Marcel Slockers

131 Summary The cohort of homeless adults in 2001 consisted of 1870 men and 260 women, with a mean age of 40.3 years. During the 10 years of follow-up, 265 persons (232 male and 33 female) died. Adjusted for age and sex, no significant difference in mortality was observed between the periods 2001–05 and 2006–10 (P = 0.9683). A different splitting in periods did not change the results. Five years of local policy efforts improved their living conditions, but left the mortality rate of a homeless cohort unchanged. Incomplete reach of the program and long previous histories of homelessness ask for additional policies beyond the provision of housing and other services. Attention to the prevention of homelessness seems needed. In chapter 5 the most frequent causes of death of homeless adults are described. The design was an uncontrolled before-and-after study assessing cause of death patterns and changes therein after introduction of social policies in Rotterdam, the Netherlands, in 2006. We included homeless adults who visited the Rotterdam shelter in 2001 and followed them for 10 years (2001-2010). We then linked the data of this cohort to Statistics Netherlands mortality figures. We calculated the shares of specific causes of death in total mortality for the entire study period. We used the ‘standardised mortality ratio’ (SMR) to compare mortality in the homeless cohort of this period with mortality figures of the general Rotterdam population. In order to be able to compare the homeless mortality rates according to cause of death in the period before (2001-2005) and after introduction of social policy measures (2006-2010), the hazard ratio (HR) was calculated. Our cohort consisted of 2130 homeless persons with a mean age of 40.3 years. The most important causes of death were unnatural death (26%; 95% CI: 21-32), cardio- vascular diseases (22%; 17-27) and cancer (17%; 13-22). Suicide and murder together were responsible for 50% of the unnatural deaths. The largest differences in mortality in comparison with the Rotterdam population were those for unnatural death (SMR: 14.8; 95% CI: 11.5-18.7), infectious diseases (SMR: 10.0; 5.2-17.5) and psychiatric conditions (SMR: 7.7; 4.0-13.5). Mortality due to suicide or murder was significantly different for both study periods (HR: 0.45; 0.20-0.97). Prevention of unnatural deaths among homeless people should be one of the priorities in homeless policy. Improvement of their living conditions may reduce the number of murders and suicides in this vulnerable group. In chapter 6 street doctors warn of epidemic of uninsured homeless persons in the Netherlands. Over the past few years, the Netherlands Street Doctors Group, a national network of doctors and nurses providing outreach primary care to homeless people in the