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

Abstract

BackgroundPeople 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.MethodsIn 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.ResultsFrom 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.ConclusionPeople 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.PROSPERO registration numberCRD42018097189.

Adverse SARS-CoV-2-associated outcomes among people experiencing social marginalisation and psychiatric vulnerability: A population-based cohort study among 4,4 million people

“… 13 The high risk of morbidity and mortality in people experiencing homelessness, imprisonment, and individuals with psychiatric disorders might be explained by high proportions of underlying medical conditions. 10 , 16 , 21 , 34 It is also likely that the individuals living in vulnerable living environments are affected by multiple exclusionary experiences, as well as undiagnosed and untreated disorders, and that these complex needs contribute to the severe health outcomes. 16 Furthermore, these groups also had lower odds for being PCR-tested.…”

“… 10 , 16 , 21 , 34 It is also likely that the individuals living in vulnerable living environments are affected by multiple exclusionary experiences, as well as undiagnosed and untreated disorders, and that these complex needs contribute to the severe health outcomes. 16 Furthermore, these groups also had lower odds for being PCR-tested. Thus, the detection of a SARS-CoV-2 infection might be postponed, which could lead to increased risk of hospitalisation and intensive care.…”

“… 11 , 12 , 13 In a systematic review of people experiencing homelessness, increased risk of SARS-CoV-2 infection, morbidity and mortality has been suggested, but the literature is scarce. 14 However, the importance of preventing infections in marginalised sub-groups has been claimed, 15 , 16 , 17 and vaccination against COVID-19 has in some countries, e.g. in Denmark and the UK, been prioritised also for people with severe mental disorders, 15 , 18 and people experiencing homelessness.…”

“… 7 COVID-19 outbreaks have been reported in shelters for homeless people, 14 , 19 but representative data on individuals experiencing homelessness, imprisonment, supported psychiatric housing, and substance abuse is lacking. 20 , 21 Social disadvantage, psychiatric disorders, and chronic medical conditions often co-occur, 16 and studies compiling information on these factors are relevant.…”

Vulnerability, Risk and Harm for People Who Use Drugs and Are Engaged in Transactional Sex: Learning for Service Delivery

“…Overall standardized mortality ratios were 8-12 times higher than the general population [6]. Tweed et al extended this analysis by looking at combinations of exclusion health categories but found few studies had considered the health of sex workers in combination with other exclusion categories apart from substance use (others being homeless, prison populations) [10]. This is a clear evidence gap.…”