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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. 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. 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). 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. 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.

In the European Union, more than 400 000 individuals are homeless on any one night and more than 600 000 are homeless in the USA. The causes of homelessness are an interaction between individual and structural factors. Individual factors include poverty, family problems, and mental health and substance misuse problems. The availability of low-cost housing is thought to be the most important structural determinant for homelessness. Homeless people have higher rates of premature mortality than the rest of the population, especially from suicide and unintentional injuries, and an increased prevalence of a range of infectious diseases, mental disorders, and substance misuse. High rates of non-communicable diseases have also been described with evidence of accelerated ageing. Although engagement with health services and adherence to treatments is often compromised, homeless people typically attend the emergency department more often than non-homeless people. We discuss several recommendations to improve the surveillance of morbidity and mortality in homeless people. Programmes focused on high-risk groups, such as individuals leaving prisons, psychiatric hospitals, and the child welfare system, and the introduction of national and state-wide plans that target homeless people are likely to improve outcomes.

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.

While human identification is a crucial aspect of medico-legal investigations, many individuals remain unidentified each year across the world. The burden of unidentified bodies is often referred to when motivating for improved methods of identification, and anatomical teaching, yet the actual burden is somewhat unclear. A systematic literature review was undertaken to identify articles that empirically investigate the number of unidentified bodies experienced. Despite the large number of articles returned, an alarmingly low number (24 articles) provided specific and empirical details on the number of unidentified bodies, demographics and trends thereof. It is possible that this lack of data is due to the variable definition of ‘unidentified’ bodies and the use of alternative terminology such as ‘homelessness’ or ‘unclaimed’ bodies. Nevertheless, the 24 articles provided data for 15 forensic facilities across ten countries of both developed and developing statuses. On average, developing countries experienced more than double (9.56%) the number of unidentified bodies when compared to developed nations (4.40%). While facilities were mandated under different legislations and infrastructures available varied greatly, the most common issue faced is the lack of standardised procedures for forensic human identification. Further to this, the need for investigative databases was highlighted. Through addressing the standardisation of identification procedures and terminology, alongside the appropriate utilisation of existing infrastructure and database creation, the number of unidentified bodies could be significantly reduced globally.

Homelessness is a significant public policy and health service challenge globally. Often identified as a 'wicked problem' homelessness is hard to define with limited data confirming the exact numbers of people who are homeless due to varying metrics employed many of which likely exclude women by design. Research and policy have primarily focused on the experiences of single men, and the impact of homelessness on women and their experiences of it are not well understood. To synthesise evidence from qualitative studies of homelessness to identify key dimensions of women in high-income countries (HIC) and their experiences navigating lives when homeless. Systematic searches of six databases [MEDLINE, Embase, Global Health, PsycINFO, CINAHL and ASSIA] were completed from 2012 to 8th January 2024. We included peer-reviewed publications published in English reporting primary qualitative data on women's experiences of homelessness in high-income countries only. A review protocol was developed and published. Noblit and Hare's Metaethnography steps guided the synthesis and are reported according to the eMERGe guidelines. Thirty-two studies were identified describing the experiences of 227 women across nine HICs. A conceptual model comprising three themes is presented within a social-ecological theoretical framework within structural and temporal axes of impact with effects on individual and societal levels. These themes, 1) Precarity, 2) Existing with Risk and Surviving, and 3) Fracturing Identity, describe the implications of homelessness and how the experience of precarity impacts identity and decision-making abilities. The impact of risk arising from violence and exclusion, coupled with descriptions of shame and stigma, presents insight into women's experiences that have hitherto had a limited presence in clinical discourses. The evidence in this review highlights the perpetual reporting of a deficit lens on homelessness. Women experiencing homelessness in HICs are a heterogeneous group that is poorly recognised and understood in the literature. It appears that there is a lack of tailored and responsive service availability and that this further perpetuates the structural underpinnings of homelessness, which cluster in highly gendered ways.

Background People experiencing homelessness have an increased risk of hepatitis C virus (HCV) infection, with rates higher than the general population. However, their access to HCV diagnosis is limited and treatment uptake is low. Objectives To identify and describe the barriers and facilitators for HCV screening and treatment for adults with lived experience of homelessness in highly developed countries. Methods Bibliographic databases (Embase, MEDLINE, CINAHL and SocINDEX) and grey literature (Google, EThOS, the Health Foundation, Social Care Online, the World Health Organisation, Shelter, Crisis and Pathway) were searched. Two reviewers independently screened and appraised all studies. The Critical Appraisal Skills Programme tool and the Joanna Briggs Institute checklist were used. The analysis involved a three‐stage process: coding, theme generation and theme mapping under Penchansky and Thomas's modified access model. Results Twelve papers/reports were included in the review. Several interacting factors influence access of people with lived experience of homelessness to HCV testing and treatment. Some mirror those identified for the general population. The precarious conditions associated with the lived experience of homelessness along with the rigidity of hospital settings and lack of awareness emerged as dominant barriers. Flexibility, outreach, effective communication, tailoring and integration of services were found to be important facilitators. Evidence from Black, Asian and minority ethnic groups is limited. Conclusions People experiencing homelessness face multiple barriers in accessing and completing HCV treatment, relating to both their lived experience and characteristics of health systems. Although some barriers are readily amenable to change, others are more difficult to modify. The facilitators identified could inform future targeted measures to improve HCV diagnosis and treatment for people experiencing homelessness. Research is warranted into successful models to promote screening, diagnosis and treatment. Patient or Public Contribution Our team includes a peer advocate, a hepatology nurse and a community volunteer, all with significant experience in promoting and engaging in HCV care and outreach for people experiencing homelessness. They contributed to the protocol, interpretation and reporting of the review findings.

Background Health inequity: defined as systematic and avoidable difference in health outcome, remain entrenched across high-income countries, with socioeconomic gaps in life expectancy exceeding 7–10 years. Upstream interventions addressing the social determinants of health are critical. This umbrella review evaluates which macro-level policies and public health interventions most effectively reduce health inequity. Methods We conducted an umbrella review of systematic reviews. Four databases (Embase, Medline, Scopus, Cochrane) were searched from May 2017, the date of the last umbrella review on the subject, to September 2024. Eligible reviews reported population-level interventions in OECD countries, with outcomes stratified by socioeconomic status or related disadvantage. Included systematic reviews were appraised using AMSTAR II. We devised a conceptual Health Equity Pyramid that classified interventions by their agentic demand and population reach. Results Thirty-five systematic reviews were included. This review evaluated evidence across six policy domains. Redistributive and welfare interventions, including cash transfers, basic income and food subsidies, consistently improved food security, household financial stability and maternal–child health outcomes. Legislative and regulatory measures, such as smoke-free policies and pharmaceutical subsidy reforms, demonstrated robust population-level gains, particularly in disadvantaged groups. Community and housing interventions improved psychological health, reduced morbidity and mortality in targeted populations, and enhanced housing stability. Health system interventions, notably tailored smoking cessation and hospital discharge coordination for people experiencing homelessness, were effective in narrowing disparities. By contrast, educational and behavioural programmes and telehealth interventions often demanded high individual agency; without contextual tailoring, may exacerbate intervention-generated inequality. Conclusions This umbrella review demonstrates that interventions characterised by low agentic demand: welfare reform, housing support, and legislative measures; yield the most consistent reductions in inequity. High agentic interventions can be effective when carefully tailored to disadvantaged populations but may otherwise exacerbate disparities. Future policy should prioritise structural, population-level strategies to achieve sustainable equity in health outcomes. Trial registration CRD42024529176.

Workers in the Global South are doomed through economic imperialism to carry the burden of the entire world. While these workers appear isolated from the Global North, they are in fact deeply integrated into global commodity chains and essential to the maintenance of global capitalism. Looking at contemporary case studies in India, the Philippines and South Africa, this book affirms the significance of political and economic representation to the struggles of workers against deepening levels of poverty and inequality that oppress the majority of people on the planet. Immanuel Ness shows that workers are eager to mobilise to improve their conditions, and can achieve lasting gains if they have sustenance and support from political organisations. From the Dickensian industrial zones of Delhi to the agrarian oligarchy on the island of Mindanao, a common element remains – when workers organise they move closer to the realisation of socialism, solidarity and equality.

Background Homelessness is becoming an international public health issue in most developed countries, including Canada. Homelessness is regarded as both political and socioeconomic problems warranting broad and consistent result-oriented approaches. Methods This paper represents the qualitative findings of a project that explored risk factors associated with family homelessness and strategies that could mitigate and prevent homelessness among families using a focused ethnographic study guided by the principles of participatory action research (PAR). The sample includes 36 family members residing at a family shelter who participated in focus groups over two years (between April 2016 and December 2017). Most of the participants were single-parent women. Results The analysis yielded five major themes including, life challenges, lack of understanding of the system, existing power differentials, escaping from hardship, and a theme of proposed solutions for reducing family homelessness in the community. Conclusion The findings illustrated the complex nature of family homelessness in Ontario; that the interaction of multiple systems can put families at risk of homelessness. Findings from this study underscore the need for urgent housing protocols aimed at educating homeless families on how to navigate and understand the system, enhance their conflict resolution skills, and develop strategies beyond relocation to help them to cope with difficulties with housing.