Morbidity and mortality in homeless individuals, prisoners, sex workers, and individuals with substance use disorders in high-income countries: a systematic review and meta-analysis

Robert W. Aldridge*, Alistair Story, Stephen W. Hwang, Merete Nordentoft, Serena A. Luchenski, Greg Hartwell, Emily J. Tweed, Dan Lewer, Srinivasa Vittal Katikireddi, Andrew C. Hayward

*Corresponding author for this work

Research output: Contribution to journalArticlepeer-review

220 Citations (Scopus)

Abstract

Background: Inclusion health focuses on people in extremely poor health due to poverty, marginalisation, and multimorbidity. We aimed to review morbidity and mortality data on four overlapping populations who experience considerable social exclusion: homeless populations, individuals with substance use disorders, sex workers, and imprisoned individuals. Methods: For this systematic review and meta-analysis, we searched MEDLINE, Embase, and the Cochrane Library for studies published between Jan 1, 2005, and Oct 1, 2015. We included only systematic reviews, meta-analyses, interventional studies, and observational studies that had morbidity and mortality outcomes, were published in English, from high-income countries, and were done in populations with a history of homelessness, imprisonment, sex work, or substance use disorder (excluding cannabis and alcohol use). Studies with only perinatal outcomes and studies of individuals with a specific health condition or those recruited from intensive care or high dependency hospital units were excluded. We screened studies using systematic review software and extracted data from published reports. Primary outcomes were measures of morbidity (prevalence or incidence) and mortality (standardised mortality ratios [SMRs] and mortality rates). Summary estimates were calculated using a random effects model. Findings: Our search identified 7946 articles, of which 337 studies were included for analysis. All-cause standardised mortality ratios were significantly increased in 91 (99%) of 92 extracted datapoints and were 11·86 (95% CI 10·42–13·30; I2=94·1%) in female individuals and 7·88 (7·03–8·74; I2=99·1%) in men. Summary SMR estimates for the International Classification of Diseases disease categories with two or more included datapoints were highest for deaths due to injury, poisoning, and other external causes, in both men (7·89; 95% CI 6·40–9·37; I2=98·1%) and women (18·72; 13·73–23·71; I2=91·5%). Disease prevalence was consistently raised across the following categories: infections (eg, highest reported was 90% for hepatitis C, 67 [65%] of 103 individuals for hepatitis B, and 133 [51%] of 263 individuals for latent tuberculosis infection), mental health (eg, highest reported was 9 [4%] of 227 individuals for schizophrenia), cardiovascular conditions (eg, highest reported was 32 [13%] of 247 individuals for coronary heart disease), and respiratory conditions (eg, highest reported was 9 [26%] of 35 individuals for asthma). Interpretation: Our study shows that homeless populations, individuals with substance use disorders, sex workers, and imprisoned individuals experience extreme health inequities across a wide range of health conditions, with the relative effect of exclusion being greater in female individuals than male individuals. The high heterogeneity between studies should be explored further using improved data collection in population subgroups. The extreme health inequity identified demands intensive cross-sectoral policy and service action to prevent exclusion and improve health outcomes in individuals who are already marginalised. Funding: Wellcome Trust, National Institute for Health Research, NHS England, NHS Research Scotland Scottish Senior Clinical Fellowship, Medical Research Council, Chief Scientist Office, and the Central and North West London NHS Trust.

Original languageEnglish
Pages (from-to)241-250
Number of pages10
JournalThe Lancet
Volume391
Issue number10117
DOIs
Publication statusPublished - 20 Jan 2018
Externally publishedYes

Bibliographical note

Funding Information:
RWA was supported by an academic clinical lectureship from the National Institute for Health Research (NIHR) and and a Wellcome Trust Clinical Research Career Development Fellowship (206602/Z/17/Z). AS is funded by University College London Hospitals Foundation Trust. ACH's salary is provided by Central and North West London National Health Service (NHS) Community Trust. EJT and SVK are funded by the Medical Research Council (MC_UU_12017/13 & MC_UU_12017/15) and the Scottish Government Chief Scientist Office (SPHSU13 & SPHSU15). SVK is also funded by a National Research Service (NHS) Research Scotland Scottish Senior Clinical Fellowship (SCAF/15/02). The views expressed are those of the authors and not necessarily those of The Wellcome Trust, NIHR, NHS, NHS Research Scotland, Medical Research Council, or the Scottish Government Chief Scientist Office.

Funding Information:
Acknowledgments RWA was supported by an academic clinical lectureship from the National Institute for Health Research (NIHR) and and a Wellcome Trust Clinical Research Career Development Fellowship (206602/Z/17/Z). AS is funded by University College London Hospitals Foundation Trust. ACH's salary is provided by Central and North West London National Health Service (NHS) Community Trust. EJT and SVK are funded by the Medical Research Council (MC_UU_12017/13 & MC_UU_12017/15) and the Scottish Government Chief Scientist Office (SPHSU13 & SPHSU15). SVK is also funded by a National Research Service (NHS) Research Scotland Scottish Senior Clinical Fellowship (SCAF/15/02). The views expressed are those of the authors and not necessarily those of The Wellcome Trust, NIHR, NHS, NHS Research Scotland, Medical Research Council, or the Scottish Government Chief Scientist Office.

Publisher Copyright:
© 2018 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license

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