experimental — accuracy not yet measured
    • cites [67] source

      The citation placement attributes the poor-access-to-health-care point to this source; medication adherence has separate citations. The Introduction reports higher morbidity and mortality among homeless people, and the Discussion recommends offering HIV/STI services, but neither passage says that poor access exacerbates health status. Searches for poor access to health care and medication adherence found no passage establishing those links (pages unavailable in our copy). (LLM, conf=0.74)

      Experimental — accuracy not yet measured

  • May combine two claims.

    Premisecitation

    Homeless people have trouble obtaining medical care and taking medications because they lack insurance, face transportation barriers, and must deal with competing priorities.

    “Homeless people have difficulty accessing medical care and adhering to medications because of an absence of medical insurance, transportation barriers, and the need to attend to competing priorities.63,86-88”
    Quote in the paperNot a substantial claim3 of 4 sources checked
    • cites [63] source

      The Discussion (page unavailable) links homelessness to poorer ART adherence and suggests that immediate survival needs can take priority over medication. It also discusses financial barriers to treatment in settings without universal access, but does not identify lack of insurance or transportation as reasons homeless people have difficulty accessing care and taking medications. (LLM, conf=0.86)

      Experimental — accuracy not yet measured
    • cites [86] source
    • cites [87] source

      The Implications and Avenues for future research sections discuss mental-health treatment and treatment adherence among prisoners, not barriers faced by homeless people. Searches for homelessness, insurance, transportation, competing priorities, and medication adherence found no passage addressing the attributed claim; the available passages have no page numbers. (LLM, conf=0.76)

      Experimental — accuracy not yet measured
    • cites [88] source

      The Discussion says homeless people avoid outpatient contacts and have difficulty managing prescribed medications. It does not attribute those difficulties to lack of insurance, transportation barriers, or competing priorities. (LLM, conf=0.88)

      Experimental — accuracy not yet measured

  • May combine two claims.

    Premisecitation

    Compared with the general population, tuberculosis infection rates in homeless people are at least 20 times higher, and in USA studies more than 40 times higher, a greater proportionate excess than for other infectious diseases studied.

    “but compared with the general population, rates of tuberculosis infection were at least 20 times higher, and for USA studies, they were more than 40 times higher—a proportionate excess compared with the general population and more than other infectious diseases studied.”
    Quote in the paperNot a substantial claim1 of 1 sources checked
    • cites [56] source

      The Results and Discussion passages address traumatic brain injury among people who are homeless, not tuberculosis. Searches for tuberculosis infection rates, the 20- and 40-fold comparisons, and other infectious diseases found no passage in our copy addressing the claim. (LLM, conf=0.78)

      Experimental — accuracy not yet measured

  • May combine two claims.

    Premisecitation

    In the USA, 68% to 80% of homeless people currently smoke, which is four times the rate in the overall US population and 2.5 times the rate in the low-income population.

    “Tobacco use is common in homeless populations; in the USA, 68–80% of homeless people are current smokers,61 which is four times the rate of the overall US population and 2·5 times that of the low-income population.105”
    Quote in the paperNot a substantial claim1 of 2 sources checked
    • cites [61] source

      The Discussion addresses alcohol and drug problems among homeless people, but does not report smoking prevalence. Searches of the full-text copy for tobacco, smoking, the 68–80% figure, and the US population comparisons found no passage supporting the claim. (LLM, conf=0.77)

      Experimental — accuracy not yet measured
    • cites [105] source

  • May combine two claims.

    Premisecitation

    Smoking cessation among homeless people is hindered by high environmental exposure in shelters and congregant living facilities, reduced health-care access, and competing health needs.

    “Several factors impede smoking cessation, including high rates of environmental exposure in shelters and other congregant living facilities, reduced access to health care,111 and competing health needs, which decrease health-care providers’”
    Quote in the paperNot a substantial claim1 of 1 sources checked
    • cites [111] source

      The paper’s introductory discussion identifies pervasive tobacco use in homeless settings and assumptions about higher-priority needs, but it does not address reduced access to health care—the factor immediately preceding this citation. Searches for health-care access and medical-care availability found no passage supporting that factor. (LLM, conf=0.73)

      Experimental — accuracy not yet measured

  • May combine two claims.

    Premisecitation

    Individual factors contributing to homelessness include poverty, early childhood adverse experiences, mental health and substance misuse problems, personal history of violence, and criminal justice system involvement.

    “Individual factors include poverty,9 early childhood adverse experiences,10 mental health and substance misuse problems,9,11 personal history of violence,11 and criminal justice system association.12”
    Quote in the paperNot a substantial claim0 of 3 sources checked
    • cites [9] source
    • cites [10] source
    • cites [11] source

  • May combine two claims.

    Premisecitation

    When structural support is unavailable, people with fewer individual vulnerabilities become homeless and overall homelessness rates increase.

    “Findings from ecological studies show that when structural support is not available, individuals with fewer individual vulnerabilities become homeless and rates of homelessness rise.7”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [7] source

  • May combine two claims.

    Premisecitation

    Structural factors that promote homelessness include a lack of low-cost housing, limited employment opportunities for low-skilled workers, and inadequate income support.

    “Structural factors that promote homelessness include the absence of low-cost housing, employment opportunities for low-skilled workers, and income support.7”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [7] source

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisenone given

    In the USA, black Americans and Native Americans are overrepresented in the homeless population.

    “In the USA, black Americans and Native Americans are overrepresented in the homeless population.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Study design and conductnone given

    Point-in-time counts tend to overestimate chronic homelessness and underestimate short episodes of homelessness.

    “Point-in-time counts overestimate chronic homelessness and underestimate short periods of homelessness.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisecitation

    Reasons for late-life homelessness include housing problems related to changes in the housing market, loss of an important relationship through death or divorce, and health crises.

    “Reasons for late-life homelessness include housing problems secondary to changes in the housing market,33 loss through death or divorce of an important relationship, or health crises.33,34”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [33] source
    • cites [34]

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

  • May combine two claims.

    Premisecitation

    Causes of excessive mortality in homeless people include infections (HIV, tuberculosis), ischaemic heart disease, substance misuse, and external factors such as unintentional injuries, suicides, homicides, and poisoning.

    “Causes of excessive mortality include infections (HIV, tuberculosis), ischaemic heart disease, substance misuse, and external factors including unintentional injuries,40 suicides, homicides,46 and poisoning (from medication and illicit substances).”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites [40] source
    • cites [46] source

  • May combine two claims.

    Premisecitation

    Countries with greater income inequality have higher rates of homelessness, suggesting income inequality may be a structural driver.

    “Income inequality itself might be a structural factor that promotes homelessness: countries with greater levels of income inequality have higher rates of homelessness.20”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [20]

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisenone given

    The rise in homelessness in the early 1980s was attributed to closure of state psychiatric facilities without expanded community mental health services, reduced affordable housing, stagnating wages, welfare policy changes, and the crack cocaine epidemic.

    “In the early 1980s, the increase in homelessness was attributed to the closing of state psychiatric facilities, without a concomitant increase in community mental health services, a decrease in affordable housing, stagnating wages, changes in welfare policies, and the crack cocaine epidemic.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisecitation

    Risk factors for becoming chronically homeless include mental health problems, substance misuse, physical health problems, a history of criminal justice involvement, and older age (44 years and older).

    “Risk factors for a person becoming chronically homeless include having mental health problems, substance misuse, or physical health problems, a history of criminal justice system association, and older age (44 years and older).21,29”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [21]

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

    • cites [29] source

  • May combine two claims.

    Premisenone given

    In a 2012 one-night count in England, there were 2309 rough sleepers, 24% of whom were in London.

    “In 2012, in one night-time count, there were 2309 rough sleepers in England, 24% of whom lived in London (panel 2).”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisenone given

    Black Americans constitute 12% of the US population but 39% of shelter populations.

    “Although black Americans make up only 12% of the US population, they make up 39% of shelter populations.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisecitation

    The homeless population is ageing; in the USA the median age now approaches 50 years.

    “The homeless population is ageing. In the USA, the median age of the homeless population now approaches 50 years.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Premisecitation

    In the USA, a bimodal mortality pattern is described: younger homeless people die disproportionately from external causes and infectious diseases, and there is also a spike in older homeless people.

    “In the USA, a bimodal pattern of mortality is described: younger people die disproportionately from external causes of death (suicide, accidental overdoses, and homicide) and infectious diseases, and there is also a spike in older homeless people.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [47] source

  • May combine two claims.

    Premisecitation

    Despite expansion of services, excess mortality among homeless people has remained similar over the past two decades, although causes of death have shifted from HIV infection toward drug overdose and substance misuse disorders.

    “There is evidence that, despite expansion of services, the excess mortality has remained similar during the past two decades, although shifts in the cause of death have occurred with fewer deaths from HIV infection and more from drug overdose and substance misuse disorders.47”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [47] source

  • May combine two claims.

    Premisecitation

    In a 2013 one-night count in the USA, 23% of homeless individuals were children in families, representing 238,110 people in families.

    “during one night-time count of homeless people in 2013, 23% of homeless individuals were children living in families (238 110 people in families were homeless).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [23]

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

  • May combine two claims.

    Premisenone given

    Chronically homeless individuals have worse clinical outcomes than those with intermittent or crisis homelessness, even though homelessness harms health regardless of duration.

    “Although homelessness negatively affects health outcomes irrespective of duration, chronically homeless individuals have worse clinical outcomes than individuals who experience either intermittent or crisis homelessness.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    The 2010 US Interagency Council on Homelessness reported that over the preceding 30 years the number of homeless people increased, with a substantial rise in homeless children and families.

    “The 2010 US Interagency Council on Homelessness Federal Strategic Plan to Prevent and End Homelessness reported an increase during the preceding 30 years in the number of people who were homeless, with a substantial increase in the number of children and families who were homeless.21”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [21]

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

  • May combine two claims.

    Premisecitation

    Suicide rates among homeless people have increased, with a Danish study reporting a standardised mortality ratio of 7 from 1999-2009, which may be even higher in younger homeless people.

    “Suicide rates have increased, with a Danish study reporting a standardised mortality ratio of 7 from 1999–2009,42 which may be even higher in younger homeless people.46”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [42] source
    • cites [46] source

  • May combine two claims.

    Premisecitation

    Denmark is the only country reporting a higher relative risk of mortality for women, although absolute death rates are higher in men than women.

    “Denmark is the only country that reports higher relative risk of mortality for women, although the absolute death rate is higher in men than women.42”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [42] source

  • May combine two claims.

    Premisenone given

    Mental health and substance misuse disorders both increase the risk of homelessness and are worsened by homelessness.

    “Mental health and substance misuse disorders both increase the risk of and are exacerbated by homelessness.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Premisenone given

    Although crisis homelessness has severe negative health effects, those who experience it generally have better clinical outcomes than those with chronic or intermittent homelessness.

    “Although crisis homelessness has severe negative effects on health, in general, those who experience crisis homelessness have better clinical outcomes than individuals who experience chronic or intermittent homelessness.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisecitation

    Family homelessness is often episodic and is more prevalent in the USA than in EU countries.

    “Family homelessness (defined as adults with minor children) is often episodic, and is more prevalent in the USA than in EU countries.20”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [20]

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

  • May combine two claims.

    Premisecitation

    In a study in three Canadian cities, 58% of homeless people had a dual diagnosis, with common combinations including depression with alcohol and post-traumatic stress disorder with crack cocaine.

    “In a study90 based in three Canadian cities, 58% of homeless people had dual diagnosis, with some patterns of comorbidity being prominent (including depression co-occurring with alcohol, and post-traumatic stress disorder with crack cocaine).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [90] source

  • May combine two claims.

    Premisecitation

    Unintentional injuries are a major cause of illness and emergency department use among homeless people and account for about 9% of their hospital admissions; rates exceed those of the general and housed poor populations, especially among elderly people.

    “Unintentional injuries are a major cause of morbidity and emergency department use in homeless people57 and represent around 9% of all admissions to hospital for this population; rates are higher than the general or housed poor population, although the discrepancy is greatest in elderly people.58”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [57] source
    • cites [58] source

  • May combine two claims.

    Premisecitation

    In homeless people, psychosis is typically about as common as depression, unlike in community and prisoner populations where depression is at least twice as common.

    “This review also identified that the prevalence of psychosis was typically as high as that of depression, which contrasts with results from surveys in community and other high-risk populations such as prisoners in which depression is at least twice as common.91”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [91] source

  • May combine two claims.

    Premisecitation

    In a review of substance misuse, alcohol dependence among homeless people ranged from 8% to 58% and drug dependence from 5% to 54%, with little information about women.

    “In relation to substance misuse and dependence, this review focused on dependence, which for alcohol varied between 8% and 58%, and for drug dependence ranged from 5% to 54%, with very little information about women.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [89] source

  • May combine two claims.

    Premisecitation

    Homeless people have higher hospital admission rates and longer stays once admitted; one study found acute admissions at least 2 days longer.

    “Homeless individuals not only have higher rates of hospital admission but also have longer stays once admitted—at least 2 days longer for acute admissions to hospital in one study.126”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [126]

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

  • May combine two claims.

    Premisecitation

    Traumatic brain injury is more common in homeless people than in non-homeless poverty populations, with rates typically between 38% and 53%.

    “Rates of traumatic brain injury are increased in homeless people, compared with non-homeless poverty populations, with rates typically ranging from 38% to 53%.60”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [60] source

  • May combine two claims.

    Interpretationcitation

    After predisposing factors are accounted for, homelessness independently predicts hospital admission and emergency department attendance, because of lower admission thresholds, barriers to timely care, and competing demands or insufficient knowledge.

    “However, homelessness is an independent risk factor for hospital admission and emergency department attendance after accounting for these predisposing factors because of lower hospital admission thresholds caused by the complexities of management of acute medical crises in homeless people, barriers to timely care that might allow health problems to deteriorate beyond what can be managed safely as”
    Quote in the paperSubstantial claim0 of 3 sources checked
    • cites [49] source
    • cites [117] source
    • cites [130]

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

51 of 51

Claims other papers make about this one

Each is checked against this paper’s own text: does it say what the citing paper says it does?

  • Living in marginal housing in impoverished environments may be more prevalent than homelessness and may create comparably severe consequences.

    “Living in marginal housing in impoverished environments may be more prevalent than homelessness and may create comparably severe consequences. 4-6”

    From The Hotel Study—Clinical and Health Service Effectiveness in a Cohort of Homeless or Marginally Housed Persons (2017) · cites this paper as [5]

    The Mortality section (page unavailable) reports that overall mortality among homeless families in New York was no higher than among residents of low-income neighbourhoods, offering a limited comparison of health consequences. It does not establish that marginal housing is more prevalent than homelessness or that marginal housing itself produces comparably severe consequences. (LLM, conf=0.72)

    Experimental — accuracy not yet measured

Cites

Flagged first, then by citations

6 of the 129 references couldn’t be matched to a known paper.

Research works printed but not linked: 1

  1. Laporte, 2010, The mental health and addictions of homeless people in Ile-de-France, la Lettre de L'Observatoire, 5, 1

Cited by

Sorted by citations

Related

Authors
Fazel, S., Geddes, J. R., & Kushel, M.
Affiliations
  • University of Oxford (GB)
  • San Francisco General Hospital (US)
Corresponding author
Fazel, Seena
ORCID
Venue
The Lancet
Publisher
Elsevier BV
Published
2014-10
Volume
384
Issue
9953
Pages
1529-1540
ISSN
  • 0099-5355 (ISSN-L)
  • 0140-6736
DOI
10.1016/s0140-6736(14)61132-6
PMC
PMC4520328
OpenAlex
W2105368594
Cited by
1,568
References
129
Citations by year
2026: 100 · 2025: 129 · 2024: 203 · 2023: 176 · 2022: 186 · 2021: 266 · 2020: 155 · 2019: 124 · 2018: 88 · 2017: 72 · 2016: 35 · 2015: 32 · 2014: 1
FWCI
7.93
Type
journal article
Language
en
Open access
Licence
www.elsevier.com/tdm/userlicense/1.0/ (tdm)
Locations
  • The Lancet (publishedVersion)
  • PubMed (publishedVersion)
  • Europe PMC (PubMed Central) (acceptedVersion)
  • PubMed Central (acceptedVersion)
  • eScholarship (California Digital Library) (submittedVersion)
Funders
  • Wellcome Trust (095806)
  • National Institute for Health and Care Research (NF-SI-0611-10150)
Topics
  • Health Sciences › Health Professions › General Health Professions › Homelessness and Social Issues
  • Social Sciences › Urban Studies › Urban and Rural Development Challenges
  • Health Sciences › Medicine › Epidemiology › HIV, Drug Use, Sexual Risk
Keywords
homelessness, health of homeless people, premature mortality, suicide, unintentional injuries, infectious diseases, mental illness, substance abuse, non-communicable diseases, accelerated aging, housing affordability, poverty, healthcare engagement, emergency department visits, health surveillance, health policy, child welfare system, psychiatric hospitals
MeSH terms
Adult, Aged, Australia, Mental Disorders, Canada, Chronic Disease, Delivery of Health Care, Europe, Health Policy, Health Services, Health Status, Ill-Housed Persons, Humans, Infections, Middle Aged, Smoking, United States, Self-Injurious Behavior, Age Distribution, Developed Countries

About these checks

Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.

Claims read under definition version 3 (extract-v3) on 2026-09-28.

Classified by jev-1.13-20260917 (gold-guideline-v0.2) on 2026-09-28.

Cited sources are checked by gpt-6-sol.

Statistics and arithmetic are recomputed, not judged.

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