Marcel Slockers

82 Chapter 5 The findings from our explorative study are in line with previous research, suggesting shifts in cause of death patterns after introducing social policy measures. We observed that after the implementation of social policy measures in the city of Rotterdam in 2006 mortality rates due to intentional injuries (suicide and homicide) were reduced, whereas total mortality rates remained unchanged. 16 These results suggest a shift in the cause of death pattern within our homeless cohort with a reduced contribution of unnatural death. The policy efforts after 2006 included temporary care and social rehabilitation. People were supported with housing projects with guidance into jobs and social education. They received psychiatric support and help with their addiction. Comparable social programs in large cities in the USA were also accompanied by shifts in the main causes of death among the (formerly) homeless. Baggett at al showed that despite expansion of services (mainly expansion of federally funded Health Care for the Homeless clinical services), the excess mortality of homeless people in Boston remained similar during the past two decades, but shifts in the causes of death occurred with fewer deaths from HIV infection and more from drug overdose and substance misuse disorders 9 . Henwood et al showed that of the participants of a Housing First program in Philadelphia (i.e. a program offering access to housing combined with ongoing community support services) only 15% died from unnatural death (accidents, suicide and homicide) compared to 49% of those staying homeless. Simultaneously the proportion of deaths due to the main natural causes (i.e. cardiovascular disease and cancer) rose to 51% in the Housing First participants compared to 30% in homeless people 10 . Because of the discussed limitations of our study design the observed reduction of mortality due to intentional injuries cannot be attributed to the social policy measures, but seems nevertheless relevant from a policy perspective. Our explorative study has generated the hypothesis that social policies providing housing, supporting the acquisition of a legal income and improving contacts with community and (mental) health care services could be accompanied by less suicides and homicides among homeless people. Mental health problems are highly prevalent among homeless people 18 and are associated with elevated suicide risks, 19 which can be further exacerbated by hopelessness, i.e. generalized negative expectations about the future. 20 We hypothesize that the Dutch social policy measures may have improved mental health and reduced hopelessness among homeless people thereby contributing to less self-harm and suicides within this vulnerable group. In addition, these measures have provided housing for many formerly homeless and may have reduced their exposure to several risks of living in the street. It has been shown that the safety index of Rotterdam improved after 2006 with a decreased street use of illegal drugs (including cocaine, which may lead to agitation, loss of impulse control and an elevated risk of intentional injury) and a reduction of violent crimes. 21