What Works in Inclusion Health? Overview of effective interventions for marginalised populations Serena Luchenski, Nick Maguire , Rob Aldridge, Andrew Hayward, Alistair Story, Patrick Perri, James Withers, Sharon Clint, Suzanne Fitzpatrick, and Nigel Hewett
Background to the Review • Lancet-commissioned series on Inclusion Health: – Paper 1 – Burden of morbidity and mortality among socially excluded groups (Aldridge et al.) – Paper 2 – Response to excess death and disease (Luchenski et al.)
What is Inclusion Health? “A research, service, and policy agenda that aims to prevent and redress health and social inequities among the most vulnerable and marginalised in a community.” • Extreme levels of mortality and morbidity • Poor access to mainstream health services • Multiple, overlapping risk factors
Aim • To synthesise the evidence on interventions that promote, protect, and improve health and the social determinants of health for people who: – Have experiences of homelessness – Engage in problematic drug use – Have been imprisoned – Engage in sex work
Design • Review of Systematic Reviews – Summation of broad literature base – Promising primary intervention studies (e.g. Housing First) • Engagement with People with Lived Experience of Social Exclusion – Interpretation of review findings
Search Strategy & Selection Criteria • Multiple databases searched – ( Medline, EMBASE, PsychINFO, CINAHL, the Cochrane Collaboration Library, and Web of Science) • Systematic and meta-analytic reviews • Health interventions, or those which impact wider determinants, which have health and / or social outcomes • 3477 papers identified, narrowed to 75 considered
Workshop with People with Lived Experience of Social Exclusion
Workshop with People with Lived Experience of Social Exclusion • Participants: – 16 volunteer peer advocates from Groundswell (experience of multiple exclusion homelessness) – 4 researchers – 2 service providers – 2 non-participant observers • Activities to reduce power dynamics and involve all participants equally
Workshop Objectives 1. Explore the meaning of ‘Inclusion Health’ 2. Explore health statistics for IHTP and views regarding data collection and surveillance 3. Share positive stories about using health and other services to identify common beneficial themes 4. Rank the importance of interventions for people with lived experience of social exclusion and to compare these against the set of interventions identified in the literature review 5. To identify key stakeholders that can make a difference to the health of IHTP 6. Provide context for article narrative
Results – Effective Interventions • Intervention Categories: – Pharmacological – Psychosocial – Case Management – Prevention – Other interventions • Women • Youth
Pharmacological Interventions Drug Methadone & buprenorphine for opioid dependency, but • Dependency methadone better for treatment retention Supervised injectable heroin effective for people refractory to • standard treatment. No other effective treatments. • Severe Long acting injectable anti-psychotics for people with • Mental Illness schizophrenia and drug dependency. Hepatitis C Standard treatment as effective among people who inject • drugs as the general population. Retention in treatment improved by simultaneous drug • dependency treatment. New short-term antiviral drugs highly promising for IHTP. • HIV Treatment outcomes improved by directly observed therapy, • medication assisted therapy, contingency management, and multi-component nurse delivered interventions. Tuberculosis Adherence is improved in the short-term by incentives, but • directly observed therapy is ineffective.
Psychosocial Interventions Mainly substance use disorders (SUD) and mental health in the community and criminal justice system Most effective when provided in combination; no clear evidence for one intervention or another. Contingency management, motivational interviewing, and cognitive behavioural therapy have shown some benefits for SUD and in therapeutic communities for re-incarceration. Mental health and drug treatment services may be more effective when provided in an integrated setting.
Case Management Can improve and enhance linkages with services and improve mental health symptoms. Evidence is mixed about whether it improves SUD and other health-related outcomes. When used with assertive community treatment, case management may also help to reduce homelessness.
Prevention Risk Needle & syringe programmes, opioid substitution behaviour, programmes, and safe injecting site programmes are blood-borne effective in community and criminal justice settings viruses, and Multicomponent harm reduction programmes better than overdose risk stand-alone interventions. Outreach effective for younger users and those with greater risk taking behaviour. Uptake of hepatitis C screening can be increased through targeted screening in primary care, use of dried blood spots instead of venous blood samples, and outreach. HIV risk reduction interventions and Hepatitis B vaccination are beneficial in criminal justice settings,. Training drug users to recognise opiate overdose and administer naloxone can reduce fatal overdose risk. Social Occupational therapy may increase education, Determinants employment and life skills. of Health Housing interventions have RCT evidence of effectiveness, but these have not been the subject of a systematic review
Other Interventions • Medical respite can reduce future hospital admission rates and use of emergency departments in homeless populations • For drug dependency, computer-based interventions and physical exercise interventions may improve outcomes. • Complementary and alternative therapies and spirituality/religion may also have potentially positive effects, but more rigorous evidence is needed
Women Gender-sensitive interventions to improve of health and social outcomes : structured counselling and social support, therapeutic communities, case management and integrated programmes, and advocacy and empowerment Effective interventions for IHTP women address the role of motherhood, trauma and violence, SUD, and education and empowerment. Interventions can be delivered in community and institutional settings to support women.
Youth Evidence limited, Potentially promising results for family-based therapy, cognitive behavioural interventions, and brief interventions for a range of outcomes. Foster care may help to reduce criminal activity and improve mental health No evidence-based transition support services for looked- after young people coming towards the end of care.
Workshop Participants’ Ranking
Workshop Participants’ Ranking Interventions Rank Identified By Housing 1 Workshop & Review Advocacy 2 Workshop & Review Psychosocial 3 Review Youth 4 Review Mental Health 4 Workshop & Review GPs/Primary Care 4 Workshop Drugs and Alcohol 5 Workshop & Review Legal 5 Workshop Training 5 Workshop Jobs 6 Workshop Pharmacological 7 Review Case Management 7 Review Specialist Care 7 Workshop Prevention 8 Review Physical Health 8 Workshop Women 9 Review Re-integration 10 Workshop Dental Care 10 Workshop ‘Other’ interventions (e.g. e -health) 11 Review
Recommendations - Practice Multi-component interventions with coordinated care • Service User Involvement • Address barriers to accessing services • Values: • – provide ample time and patience to really listen – strive to develop trust and acceptance – provide supportive, unbiased, open, honest and transparent services in inclusive spaces and places – encourage clients to accept personal responsibility for health – allow clients to take ownership and participate in decisions Above all, promote accessibility, fairness and equality for • all.
Recommendations - Policy • Reduce material poverty and deprivation – especially among families with concerns about child maltreatment. • Prioritise IHTP • Policy principles: 'personalisation' and 'deinstitutionalisation‘. • Prioritise provision of suitable and stable housing in ordinary community settings
Recommendations - Research Social Determinants IHTP Women - particularly sex workers; no reviews identified in high-income countries IHTP Youth transitioning out of the children’s care system into adult services Peer-led interventions - impacts, cost-effectiveness, and settings Models of care - Specialist vs mainstream Mechanisms of behaviour change - agents that promote (or inhibit) engagement with and adherence to interventions Routine electronic data – producing evidence at scale
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