Marcel Slockers

75 Changes in the causes of death of homeless people in Rotterdam Introduction Both in the European Union and the USA around half a million persons are homeless on any given day. 1–2 Homeless people have higher rates of premature mortality than the rest of the population, which is most evident among younger people. 2–6 This result in a largely reduced life expectancy, e.g homeless persons losing 14–16 life years in the Netherlands 7 and losing 17–22 life years in Denmark. 8 The contribution of specific causes of death to this excess mortality has not been studied extensively yet due to difficulties to reach out this vulnerable population. A limited number of studies in a few countries have shown an increased proportion of deaths resulting from substance misuse, 9 accidents, suicide and homicide 1,2,10,11 and mental disorders, infectious diseases and ischaemic heart disease. 1 According to several review studies social policy interventions may improve the health status of homeless people. 1,12–14 Many different types of interventions, including case management, are effective in the reduction of substance misuse. 12,13 For homeless people with substance abuse provision of housing is associated with decreased substance use, and health promotion programs can decrease risk behaviours among homeless populations. 14 Programmes focused on high risk groups, such as individuals leaving prisons and psychiatric hospitals and the introduction of national and state wide plans that target homeless people are likely to improve the mental health status of homeless people. 1 In the Netherlands, in 2006 social policy measures were introduced in the four largest cities aimed at housing and access to community services and medical care of homeless people. The Dutch Government, together with the four major Dutch cities (Amsterdam, Rotterdam, The Hague and Utrecht) started an ambitious programme to guide all homeless persons into temporary care and social rehabilitation and subsequently into clustered or individual supported housing projects. Since 2006, substantial local policy efforts have been made in Rotterdam, which have led to large improvements of the living conditions of homeless people in this city. Homeless people were supported with housing projects with guidance into jobs, daytime activities and social education. They received psychiatric support and help with controlling their drug and alcohol addiction. In 2010, a policy evaluation showed that 3634 homeless persons had started an individual help trajectory and 2108 homeless people had been provided with housing for at least 3 months, were acquiring a legal income and had stable contacts with community services. 15 These measures showed a positive effect on feelings of safety and other social outcome measures, but not on total mortality rates of homeless in the city of Rotterdam. 16