Housing Exclusion Research Articles

Community and Care: Black Civil Society and the Influenza Pandemic of 1918 in the United States

Abstract During the deadliest pandemic of the twentieth century, the Great Influenza pandemic of 1918–1920, African Americans in the United States appeared to be an especially vulnerable population. The health effects of racialized segregation, produced by congested housing conditions, environmental racism, and exclusion from or discrimination in healthcare services, threatened a devastating situation during the second wave of the pandemic in late 1918. This paper argues that a network of Black civil society organizations and activists sprang into action to ameliorate the worst effects of this public health emergency, and that it was able to provide care and relief that would have largely been denied by white-led public and private institutions. This network had been built up in the preceding decades and can therefore serve as an important model and informational resource in utilizing community-centered planning to prepare marginalized peoples for the spread of pandemic disease.

Moving on: The overrepresentation of Black and minoritised households in out of area housing placements in England

Based on freedom of information request data supplied by English local authorities, this paper identifies significant under-reporting of out of area housing placements in government statistics alongside an overrepresentation of Black and minoritised households amongst such placements. In a context of neoliberalism, housing policy has become abstracted from contextual factors that shape experiences of housing. With housing increasingly commodified, this paper explores housing challenges beyond economic factors to include historical legacies and exclusion. Housing is therefore positioned as a conduit between people and place, with place understood as a spatial representation of social and economic networks. The fracturing of these networks illustrates a geographical manifestation of housing policy, crisis, and exclusion. This paper reflects on the social and economic context that drives such experiences and situates the overrepresentation of out of area housing for Black and minoritised households.

Homeless patients requiring haemodialysis: incidence, caseload characteristics, and implications for care

Background Homelessness is a recognized risk factor for the development of kidney failure. However, the risk of requiring renal replacement therapy (RRT) in homeless populations remains unknown. Furthermore, access to and provision of RRT for homeless populations have not been described. Methods We performed a retrospective study of all patients who newly commenced in-centre haemodialysis at St. James’s Hospital, Dublin, from January 2021 to December 2023. Housing status was captured using registered addresses and a review of social workers’ assessments. Homelessness was defined according to the European Typology on Homelessness and Housing Exclusion Criteria. Using publicly available census and homelessness data, we estimated the risk of commencing haemodialysis among homeless and non-homeless populations in the catchment area. Results The overall prevalence of homelessness among adults in the catchment area was approximately 2000/270,000 (0.74%). Of the 74 patients who commenced haemodialysis over the 3-year period, 13 (17.6%) were homeless. There was a significant difference in the incidence of commencing haemodialysis between non-homeless and homeless individuals in the catchment area (p<0.001, chi-square test). Among patients who commenced haemodialysis, the mean age was 53 years in homeless patients and 62 years in non-homeless patients (p<0.05, one-way ANOVA). 3/13 homeless patients (23%) had received nephrology healthcare at least 3 months prior to haemodialysis, compared with 39/61 non-homeless patients (64%) (p <0.05, chi-square). Of the three homeless patients who had received three months of nephrology healthcare prior to haemodialysis, all three patients commenced haemodialysis via an arteriovenous fistula. Mental health comorbidities were more frequent among homeless patients than among non-homeless patients (23% versus 8%) (not statistically significant), as were substance use disorders (38% versus 7%) (p<0.05, chi-squared test). Conclusion The incidence of kidney failure requiring haemodialysis was higher in homeless adults than in their non-homeless peers. Homeless patients were younger and started haemodialysis more urgently. There is an unmet need for nephrology healthcare for the homeless population.

Housing the poor? Accessibility and exclusion in the local housing systems of Vienna and Milan

Despite featuring very different housing systems, both in Vienna and Milan a growing number of people struggle to access affordable and decent housing. Even though social housing policies are in place in both contexts, for many the unregulated and often unaffordable private housing market is the only option. Building upon Antonio Tosi’s work, we centre our analysis on the poor and compare how two very different local housing systems create the conditions for their inclusion or exclusion. Through a comparative analysis of the Viennese and Milanese local housing regimes and adopting a mixed methodology, we discuss how both generate conditions of exclusion and who the ones excluded are, which local policies address the poor and how appropriate these are for mitigating housing exclusion. Finally, we indicate some directions for policies aimed at tackling the intersections of poverty and housing exclusion, advocating for a maximization of the ‘sociality’ of housing policies, involving a shift in prioritisation from the middle classes to the most vulnerable groups and the loosening of certain formal access requirements to housing or welfare services that constitute barriers to these groups, where possible.

Unravelling social housing exclusion. Marketization, privatization and neoliberal reforms in the Métropole européenne de Lille

The conceptualization of the neoliberalization of social housing has been largely dominated by Harloe’s models, which define it as the transition from a ‘mass’ to a ‘residual’ model. However, this definition fails to capture the emergence of ‘affordable’ housing policies. Blessing suggests instead conceptualizing neoliberalization through privatization and marketization. This definition helps analyze the focus on the diversification of the supply into mid-market rents. Drawing on mixed-method research, this paper demonstrates the relevance of Blessing’s analysis. To illustrate this, I will take the example of a large French intercommunality, which appears as non-neoliberal due to the absence of residualization. Our findings demonstrate that marketization and privatization have, however, influenced the nature of social housing provision by leading to an absolute decrease in low-rent units through demolitions and sales, and an increase in mid-market rent housing units. In conclusion, the findings emphasize the need for researchers to delve into the issue of social housing exclusion and its underlying mechanisms.

The Needs of Women Using Homelessness Services: The Results of Collaborative Research in London

This paper explores the results of a study conducted in collaboration with the homelessness sector in central London and an academic team. Data were collected on 134 women who used homelessness services in an area of central London during a nine-day window. In addition, fully anonymised service history records, covering an average period of 85 months, were reviewed with the consent of another 59 women with lived experience of homelessness. Nine women also agreed to in-depth interviews. Five key stakeholders in policy and practice were also interviewed. The research supports the findings of earlier research into the gender dynamics of homelessness. The results highlight the presence of a high-cost, high-risk population of women who are characterised by sustained and recurrent experience of homelessness, housing exclusion, and deprivation and who make repeated and sustained use of homelessness and other services without escaping homelessness. Strong associations between domestic abuse and women’s homelessness are evident in the results of the research, again echoing the results of earlier work. The possibilities of developing new strategic responses to women’s homelessness, including specialised forms of Housing First, are considered.

Can New Housing Supply Mitigate Displacement and Exclusion?

Problem, research strategy, and findings The housing affordability crisis is exacerbating displacement and exclusion in built-up urban neighborhoods. Although new housing development might help, it faces local opposition. Researchers have struggled to inform this debate because of data challenges, so we constructed a unique database on construction and household-level mobility to determine how development affects displacement and exclusion in the subsequent 5 years in Los Angeles (a typical coastal “hot market” in California) and San Francisco (the extreme “superstar city” case in California). We found that developing new market-rate housing generally helped slightly to alleviate both displacement and exclusion pressures for low-income households in Los Angeles and helped increase in-migration into weaker market neighborhoods in San Francisco. But particularly in the hottest markets, the new market-rate units could fail to spur low- and moderate-income households’ in-migration and exacerbate their out-migration. Likewise, the positive impacts of the new market-rate units may fade over time. Subsidized housing generally mitigated both exclusion and displacement slightly in most markets. Future research should examine long-term effects in a variety of contexts, controlling for the role of housing policies such as rent stabilization. Takeaway for practice Market-rate housing development may help alleviate rent pressures locally and regionally, but it is not sufficient to address displacement and exclusion at the neighborhood level. Because new production helps to mitigate displacement and exclusion in some contexts but exacerbates it in others, planners need to understand the market and neighborhood context for development. In addition to supporting more market-rate and subsidized housing development through zoning and fiscal tools, planners should implement complementary policies such as housing preservation and tenant protections.

A conceptual framework to model social determinants of COVID-19 vaccination uptake among underserved homeless populations

BackgroundHomeless people have a higher risk of COVID-19 infection, linked to several social, economic and environmental determinants, frequent comorbidities, obstacles to exercising their constitutional social and health rights, poor medical cover, and insufficient use of the healthcare system. Data on COVID-19 vaccine uptake and its main determinants are lacking for this underserved population. ObjectivesTo construct and testa conceptual framework to model structural social determinants of COVID-19 vaccine uptake among underserved homeless populations, and to test this model to identify the determinants of COVID-19 vaccine uptake on the homeless population living in two metropolitan areas in France. MethodsWe implemented a multicenter cross-sectional survey from 15/11/2021 to 22/12/2021 in homeless adults in the city of Marseille and in the greater Paris area.Persons sheltered in migrant worker hostels or in emergency social shelters, members of the COVID HOMELESS cohort study in Marseille, and Travelers living in traditional housing were all eligible. A standardized face-to-face questionnaire was administered to the participants where they lived in various languages by trained interviewers. We used structural equation modeling to analyze the structural social determinants of COVID-19 vaccine uptake, the latter defined as receiving at least one dose. ResultsThe participation rate was 64 %, accounting for 3811 participants. There were three main factors associated with greater vaccine uptake: i) opportunity, which included having a personal general practitioner (β = 0.05, p < 0.05), healthcare cover (β = 0.05, p < 0.05), and somebody to accompany the participant for medical appointments (β = -0.04, p < 0.05); ii) motivation, which included attitudes towards vaccination (β = 0.55, p < 0.05), press- and poster-based information (β = 0.03, p < 0.05), and vaccination history (β = 0.03, p < 0.05); iii) type of housing (β = 0.13, p < 0.05) and housing stability (β = 0.04, p < 0.05). ConclusionOur results highlight that housing exclusion is a structural social determinant of COVID-19 vaccine uptake in homeless people in France. They also underline the role which opportunity and motivation play in improving uptake in this underserved homeless population.

Suicidal ideation and attempt among young people living in gosiwons in South Korea.

Young people living in gosiwons could be at high risk for suicide owing to inadequate living conditions and the social stigma towards them. However, this topic has not received adequate academic attention. Gosiwon is a type of small residence consisting of several tiny rooms densely packed together and usually does not meet minimum housing standards. However, gosiwons are favored by low-income groups, especially young people, because they are cheaper than other residences. This study aimed to examine the factors that increase the risk of suicidal ideation and attempt among young people living in gosiwons. A sample of 300 young people aged 19-34 years living in gosiwons for over 6 months was analyzed. A set of multinomial logistic regression was conducted to examine the factors that differentiate the suicidal ideation and attempt group from the no-suicidal risk group. Approximately 30% of the study participants experienced suicidal ideation or attempted suicide. Among several risk factors, social exclusion and depressive symptoms distinguished the group with suicidal ideation from the no-risk group. Depressive symptoms were the only factor that differentiated the group with suicide attempts history from the no-risk group. The results emphasize the need to focus on social exclusion and depressive symptoms among young people living in poor housing conditions. Interventions to address social exclusion and depressive symptoms may help prevent suicide risk among young people exposed to housing exclusion.

Investigating local policy responses to support care-experienced young people in China – A scoping review

An increasing amount of attention is being paid to young people with care experience on an international scale. They are often associated with negative outcomes after leaving care, such as low educational attainment, unstable housing, job instability and social exclusion. While many countries have prescribed social policies for supporting them for a more fruitful transition out of care, there is little information available in the context of China at local levels. Given this, this paper maps and examines existing local policies, exploring how local authorities support care-experienced young people in China. To achieve, it adopts a scoping review. The findings highlight (i) China’s local polices as a whole prescribe a variety of services, resources, and/or measures to support care-experienced young people, of which housing and employment are at the top of the list; (ii) current policy responses are insufficient, and opportunities of this group of people to access the stipulated support are quite limited. The findings of this study indicate that policymakers need to improve local policies in order to make them more operable, sophisticated, and comprehensive, so that care-experienced young people can reap the greatest benefits from them. Also, a national leaving-care policy that provides guidance to local authorities should be considered, adding consistency and clarity to relevant policies across the country. The limitations of this paper relate mainly to its review methods, which point to the need to expand data sources and conduct cross-reviews to enhance the findings’ credibility and robustness.

세대별 가계특성의 판별요인 분석

The purpose of this study is to investigate the determinants based on the current household characteristics for the correct asset composition and selection according to the household characteristics of each generation. This study analyzed the determinants that reveal statistical differences according to the characteristics of each generation divided into the younger generation, the middle-aged generation, and the older generation. In the case of determinant function 1, it appeared in the form of occupation, and the household characteristics of determinant function 2 were total assets, total debt, housing (residential real estate), and non-housing (non-residential real estate). The following are particular analysis findings. First, the younger generation considerably determined the kind of occupancy with a high non-ownership rate, while the older generation significantly determined the type of occupancy with a high ownership rate. Second, in the case of large total assets, the middle-aged generation was significantly identified, and the smaller total assets were significantly identified as the older generation. Third, the middle-aged generation was significantly identified for the large total debt, and the older generation was significantly identified for the smaller total debt. Fourth, middle-aged households with high housing market value and the older generation with low housing market value was significantly distinguished; middle-aged households with large housing exclusion (non-residential real estate) and the older generation with small housing exclusion (non-residential real estate). In conclusion, it has been confirmed that there are differences in household characteristics according to generation in the housing supply policy, and appropriate government policy support and household asset management strategies are needed to avoid difficulties in the economic activities of the the older generation.

Mental health and homelessness in the social service providers' outlook (Luxembourg case)

PurposeThe purpose of this paper is to explore the perception of the mental health problems of the homeless population in a high-income country (Luxembourg) by social service providers and to develop proposals for better inclusion of homeless people into the mental health services and homeless people with mental health issues into society.Design/methodology/approachThe study was of qualitative design and conducted using a semi-structured interview method (in person). The semi-structured interviews (seven participants) were conducted to analyse the challenges, practice approaches and prospects of stakeholders or decision-makers working in housing exclusion and homelessness. A secondary thematic analysis of this content regarding mental health issues was performed.FindingsThree main themes in the social providers’ perception were identified related to mental health and homelessness: the general view on the mental health problems of homeless people (accent on substance use disorders [SUDs], overshadowing of other mental health conditions by the SUDs); the positive impact of housing and social services on the mental health of the homeless per se (role of social rhythms, social connectedness and multidisciplinary approach are emphasised); and the need for improvement of mental health services in the country (need for the long-term timely continuing mental health support and recognition of the importance of complex intersectional and multidisciplinary solutions).Research limitations/implicationsMental health themes were not the primary focus while research was planned and conducted. They were revealed as results of secondary qualitative data analysis. Therefore, additional mental health-focused mixed methods research is needed to verify the conclusions. The paper is written on the results of the research project “Social Housing and Homelessness” (SOHOME), implemented at the University of Luxembourg with the financial support of the Fonds National de la Recherche of Luxembourg (FNR12626464). The sponsor had no involvement in the study design, the collection, analysis and interpretation of data or the preparation of the paper.Practical implicationsThe study brings together different perspectives from social workers, stakeholders and decision-makers. The results show that there are cross-field connections between homelessness and mental health that require specialised and coordinated services. The first existing approaches seem to be promising in their continuation but need to be promoted by social policy.Social implicationsTo promote social cohesion in the Luxembourgish society and also to include one of the most vulnerable people, the study points to the importance of the link between homelessness and compromised mental health. Appropriate support and service provision as well as social and affordable housing play a central role.Originality/valueTo the best of the authors’ knowledge, this study is the first of its kind, revealing several social work stakeholders’ perspective on the mental health of homeless people in Luxembourg.

"Znaš što, ja ću o tome napisati knjigu!" – analize životnih povijesti osoba u situacijama ugroženoga stanovanja

In the context of vulnerable housing situations (homelessness and housing exclusion), the life course perspective, the concept of housing careers and housing pathways emphasise different life experiences, differential circumstances, and the social contexts of arriving at such a position, depending on age. Keeping this in perspective, the research identified the dominant events and circumstances that marked people's descent into one of the vulnerable housing situations across: a) youth and early middle age, b) late middle age, and c) old age. The study was conducted between December 2021 and February 2022 in the city of Novi Sad (Republic of Serbia). 35 respondents who are in one of the vulnerable housing situations took part in the research. Convenience, purposive and snowball sampling were applied, and the data was collected through a semi- -standardised, in-depth interview. The obtained results indicate the multiplicity and cumulativeness of adverse events and characteristics in the life trajectories of persons in vulnerable housing, as well as the specificity of unfavourable circumstances depending on age. In conclusion, the research confirmed the findings of previous literature in the domain of the life history of vulnerable housing and indicated possible directions for improving the understanding of this topic.

Whole genome sequencing reveals two genetically distinct MRSA outbreaks among people who inject drugs and homeless people in Copenhagen.

Whole genome sequencing (WGS) has greatly improved the detection of methicillin-resistant Staphylococcus aureus (MRSA) transmission between people. We describe the transmission of two unique MRSA clones among homeless people in Copenhagen using WGS and core genome MLST (cgMLST). In 2014, an accumulation of MRSA bacteremia cases among homeless people admitted to our hospital was recognized, all having the rare MRSA spa t5147/ST88. The European Typology of Homelessness and Housing Exclusion (ETHOS) categories revealed that people who inject drugs (PWID) frequently visiting the milieu but living in private accommodation accounted for most cases. Hoping to terminate the transmission, 161 homeless people were MRSA screened in 2015, but no additional cases were found. From 2009 to 2018, 60 patients with genomically related t5147/ST88 isolates were found, of these 70% were confirmed to come from the homeless setting and 17% had bacteremia. From 2017 to 2020, cgMLST revealed a smaller MRSA outbreak including 13 PWID with a completely different clone, t1476/ST8, of which 15% had bacteremia. Our study confirms that WGS and cgMLST is excellent to reveal MRSA outbreaks. The ETHOS categorization can be useful to find the primary source of spread in the homeless community.

Editorial: Hit by a Pandemic in a Time of Scarcity

The pandemic hit at a time of high rates of housing exclusion globally. While there have been many discussions of "a new normal", what we have seen is increased housing costs and therefore increased exclusion. This editorial presents concern for the lack of structural changes and a call for us as a global community to do better in preventing and ending homelessness.

Getting Suburbs to Do Their Fair Share: Housing Exclusion and Local Response to State Interventions

Massachusetts has engaged in a fifty-year experiment in overriding local zoning to create affordable housing in the suburbs. Studying suburbs as sites of persistent resistance, this work interrogates a local decision-making process to reveal how structures and gaps in the law help to maintain, rather than challenge, the exclusionary status quo. Analysis is based on five years of observations of public hearings across four Boston suburbs. I argue that this decision-making process is characterized by participants’ use of narratives and logics to resist, make sense of, and adapt to the law. Further, although the eventual decision is almost always to build housing, this study reveals a structural similarity between zoning and the law as well as a cultural process of sense-making that leads to minimal compliance and a reassertion of the local power over regional housing needs.

Generation rent on the housing treadmill: A study on South Korea's housing allowance programmes and recurring precarity

AbstractGiven the ongoing economic crisis and the increase in housing prices, many young adults —known as “generation rent”—use a large portion of their wages for rent and cannot buy a house. In South Korea, generation rent in lower income brackets are particularly vulnerable to overlapping precarities as housing inequality worsens. In response, South Korean local governments have offered housing allowance programmes since 2019, but studies on the impact of housing allowance on young adults are scant. This article examines how and to what extent housing allowance for young adults relieves precarity through a grounded theory approach. Eighteen young adults who benefit from the programme participated in in‐depth interviews. Results show that after living independently, participants experienced multidimensional precarity: housing, financial, professional and social support exclusion. To alleviate their precarity, they applied for a housing allowance programme, thereby experiencing changes. Although their precarity was reduced, it was not entirely allayed because of the programme's short duration, which kept them stuck on the “housing treadmill.”

Chronic diseases and multi-morbidity in persons experiencing homelessness: a cross-sectional study

Abstract Background Persons experiencing homelessness (PEH) suffer a high burden of chronic diseases, yet face significant barriers in accessing health services. We describe and compare chronic diseases and multi-morbidity in PEH, housing exclusion and secure housing who lacked access to regular health services in the wake of the COVID-19 pandemic in Germany. Methods Study participants were adults who sought care at clinics of the humanitarian organisation “Ärzte der Welt” in Munich, Hamburg and Berlin in 2020. The patients were categorised into three groups according to the European Typology of Homelessness and Housing Exclusion (ETHOS). We described socio-demographic characteristics, self-rated health, chronic diseases, multi-morbidity and SARS-COV-2 infections in each group. Logistic regression analysis was used to identify socio-demographic factors associated with higher odds of chronic diseases and multi-morbidity. Results Of the 695 study participants, 333 experienced homelessness, 292 housing exclusion and 70 had secure housing. 92.3 % had no or limited health insurance and 96.7% were below the poverty line. Males and EU citizens were highly represented among PEH (74.2% and 56.8% respectively). PEH had lower self-rated health (47.8%, p = 0.04), and higher rates of psychiatric illness (20.9%, p = 0.04). In adjusted analyses, being 35-49 and ≥50 years was associated with greater odds of chronic diseases (AOR= 2.33, 95% CI = 1.68-3.24; AOR=3.57, 95% CI = 2.55-5.01, respectively), while being male was associated with lower odds of multi-morbidity (AOR=0.602, 95% CI = 0.38-0.9). Of the 18 symptomatic patients tested for SARS-COV-2 infection, 15 were PEH, of whom one tested positive. Conclusions Housing was not a risk factor for chronic disease and multi-morbidity in this study. However, PEH reported poorer self-rated and psychiatric health. Strategies to improve access to health services for persons experiencing homelessness and housing exclusion are much needed in Germany. Key messages • Research to highlight the health inequity, both in access and outcomes, in persons experiencing all forms of homelessness is much needed. • This study provides data on a population disconnected from the formal healthcare system. Making such data visible is a step towards addressing the structural causes of social exclusion.

Chronic diseases and multi-morbidity in persons experiencing homelessness: results from a cross-sectional study conducted at three humanitarian clinics in Germany in 2020

BackgroundPersons experiencing homelessness (PEH) suffer a high burden of chronic diseases and multi-morbidity, yet face significant barriers in accessing healthcare services. These health inequalities were further aggravated during the COVID-19 pandemic. While there is a lack of comprehensive health data on PEH, even less is known about populations experiencing housing exclusion, a hidden form of homelessness. This study examines and compares chronic diseases and multi-morbidity in PEH, persons experiencing housing exclusion, and persons with secure housing who lacked access to regular healthcare services in the wake of the COVID-19 pandemic in Germany.MethodsStudy participants were adults who sought medical care at clinics of the humanitarian organisation “Ärzte der Welt” in Munich, Hamburg and Berlin in 2020. The patients were categorised into three housing groups according to the ETHOS classification of homelessness and housing exclusion. Socio-demographic characteristics, self-rated health, chronic diseases and multi-morbidity were described in each group. Logistic regression analysis was used to identify socio-demographic factors associated with higher odds of chronic diseases and multi-morbidity in each housing group.ResultsOf the 695 study participants, 333 experienced homelessness, 292 experienced housing exclusion and 70 had secure housing. 92.3% of all patients had either no or limited health coverage, and 96.7% were below the poverty line. Males and EU/EEA citizens were highly represented among PEH (74.2% and 56.8% respectively). PEH had lower self-rated health (47.8%, p = 0.04), and a higher prevalence of psychiatric illness (20.9%, p = 0.04). In adjusted analyses, belonging to the age group 35–49 and ≥ 50 years were associated with greater odds of chronic disease (AOR = 2.33, 95% CI = 1.68–3.24; AOR = 3.57, 95% CI = 2.55–5.01, respectively) while being ≥ 50 years old was associated with multi-morbidity (AOR = 2.01, 95% CI = 1.21, 3.33). Of the 18 participants tested for SARS-COV-2, 15 were PEH, 1 of whom tested positive.ConclusionsHousing status was not an independent risk factor for chronic disease and multi-morbidity in our study population. However, PEH reported poorer self-rated and psychiatric health. Strategies to improve access to healthcare services amongst persons experiencing homelessness and housing exclusion are needed in Germany.

The health of individuals experiencing homelessness: a 15-year retrospective cohort study

ABSTRACT People experiencing homelessness (IEHs) and housing exclusion have more chronic diagnoses and lower life expectancy than the general population. There are no studies of large samples of IEHs in Spain, especially studies that analyze health records and diagnoses. The objective of this study was to analyze the health of IEHs in Spain. We conducted an observational retrospective cohort study of the health of 3,854 IEHs, according to age and gender, using diagnoses registered in the health service, over the 15 years between 2006 and 2020. The results obtained indicated that 40% of the IEHs studied suffered from a physical disorder. Between 4.1% and 13.2% had some type of infection, and between 4.0% and 13.8% a chronic pathology. Of the total population, 13.2% died during the period of analysis. The main causes of death were suicide, cirrhosis of the liver, overdose, chronic obstructive pulmonary disease flare-up, cardiopathy, AIDS, cancer, and meningitis. Older people had more health problems. Women were in poorer health and had a higher mortality rate than men. These results, the first ones from a large sample of IEHs in Spain, highlight health problems of IEHs, especially women.