Health of people experiencing co-occurring homelessness, imprisonment, substance use, sex work and/or severe mental illness in high-income countries: a systematic review and meta-analysis

Tweed, E. J. et al. (2021) Health of people experiencing co-occurring homelessness, imprisonment, substance use, sex work and/or severe mental illness in high-income countries: a systematic review and meta-analysis. Journal of Epidemiology and Community Health, 75(10), pp. 1010-1018. (doi: 10.1136/jech-2020-215975) (PMID:33893182) (PMCID:PMC8458085)

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Background: People affected by homelessness, imprisonment, substance use, sex work or severe mental illness experience substantial excess ill health and premature death. Though these experiences often co-occur, health outcomes associated with their overlap have not previously been reviewed. We synthesised existing evidence on mortality, morbidity, self-rated health and quality of life among people affected by more than one of these experiences. Methods: In this systematic review and meta-analysis, we searched Medline, Embase, and PsycINFO for peer-reviewed English-language observational studies from high-income countries published between 1 January 1998 and 11 June 2018. Two authors undertook independent screening, with risk of bias assessed using a modified Newcastle-Ottawa Scale. Findings were summarised by narrative synthesis and random-effect meta-analysis. Results: From 15 976 citations, 2517 studies underwent full-text screening, and 444 were included. The most common exposure combinations were imprisonment/substance use (31% of data points) and severe mental illness/substance use (27%); only 1% reported outcomes associated with more than two exposures. Infections were the most common outcomes studied, with blood-borne viruses accounting for 31% of all data points. Multiple exposures were associated with poorer outcomes in 80% of data points included (sign test for effect direction, p<0.001). Meta-analysis suggested increased all-cause mortality among people with multiple versus fewer exposures (HR: 1.57 and 95% CI: 1.38 to 1.77), though heterogeneity was high. Conclusion: People affected by multiple exclusionary processes experience profound health inequalities, though there are important gaps in the research landscape. Addressing the health needs of these populations is likely to require co-ordinated action across multiple sectors, such as healthcare, criminal justice, drug treatment, housing and social security.

Item Type:Articles
Additional Information:EJT, RT, and SVK are funded by the Medical Research Council grants MC_UU_12017/13 and MC_UU_12017/15, and the Chief Scientist Office grants SPHSU13 and SPHSU15. In addition, EJT is funded by a Chief Scientist Office Clinical Academic Fellowship (CAF/17/11); SVK by an NRS Scottish Senior Clinical Fellowship (SCAF/15/02); RT by a Wellcome Trust Research Fellowship for Health Professionals (218105/Z/19/Z); AK by a Wellcome Trust Clinical PhD Programme fellowship (203919/Z/16/Z); and AKP by a Medical Research Council PhD Studentship (MC_UU_12017/13); DL by a National Institute for Health Research Doctoral Research Fellowship (DRF-2018-11-ST2-016); RWA by a Wellcome Clinical Research Career Development Fellowship (206602).
Glasgow Author(s) Enlighten ID:Katikireddi, Professor Vittal and Thomson, Dr Rachel and Tweed, Dr Emily and PURBA, Amrit
Authors: Tweed, E. J., Thomson, R. M., Lewer, D., Sumpter, C., Kirolos, A., Southworth, P. M., Purba, A. K., Aldridge, R. W., Hayward, A., Story, A., Hwang, S. W., and Katikireddi, S. V.
College/School:College of Medical Veterinary and Life Sciences
College of Medical Veterinary and Life Sciences > School of Health & Wellbeing > MRC/CSO SPHSU
Journal Name:Journal of Epidemiology and Community Health
Publisher:BMJ Publishing Group
ISSN (Online):1470-2738
Published Online:23 April 2021
Copyright Holders:Copyright © 2021 The Authors
First Published:First published in Journal of Epidemiology and Community Health 75(10): 1010-1018
Publisher Policy:Reproduced under a Creative Commons Licence

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Project CodeAward NoProject NamePrincipal InvestigatorFunder's NameFunder RefLead Dept
301147Morbidity and mortality among people experiencing severe and multiple disadvantage: a cohort study using cross-sectoral data linkageEmily TweedChief Scientist Office (CSO)CAF/17/11HW - MRC/CSO Social and Public Health Sciences Unit
727651SPHSU Core Renewal: Measuring and Analysing Socioeconomic Inequalities in Health Research ProgrammeAlastair LeylandMedical Research Council (MRC)MC_UU_12017/13IHW - MRC/CSO SPHU
727671SPHSU Core Renewal: Informing Healthy Public Policy Research ProgrammePeter CraigMedical Research Council (MRC)MC_UU_12017/15IHW - MRC/CSO SPHU
Chief Scientist Office (CSO)SPHSU13
Chief Scientist Office (CSO)SPHSU15
172690Understanding the impacts of welfare policy on health: A novel data linkage studySrinivasa KatikireddiOffice of the Chief Scientific Adviser (CSO)SCAF/15/02HW - Public Health
306430Predicting the impacts of universal basic income on mental health inequalities in the UK population: a microsimulation modelRachel ThomsonWellcome Trust (WELLCOTR)218105/Z/19/ZHW - MRC/CSO Social and Public Health Sciences Unit