Investigating the health of the socially excluded: physical and mental health multimorbidities across the social gradient in a nationally representative sample

King’s College London (KCL) is requesting to retain the APMS 2014 record-level data for use in a research project investigating physical and mental health multimorbidities, defined as the co-existence of two or more chronic conditions, one of which is either a mental health or physical health condition of long duration, or an infectious disease of long duration (Academy of Medical Sciences, 2018). Previous research in this area has been limited but has highlighted an association between residency in deprived areas and the presence of a larger number of multi-morbidities (Barnett et al 2012). Using the retained data from APMS 2014 and from 2007 surveys KCL aims to explore these issues further.

Justification for the processing of the data is under Article 6(1)(e) of the GDPR, for the performance of a task in the public interest; and Article 9(2)(j) of the GDPR, where processing of the data is necessary for research purposes in the public interest.

The present project will not only look at the social gradient of health morbidities – KCL will also address concerns that individuals who may have experienced social exclusion and extreme inequalities have worse health outcomes across the life course. A recent international meta-analysis of previous research has found that health inequalities persist in these groups for mortality and across a wide range of health conditions (Aldridge et al., 2018). The present analysis will build on this work with a focus on the presence of physical health morbidity with mental health conditions, which are known to be elevated in prevalence in these groups. Further knowledge on mental and physical health multi-morbidities across the social gradient and beyond is valuable to provide recommendations for co-ordinated and evidence-based healthcare and inform public health policy for individuals who are socially disadvantaged and excluded.

KCL's objectives are to look at (1) The association of occupational social class and other indicators of socioeconomic position with the presence of multi-morbidities, specifically characterising prevalence and types of multi-morbidity clusters most common in those of lower socioeconomic position compared to those of a higher socioeconomic position; (2) The presence, prevalence and nature of multi-morbidities in individuals who are socially excluded. Based on the literature this will include people who have experienced extreme social exclusion, for example have had previous or current experience of homelessness, sex work, or imprisonment. Patterns of physical and mental health multi-morbidities in this group will be compared to individuals who have not reported having these experiences.

As described in the NHS long-term plan (January 2019), addressing health inequalities is a key priority for research, policy and clinical practice. This project is part of a wider body of work into health inequalities which is being conducted by King’s College London researchers in the Department of Psychological Medicine, at the Institute of Psychiatry, Psychology and Neuroscience.

King's College London is the data controller and also processes the data for this study. No other organisations process the data for this purpose. The data analysis will take place entirely at KCL. Only approved KCL researchers will have access to record level data, which will only be enabled through secure, password protected KCL computers operated by KCL research staff. KCL is not receiving any funding or involvement from any external body for this project. No other organisation is involved in this work.

‘The project lead at KCL is funded by the Economic and Social Research Council for a PhD studentship under the London Interdisciplinary Social Science Doctoral Training Partnership (ES/P000703/1).

Planned outputs include:

1. One or two published peer reviewed reports in open access journals by the end of 2022. These will be in clinical or epidemiology journals, eg the Lancet or BMJ. This will be widely disseminated to researchers and academics, healthcare providers, clinicians, public health practitioners and policy makers.

2. At least one presentation to disseminate findings to healthcare and public health practitioners, clinicians and the wider academic community, by the end of 2022.

3. At least one online blog and social media posts (on Twitter) sharing findings to reach communities, by the end of 2022.

Further research posters and/or oral presentations will be submitted to relevant conferences, including the Health Inequalities Research Network (HERON) Conference in 2020 (https://heronnetwork.com/). HERON is funded by the Wellcome Trust and is run by an academic in the Department of Psychological Medicine, IoPPN, KCL. Yearly HERON conferences are instrumental in promoting public engagement for inclusion health research and initiatives to allow cohesive and evidence-based recommendations for policy and clinical practice. By submitting research outputs from the current project to HERON, KCL are promoting impact by sharing the findings with the community, local charities, public health researchers, health practitioners and stakeholders at this event.

KCL will use institutional websites and social media accounts to share findings through links and summaries of any published work, which will promote engagement efforts to reach communities and services.

Outputs will also be fed back to NHS Digital.

All outputs (for dissemination, publication, presentations or otherwise) will only contain data that are aggregated with small numbers. Outputs will be suppressed in line with the HES Analysis Guide and will comply with the NHS Digital disclosure control rules.

Updated outputs July 2022: Preliminary results have been presented at the Health Studies User Conference in July 2022 (planned output #2 in the original DARS submission). Outputs from this project were shared at the 20th biennial congress of the EPA Section of Epidemiology & Social Psychiatry in September 2022. A paper is currently being drafted for submission to a peer-reviewed academic journal (planned output #1). Results will be detailed in the lead researcher PhD thesis. Results will continue to be disseminated via the outputs detailed above.

Publication References:

Academy of Medical Sciences (2018). Multimorbidity: a priority for global health research. https://acmedsci.ac.uk/file-download/82222577

Aldridge, R. W., Story, A., Hwang, S. W., Nordentoft, M., Luchenski, S. A., Hartwell, G., ... & Hayward, A. C. (2018). Morbidity and mortality in homeless individuals, prisoners, sex workers, and individuals with substance use disorders in high-income countries: a systematic review and meta-analysis. The Lancet, 391(10117), 241-250.

Barnett, K., Mercer, S. W., Norbury, M., Watt, G., Wyke, S., & Guthrie, B. (2012). Epidemiology of multimorbidity and implications for health care, research, and medical education: a cross-sectional study. The Lancet, 380(9836), 37-43.

The analysis in this project is ongoing, but preliminary results so far evidence and quantify the severe inequalities in multimorbidity for socially excluded and socioeconomically deprived groups, specifically people who have experienced homeless. This has important implications for clinical NHS practice, and is timely in light of the recently published NICE guidelines on integrated healthcare for people experiencing homelessness (https://www.nice.org.uk/guidance/ng214) and NHS Integrated Care Systems (https://www.england.nhs.uk/integratedcare/what-is-integrated-care/). The results are being shared with NHS and health organisations cited in the original DARS agreement (for example, Pathway) and research community (for example, in conferences) to impact clinical practice and address the gap in the research literature. We continue to work towards the benefits as described in the original DARS application as this analysis develops and we disseminate results.

King’s College London (KCL) is requesting the APMS 2014 record-level data for use in a research project investigating physical and mental health multimorbidities, defined as the co-existence of two or more chronic conditions, one of which is either a mental health or physical health condition of long duration, or an infectious disease of long duration (Academy of Medical Sciences, 2018). Previous research in this area has been limited but has highlighted an association between residency in deprived areas and the presence of a larger number of multi-morbidities (Barnett et al 2012). Using data from APMS 2014 and from 2007 surveys KCL aims to explore these issues further.

Justification for the processing of the data is under Article 6(1)(e) of the GDPR, for the performance of a task in the public interest; and Article 9(2)(j) of the GDPR, where processing of the data is necessary for research purposes in the public interest.

The present project will not only look at the social gradient of health morbidities – KCL will also address concerns that individuals who may have experienced social exclusion and extreme inequalities have worse health outcomes across the life course. A recent international meta-analysis of previous research has found that health inequalities persist in these groups for mortality and across a wide range of health conditions (Aldridge et al., 2018). The present analysis will build on this work with a focus on the presence of physical health morbidity with mental health conditions, which are known to be elevated in prevalence in these groups. Further knowledge on mental and physical health multi-morbidities across the social gradient and beyond is valuable to provide recommendations for co-ordinated and evidence-based healthcare and inform public health policy for individuals who are socially disadvantaged and excluded.

KCL's objectives are to look at (1) The association of occupational social class and other indicators of socioeconomic position with the presence of multi-morbidities, specifically characterising prevalence and types of multi-morbidity clusters most common in those of lower socioeconomic position compared to those of a higher socioeconomic position; (2) The presence, prevalence and nature of multi-morbidities in individuals who are socially excluded. Based on the literature this will include people who have experienced extreme social exclusion, for example have had previous or current experience of homelessness, sex work, or imprisonment. Patterns of physical and mental health multi-morbidities in this group will be compared to individuals who have not reported having these experiences.

As described in the NHS long-term plan (January 2019), addressing health inequalities is a key priority for research, policy and clinical practice. This project is part of a wider body of work into health inequalities which is being conducted by King’s College London researchers in the Department of Psychological Medicine, at the Institute of Psychiatry, Psychology and Neuroscience.

King's College London is the data controller and also processes the data for this study.  No other organisations process the data for this purpose. The data analysis will take place entirely at KCL. Only approved KCL researchers will have access to record level data, which will only be enabled through secure, password protected KCL computers operated by KCL research staff. KCL is not receiving any funding or involvement from any external body for this project. No other organisation is involved in this work.

References:

Academy of Medical Sciences (2018). Multimorbidity: a priority for global health research. https://acmedsci.ac.uk/file-download/82222577

Aldridge, R. W., Story, A., Hwang, S. W., Nordentoft, M., Luchenski, S. A., Hartwell, G., ... & Hayward, A. C. (2018). Morbidity and mortality in homeless individuals, prisoners, sex workers, and individuals with substance use disorders in high-income countries: a systematic review and meta-analysis. The Lancet, 391(10117), 241-250.

Barnett, K., Mercer, S. W., Norbury, M., Watt, G., Wyke, S., & Guthrie, B. (2012). Epidemiology of multimorbidity and implications for health care, research, and medical education: a cross-sectional study. The Lancet, 380(9836), 37-43.

Planned outputs include:

1. One or two published peer reviewed reports in open access journals which will be widely disseminated to healthcare and public health practitioners, clinicians and the wider academic community, by the end of 2022;

2. At least one presentation to disseminate findings to healthcare and public health practitioners, clinicians and the wider academic community, by the end of 2022;

3. At least one online blog and social media posts (on Twitter) sharing findings to reach communities, by the end of 2022.

The findings will be submitted for publication to open-access, peer-reviewed academic journals. These will be clinical or epidemiology journals, eg the Lancet or BMJ. The estimated publication date will be in December 2022. Anticipated audiences for this manuscript will be researchers and academics, healthcare providers, clinicians, public health practitioners and policy makers.

Further research posters and/or oral presentations will be submitted to relevant conferences, including the Health Inequalities Research Network (HERON) Conference in 2020 (https://heronnetwork.com/). HERON is funded by the Wellcome Trust and is run by an academic in the Department of Psychological Medicine, IoPPN, KCL. Yearly HERON conferences are instrumental in promoting public engagement for inclusion health research and initiatives to allow cohesive and evidence-based recommendations for policy and clinical practice. By submitting research outputs from the current project to HERON, KCL are promoting impact by sharing the findings with the community, local charities, public health researchers, health practitioners and stakeholders at this event.

KCL will use institutional websites and social media accounts to share findings through links and summaries of any published work, which will promote engagement efforts to reach communities and services.

Outputs will also be fed back to NHS Digital.

All outputs (for dissemination, publication, presentations or otherwise) will only contain data that are aggregated with small numbers. Outputs will be suppressed in line with the HES Analysis Guide and will comply with the NHS Digital disclosure control rules.

Yielded Benefits is not a requirement for new applications.