"In Canada and the United States, street youth are generally 25 years or younger, and approximately a third of them are girls," the authors provide as background information in the article. "They are homeless or, more frequently, they live in highly unstable residential conditions." These youth "frequently engage in high-risk behaviors such as prostitution and substance abuse, including injection drug use. They are increasingly recognized as population at risk for a wide range of physical and mental health problems."
Elise Roy, M.D., M.Sc., from Direction de Sante Publique de Montreal, Canada, and colleagues recruited 1,013 youth from January 1995 to September 2000. Participants were interviewed twice a year. They were eligible for follow-up until they reached 30 years of age or until they reported in four consecutive study questionnaires that they were not using services from street youth organizations and not homeless. The average age of the participants when the study started was 19.9 years.
"Twenty-six youth died during follow-up for a mortality rate of 921 per 100,000 person-years," the authors report. "The observed causes of death were as follows: suicide (13), overdose (8), unintentional injury (2), fulminant hepatitis A (1), heart disease (1); 1 was unidentified." In further analysis the authors found, HIV infection, daily alcohol use in the last month, homelessness in the last 6 months, drug injection in the last 6 months and being male were identified as independent predictors of mortality.
"The mortality rate of 921 per 100,000 person-years observed in our study participants is extremely high, exceeding 11 times the rate observed among youth in the general population," the authors state.
"In conclusion, mortality is high in the street youth population. Treatment of addiction and mental health problems should represent public health priorities to prevent deaths in these young people. Additional studies providing a better understanding of the role of other factors such as HIV infection and homelessness are also needed to support the development of appropriate health and social services for these vulnerable youth."
(JAMA. 2004;292:569-574. Available post-embargo at JAMA.com)
Editor's Note: This study was financially supported, through unconditional grants, by the Medical Research Council of Canada, Health Canada, Ministere de la Sante et des Services sociaux du Quebec, and Fonds de recherché en sante du Quebec.
Editorial: Street Youth Mortality
In an accompanying editorial, Sue Ellen Abadalian, M.D., from Tulane University Health Sciences Center, New Orleans, writes, "the study of mortality among Montreal street youth by Roy et al in this issue of JAMA is a reminder of the vulnerability of street youth that belies their bravado."
"Unlike earlier investigations of the mortality of homeless populations, this study treated homelessness as a time-dependent variable, permitting the authors to further conclude that mortality risk is increased during homeless periods; thus, homelessness in itself, not just being a street youth with tenuous housing and risky behavior, is an independent predictor of death." Abadalian notes that Roy and colleagues were able to prospectively follow these street youth an average of 33.4 months and that "tracking street youth for this length of time is difficult."
Abadalian comments that "the findings of Roy et al demonstrate that strategies that move street youth off the street are needed to further reduce mortality, including services that connect youth with trustworthy adults and a responsive community, support youth development and do not withdraw when faced with youth failures and rejections, provide opportunities for youth service and leadership, and open opportunities for skill development. … Finally, addressing street youth mortality entails providing these young people with a continuum of shelter, transitional housing, and supportive independent living."
(JAMA. 2004;292:624-625. Available post-embargo at JAMA.com)
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