MRC/CSO Social and Public Health Sciences Unit, University of Glasgow Institute of Health and Wellbeing, Glasgow, UK
MRC/CSO Social and Public Health Sciences Unit, University of Glasgow Institute of Health and Wellbeing, Glasgow, UK.
J Epidemiol Community Health. 2021 Oct;75(10):1010-1018. doi: 10.1136/jech-2020-215975. Epub 2021 Apr 23.
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.
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.
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.
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.
CRD42018097189.
无家可归、监禁、药物使用、性工作或严重精神疾病会对人们造成严重的健康不良和过早死亡。尽管这些经历经常同时发生，但以前尚未对与其重叠相关的健康结果进行审查。我们综合了关于这些经历中不止一种经历的人群的死亡率、发病率、自我评估健康和生活质量的现有证据。
在这项系统评价和荟萃分析中，我们检索了 1998 年 1 月 1 日至 2018 年 6 月 11 日发表的来自高收入国家的同行评议的英文观察性研究，检索数据库包括 Medline、Embase 和 PsycINFO。两名作者独立进行筛选，使用改良的纽卡斯尔-渥太华量表评估偏倚风险。通过叙述性综合和随机效应荟萃分析总结结果。
从 15976 条引文，2517 项研究进行了全文筛选，444 项被纳入。最常见的暴露组合是监禁/药物使用（占数据点的 31%）和严重精神疾病/药物使用（占 27%）；只有 1%报告了与两种以上暴露相关的结果。感染是研究最多的结果，血源性病毒占所有数据点的 31%。在纳入的 80%的数据点中，多种暴露与较差的结果相关（方向检验的效应检验，p<0.001）。荟萃分析表明，与暴露较少的人相比，暴露较多的人全因死亡率更高（HR：1.57，95%CI：1.38 至 1.77），但异质性很高。
受多种排斥过程影响的人群经历了深刻的健康不平等，尽管研究领域存在重要差距。满足这些人群的健康需求可能需要医疗保健、刑事司法、药物治疗、住房和社会保障等多个部门的协调行动。
PROSPERO 注册号：CRD42018097189。
