Marcel Slockers

38 Chapter 2 vantages, as compared to the general population, were found for homeless women and the younger age groups. In homeless women mortality was more than 5 times higher and in homeless men 3 times higher. For the age groups 20–44 years, mortality was almost 8 times higher and about 1.5 times for the age group 60+ years. Remaining life expectancy of homeless people at age 30 years was substantially lower compared with Rotterdam's general population: a disparity of 11 years for men and 16 years for women. Our study confirms large excess mortality among homeless people as compared to the general population, and variations in the excess mortalitywith age, generally showing higher excess risks at younger ages. 1,4,31 This study extends the available evidence from a limited number of countries by including data from the Netherlands, with results on mortality and life expectancy of a comprehensive homeless cohort from Rotterdam. Another study performed in the Netherlands also investigated mortality of homeless people, but focused on homeless in convalescence care only. 13 Moreover, our study examined mortality in the period 2001–2010, thereby extending and updating the evidence base. Our RRs of 3.3 (men), 5.6 (women), 3.5 (both sexes combined) are in line with other studies reporting RRs ranging from 3.1 2 to 5.6 10 in men, from 2.5 2 to 6.7 10 in women, and 4.4 9 for both sexes combined. Thus, the present study provides the evidence that in the 21 st century homelessness is still associated with a large excess mortality, even in a country like the Netherlands with an extensive social security system. The high excess mortality in the current century is in line with a recent study reporting that in 2003–2008 the mortality rate of 18–64 year-old homeless in Boston has not changed as compared to 1988–1993. 15 Previous studies comparing mortality among homeless men and women report incon- sistent results, which may (in part) reflect the use of different outcome measures and/or statistical analyses and/or study populations, and perhaps variations by age. However, similar to our study, some studies found no significant overall difference in mortality between homeless men and women, 2,11 whereas others found lower mortality and higher life expectancies in homeless women. 10,30 A study based on 7 cities found that mortality rates among younger homeless women often approach or equal those of homeless men, but were lower in females at older ages. 3 Similar to our study, most other comparisons of mortality rates between homeless men/women and men/women in the general population, showed higher excess mortality in women than in men. 1,5,7,10,11 An exception was a study among Canadian homeless and marginally housed people which reported smaller stan- dardized mortality ratios and a smaller gap in life expectancy when comparing women living in shelters, rooming houses and hotels with the entire cohort. 32 Strikingly, a large register-based study in Denmark also found a smaller gap in life expectancy of homeless as compared to the general population of women, 10 which is in contrast to the higher overall