Marcel Slockers

39 Health status of homeless people measured by mortality rates standardized mortality rate for females reported in the same study. Similar to most other studies, including the Danish study, 10 we found higher excess mortality in women in terms of mortality RRs; however, in our study this was confirmed by a larger disparity in life expectancy as compared to the general population in women. Mortality RRs and life expectancy measures summarize mortality across age. Differences between these aggregated measures may yield less interpretable outcomes if mortality variations differ by age. For life expectancy this is widely recognized and life table decom- position analysis is often used to provide insight into the contributions of different age groups. 29 In the present study, the decomposition of the disparity in life expectancy at age 30 years between homeless people and the general Rotterdam population by age showed particularly for women large contributions of the age groups 30–44 and 45–59 years to the gap in life expectancy. Decomposition analyses may provide a better understanding of the inconsistent gender differences in excess mortality in the Danish study. 10 Our study includes homeless people in contact with a wide range of services (i.e. persons who use only day care, only night care, both night and day care, convalescence care, and sleeping rough). Homeless in convalescence care had about 70% higher mortality compared with homeless persons using only day care (Table 3) and 80% higher compared with all other services combined (data not shown). The higher mortality of homeless in convalescence care may well be a selection effect. Therefore, to avoid underestimation of mortality among homeless people, it is important to include this vulnerable latter group in the study population. Our study has some limitations. First, homeless people who did not use any local service in 2001 were not included, and not all institutes could provide data for 2001. In addition, the present study lacks data on 130 addicted female sex workers and about 225 persons living in social pensions. Female sex workers may have a higher mortality rate than the women included in our study. Also, one institution provided a list that was based on their 2001 administration but was actually compiled at a later date. Another limitation is that we were unable to link (a maximum of) 1238 homeless who were on the lists in 2001. In the Netherlands, in 2001 the ‘citizen service number’ (BSN; a unique identification number) was not yet legally required and was not used in the lists. We cannot rule out that specific groups with a higher mortality rate were more likely to be missed. Also, differences and/or errors in spelling are more likely to occur with non-Dutch names. Homeless immigrants without a legal residence status who were not later legalized could by definition not be matched and may have faced worse living circumstances than their legal homeless peers. On the other hand, the 1,238 records that could not be matched