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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.<\/jats:p>\n               <\/jats:sec>\n               <jats:sec>\n                  <jats:title>Methods<\/jats:title>\n                  <jats:p>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.<\/jats:p>\n               <\/jats:sec>\n               <jats:sec>\n                  <jats:title>Results<\/jats:title>\n                  <jats:p>From 15\u2009976 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&lt;0.001). Meta-analysis suggested increased all-cause mortality among people with multiple versus fewer exposures (HR: 1.57 and 95%\u2009CI: 1.38 to 1.77), though heterogeneity was high.<\/jats:p>\n               <\/jats:sec>\n               <jats:sec>\n                  <jats:title>Conclusion<\/jats:title>\n                  <jats:p>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.<\/jats:p>\n               <\/jats:sec>\n               <jats:sec>\n                  <jats:title>PROSPERO registration number<\/jats:title>\n                  <jats:p>CRD42018097189.<\/jats:p>\n               <\/jats:sec>","DOI":"10.1136\/jech-2020-215975","type":"journal-article","created":{"date-parts":[[2021,4,23]],"date-time":"2021-04-23T13:32:08Z","timestamp":1619184728000},"page":"1010-1018","update-policy":"https:\/\/doi.org\/10.1136\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":54,"title":["Health of people experiencing co-occurring homelessness, imprisonment, substance use, sex work and\/or severe mental illness in high-income countries: a systematic review and meta-analysis"],"prefix":"10.1136","volume":"75","author":[{"ORCID":"https:\/\/orcid.org\/0000-0001-6659-812X","authenticated-orcid":false,"given":"Emily J.","family":"Tweed","sequence":"first","affiliation":[{"name":"MRC\/CSO Social and Public Health Sciences Unit, University of Glasgow Institute of Health and Wellbeing, Glasgow, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Rachel M.","family":"Thomson","sequence":"additional","affiliation":[{"name":"MRC\/CSO Social and Public Health Sciences Unit, University of Glasgow Institute of Health and Wellbeing, Glasgow, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-3698-7196","authenticated-orcid":false,"given":"Dan","family":"Lewer","sequence":"additional","affiliation":[{"name":"Collaborative Centre for Inclusion Health, University College London, London, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Colin","family":"Sumpter","sequence":"additional","affiliation":[{"name":"Department of Public Health, NHS Forth Valley, Stirling, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Amir","family":"Kirolos","sequence":"additional","affiliation":[{"name":"Department of Clinical Infection, Microbiology & Immunology, Institute of Infection, Veterinary & Ecological Sciences, University of Liverpool, Liverpool, UK"},{"name":"The University of Edinburgh Usher Institute of Population Health Sciences and Informatics, Edinburgh, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Paul M.","family":"Southworth","sequence":"additional","affiliation":[{"name":"Department of Public Health, NHS Dumfries and Galloway, Dumfries, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Amrit Kaur","family":"Purba","sequence":"additional","affiliation":[{"name":"MRC\/CSO Social and Public Health Sciences Unit, University of Glasgow Institute of Health and Wellbeing, Glasgow, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Robert W.","family":"Aldridge","sequence":"additional","affiliation":[{"name":"Institute of Health Informatics, University College London, London, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Andrew","family":"Hayward","sequence":"additional","affiliation":[{"name":"Collaborative Centre for Inclusion Health, University College London, London, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Alistair","family":"Story","sequence":"additional","affiliation":[{"name":"Find and Treat Service, University College London Hospitals NHS Foundation Trust, London, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Stephen W.","family":"Hwang","sequence":"additional","affiliation":[{"name":"Centre for Urban Health Solutions, St. Michael\u2019s Hospital, Toronto, Ontario, Canada"},{"name":"Department of Medicine, University of Toronto, Toronto, Ontario, Canada"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-6593-9092","authenticated-orcid":false,"given":"Srinivasa Vittal","family":"Katikireddi","sequence":"additional","affiliation":[{"name":"MRC\/CSO Social and Public Health Sciences Unit, University of Glasgow Institute of Health and Wellbeing, Glasgow, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"239","published-online":{"date-parts":[[2021,4,23]]},"reference":[{"key":"2025100301412184000_75.10.1010.1","doi-asserted-by":"crossref","unstructured":"Levitas R . 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