What Works in Inclusion Health? Overview of effective - - PowerPoint PPT Presentation

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
• ther 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 Dependency

• Methadone & buprenorphine for opioid dependency, but

methadone better for treatment retention

• Supervised injectable heroin effective for people refractory to

standard treatment.

• No other effective treatments.

Severe Mental Illness

• Long acting injectable anti-psychotics for people with

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 behaviour, blood-borne viruses, and

• verdose risk

 Needle & syringe programmes, opioid substitution programmes, and safe injecting site programmes are effective in community and criminal justice settings  Multicomponent harm reduction programmes better than 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 Determinants

• f Health

 Occupational therapy may increase education, employment and life skills.  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

Thank You

Acknowledgements A special thank you to Groundswell for their contributions to this paper: peer advocates, Atakilte Mekuria, Barbara Stancanelli, Billy McCarthy, David McCarthy, Dereck James, James Brodie, Macs Ali, Mayada Elmaki, Ousainou Sarr, Rob Edgar, Saira Munshi, Terry Hutton, Sonia Johns, Bassil Turner, Chris Hayes, Stacey Tannahill, and Dennis Rogers; and staff, Kate Bowgett and Athol Hallé. We would also like to thank Phillip Windish and Fatima Wurie who served as non-participant observers for the peer engagement workshop and Debra Morris who assisted with the literature search strategy for this review. Role of Funding Source No relevant sources of funding.

What Works in Inclusion Health?

Overview of effective interventions for marginalised populations

End

Questions

• Where do the results reflect what is

‘known’ to be effective in practice? Where don’t they?

• How could such a review be used

to inform services in practice?

Records identified through database searching (n = 3467)

Screening Included

Eligibility

Identification

Additional records identified through expert opinion (n = 10) Records after duplicates removed (n = 2647) Records screened (n = 2647) Records excluded (n = 2379) Full-text systematic reviews assessed (n = 268) Case Management Interventions Total (n = 7) Included (n = 4) Pharmacological Interventions Total (n = 90) Included (n = 23) Interventions for Prevention Total (n = 24) Included (n = 8) ‘Other’ Interventions Total (n = 25) Included (n = 7) Psychosocial Interventions Total (n = 71) Included (n = 13) Interventions for Women Total (n = 28) Included (n = 11) Interventions for Youth Total (n = 23) Included (n = 9) Studies included in qualitative synthesis (n = 75) Full-text articles excluded, with reasons (n = 182)

Study Selection Flow Diagram