Marcel Slockers

40 Chapter 2 is probably an overestimation of the number of unmatched persons as it may include duplicates and persons already included in the study cohort. The strict matching approach guaranteed that we had almost complete information on the vital status throughout the study follow-up. Only for 242 persons registered as ‘emigrated’ was the follow-up not complete; however, excluding these latter persons did not change the study conclusions. We have no data on whether those homeless in 2001 were still homeless during follow-up. Some probably succeeded in acquiring housing, which may have led an underestima- tion of mortality related to homelessness. However, this limitation does not hamper our comparison with other studies, as almost all studies assessed the effect of homelessness at the start of follow-up. Our study cohort was relatively small, with comparatively few women (n=250). This is partly compensated by the relatively long follow-up period; nevertheless, our results based on data for women should be interpreted with caution (especially since data on 130 addicted female sex workers were not included). Another limitation is that our study does not provide information on cause of death or on any other characteristic (apart from age, sex and type of service use). Based on almost 10 years of follow-up, for a representative cohort of homeless people this study presents: 1) mortality RRs comparing mortality among demographic subgroups of homeless people, 2) mortality RRs comparing mortality between homeless men and women and men and women in the general Rotterdam population, and 3) life expectancy differences for men and women between homeless people and the general Rotterdam population. The comparisons among the homeless population, and between the homeless and the general population, provide some useful insights which complement each other. Large excess mortality indicates high losses associated with homelessness and shows that large potential gains might be achieved by preventing persons from becoming homeless, or by reducing the adverse health effects associated with being homeless. The adverse health effects appear to be greater for women. This higher excess mortality may reflect that younger homeless women, compared with homeless men, practice worse health behaviors, 17,23 have a higher risk of alcohol/drug use disorders 17 and have a higher risk for psychiatric disorders. 17 Younger homeless women have been found to have a significant higher risk for hospital admission; risks were considerably elevated for diseases of the genital organs, viral hepatitis, and poisoning . 33 A recent meta-synthesis study of Finf- geld-Connett 34 describes the downward spiral of women becoming homeless and the role of complex interconnected stressors, the non-adaptive attachments with men, and flawed problem-solving and decision-making skills of homeless women in their life as homeless. Homelessness is much less frequent among women, 33,35 and hence homeless women may