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Small numbers, big impact: making a utilitarian case for the contribution of inclusion health to population health in England
  1. Claire X Zhang1,2,
  2. Dan Lewer3,4,5,
  3. Robert W Aldridge2,
  4. Andrew C Hayward3,4,
  5. Carlotta Cornaglia1,
  6. Peta Trussell1,
  7. Charlotte Lillford-Wildman1,
  8. Joanna Castle1,
  9. Jake Gommon1,
  10. Ines Campos-Matos1
  1. 1 Addictions & Inclusion Directorate, Office for Health Improvement and Disparities, Department of Health and Social Care, London, UK
  2. 2 Institute of Health Informatics, University College London, London, UK
  3. 3 Institute of Epidemiology & Health Care, University College London, London, UK
  4. 4 UCL Collaborative Centre for Inclusion Health, University College London, London, UK
  5. 5 Bradford Institute for Health Research, Bradford, UK
  1. Correspondence to Claire X Zhang, UCL Institute of Health Informatics, London, NW1 2DA, UK; claire.zhang.19{at}


Inclusion health groups make up a small proportion of the general population, so despite the extreme social exclusion and poor health outcomes that these groups experience, they are often overlooked in public health investment and policy development. In this paper, we demonstrate that a utilitarian argument can be made for investment in better support for inclusion health groups despite their small size. That is, by preventing social exclusion, there is the potential for large aggregate health benefits to the whole population. We illustrate this by reframing existing published mortality estimates into population attributable fractions to show that 12% of all-cause premature deaths (95% CI 10.03% to 14.29%) are attributable to the circumstances of people who experience homelessness, use drugs and/or have been in prison. We also show that a large proportion of cause-specific premature deaths in the general population can be attributed to specific inclusion health groups, such as 43% of deaths due to viral hepatitis (95% CI 30.35% to 56.61%) and nearly 4000 deaths due to cancer (3844, 95% CI 3438 to 4285) between 2013 and 2021 attributed to individuals who use illicit opioids. Considering the complexity of the inclusion health policy context and the sparseness of evidence, we discuss how a shift in policy framing from ‘inclusion health vs the rest of the population’ to ‘the impact of social exclusion on broader population health’ makes a better case for increased policy attention and investment in inclusion health. We discuss the strengths and limitations of this approach and how it can be applied to public health policy, resource prioritisation and future research.

  • Health inequalities

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  • Contributors Conceptualisation: CXZ, AH, DL, RA and IC-M. Methodology: CXZ, AH, DL, RA and IC-M. Production of visualisations: CXZ, DL and CC. Analysis: CXZ, DL and RA. Writing-original draft preparation: CXZ. Writing review and editing: All authors. Project administration: CXZ. Guarantor: CZ. All authors have read and agreed to the published version of the manuscript.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.