Understanding the health of people experiencing homelessness, justice involvement, substance use, sex work, and severe mental illness

Tweed, Emily Jane (2022) Understanding the health of people experiencing homelessness, justice involvement, substance use, sex work, and severe mental illness. PhD thesis, University of Glasgow.

Abstract

Background: Public health research has often been dominated by a relatively narrow understanding of health inequalities, which may neglect broader aspects of social experience and the ways in which they intersect. Homelessness, involvement in the criminal justice system, problem substance use, sex work, and severe mental illness are characterised by social marginalisation and stigmatisation, and often co-occur. In this thesis, I aimed to explore health inequalities associated with these experiences, and their intersections, and to investigate the potential contribution of administrative data to this field.

Methods: This multi-method study comprised: a discourse analysis of UK health inequalities policy reviews; a systematic review of health outcomes associated with co-occurrence of the experiences of interest; the creation and characterisation of a novel electronic cohort to investigate the extent of these intersections, using linked administrative data; an analysis of premature mortality within this cohort; and an interrupted time series analysis using pharmacy data to investigate health impacts of a comprehensive smoke-free policy in Scottish prisons.

Results: The experiences of interest featured to some extent in existing health inequalities policy, but conceptual and explanatory frameworks were poorly developed. The linked cohort analysis constitutes one of the few population-based studies examining the intersections between these experiences and appears to be the first to use individual record linkage to do so. Building on the systematic review finding that multiple forms of marginalisation are associated with poorer health outcomes, the cohort analysis demonstrated a high burden of preventable and treatable mortality, including from non-communicable disease. Smoke-free prisons appeared to have positive impacts on respiratory health, suggesting scope to mitigate these inequalities through interventions in relevant settings and services.

Implications: Co-occurrence of these experiences is not uncommon and associated with profound health inequalities. Redressing these inequalities may require new approaches to services and policy, analogous to the demands of multi-morbidity in healthcare. Administrative data offer valuable opportunities for characterising needs and evaluating interventions, though this will require substantial reform to governance and infrastructure for cross-sectoral data sharing and linkage. Future work should aim to situate these experiences within broader understandings of social processes giving rise to inclusion, exclusion, and inequality.

• Item Type: Thesis (PhD)
• Qualification Level: Doctoral
• Additional Information: Supported by funding from the Chief Scientist Office and the Inequalities programme at the MRC/CSO Social and Public Health Sciences Unit.
• Colleges/Schools: College of Medical Veterinary and Life Sciences > School of Health & Wellbeing > MRC/CSO Unit
• Supervisor's Name: Katikireddi, Professor S. Vittal
• Date of Award: 2022
• Depositing User: Theses Team
• Unique ID: glathesis:2022-82945
• Copyright: Copyright of this thesis is held by the author.
• Date Deposited: 09 Jun 2022 10:33
• Last Modified: 14 Mar 2025 11:01
• Thesis DOI: 10.5525/gla.thesis.82945
• URI: https://theses.gla.ac.uk/id/eprint/82945

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