Abstract Background Migrants are at increased risk of infections including HIV, tuberculosis and viral hepatitis, with poorer outcomes. Early diagnosis and management can reduce morbidity, mortality and onward transmission. This systematic review summarises prevalence of HIV, latent and active tuberculosis and hepatitis B and C among UK migrants and evaluates associated risk factors. Methods PubMed/Medline, EMBASE, Web of Science and the Cochrane Library were systematically searched from 2004 to 11 June 2025. The review was conducted using PRISMA guidelines and registered with PROSPERO (registration CRD42024521191). Quality assessment was performed using the Joanna Briggs Institute Critical Appraisal Checklist for Prevalence Studies. High heterogeneity (I2 = 95.2%, 99.2%, 87.2%, 96.9% and 91.6% for IGRA, active TB, HIV, HBV and HCV yields, respectively) indicated that meta-analysis was not appropriate. The impact of risk factors on prevalence was explored through meta-regression and descriptive analysis. Results Of 2033 identified records, 36 were included, reporting Interferon Gamma Release Assay (IGRA) (n = 13), active TB (n = 10), HIV (n = 12), HBV (n = 16) and HCV (n = 11) test yields. An additional two publications excluded from the main analysis for reporting duplicate study data were included in the risk factor analysis because they stratified prevalence by additional risk factors. Highest yield was for IGRA which, excluding one lower prevalence outlier (6.9% (n = 1617)), was 15.1%–22.1%. There was high heterogeneity in active TB prevalence: 62–1,484/100,000. HIV prevalence among larger studies (n > 200) was 0.18%–0.48%. HBV prevalence was 0.00%–8.93% (all studies) and 1.06%–4.75% for larger studies (n > 1000). HCV prevalence was lower: 0.00%–1.67%, with only two of 11 included estimates above 0.50%. There was considerable heterogeneity in risk factors analysed making comparisons difficult. Conclusions Despite heterogeneity, infection prevalence was generally high, particularly IGRA yield and HBV. This underscores the need to maintain effective monitoring, testing and treatment for key infections among migrant populations, especially given the rapidly evolving epidemiological and demographic landscape for this population.

Evidence suggests that people reporting a minority sexual identity (that is gay, lesbian, bisexual or another sexual minority), are more likely to experience poorer health and wellbeing compared to heterosexual people. Understanding whether inequalities by sexual identity were present during the COVID-19 pandemic is important for informing interventions that address such disparities. We analysed data from 6,016 sexually experienced people aged 18–59 years who participated in Britain’s Natsal-COVID Wave 2, a cross-sectional, quasi-representative webpanel survey, carried out one year after Britain’s first national COVID-19 lockdown. We estimated adjusted odds ratios (AOR) for reported general, mental, and sexual health indicators among gay/lesbian and bisexual participants, stratified by gender and compared to their heterosexual counterparts, using binary logistic regression. We also examined clustering of poor health indicators within and across health domains. 96.2

Objectives To measure differences in hospital use between homeless adults using the homeless health peer advocacy (HHPA) service (clients) and non-clients in London.Design We conducted a cohort study with linkage to Hospital Episode Statistics (HES) 1 year prior and postenrolment.Setting London, UK.Population People who are homeless in London aged over 18 years residing in a hostel, attending a day centre or being referred by a homelessness service; experiencing difficulties accessing healthcare; and speaking either English or Polish. Participants were required to provide consent for linkage to HES. To be classified as a client, individuals must have used the HHPA service at least once between January and July 2021; non-clients were those who had never used the service.Intervention Peer advocacy is the provision of support by volunteer-trained advocates with lived experience of homelessness to individuals to overcome barriers to accessing health services.Outcomes The primary outcome was not attending a scheduled outpatient appointment (‘did-not-attend’) over 12 months postrecruitment, commencing from their baseline interview date. Secondary outcomes included the number of accident and emergency (A&E) and inpatient admissions (all and planned admissions) during that same period.Methods We estimated the probability of non-attendance using Poisson regression and the number of inpatient admissions and A&E visits using negative binomial regression models. Models included: (1) propensity score weights and (2) propensity score weights and imbalanced confounders. Sensitivity analyses assumed that participants who did not link to HES had no hospital attendance. Exploratory analyses examined differential effects of peer advocacy by clients’ type of peer advocacy engagement (new vs ongoing clients; supported vs unsupported) and by clients’ anxiety or depression symptom scores measured with the Patient Health Questionnaire-4 (PHQ4).Results 153 clients and 158 non-clients were recruited between July and December 2021. Most were male (77.5%) with a median age of 48 years. Weighted regression models suggested no evidence of effect of peer advocacy on non-attendance (rate ratio (RR) 0.97 (95% CI 0.67 to 1.42)), no difference in the mean number of A&E visits (2.59 95% CI 1.93, 3.24 vs 1.76 95% CI 1.13, 2.40) but more inpatient admissions (1.65 95% CI 1.10, 2.20 vs. 0.53 95% CI 0.27, 0.82) for HHPA clients vs non-clients respectively. This was supported in sensitivity analyses. In exploratory analyses, clients with PHQ4 scores of 9–12 had greater probability of non-attendance at outpatient appointments (RR 1.98 (95% CI 1.0 to 3.89)) compared to non-clients. Those with scores of 6–8 had 5.86 (95% CI 2.73 to 9.0) completed appointments versus 1.87 (95% CI 0.41 to 3.34) among non-clients and 1.13 (95% CI 0.01 to 0.27) inpatient admissions compared with 0.13 (95% CI −0.01 to −0.27) among non-clients.Conclusions Following COVID-related disruptions to the work of peer advocates and health services, we found mixed evidence on the effect of peer advocacy: with no evidence of impact on outpatient appointments or use of emergency services; but increased inpatient admissions.

Background:Inequitable access to health care increases morbidity and mortality among people experiencing homelessness. Peer advocates ('peers') with lived experience may help others to access health care. Objectives:To evaluate the impact and cost-consequence of Groundswell's Homeless Health Peer Advocacy programme on healthcare access, the processes through which it operates and the impact for peer advocates themselves. Ethics and design:A participatory mixed-method design with three components: qualitative study (A), prospective cohort (B), and cost-consequence analysis (C) using cohort and programmatic data. Ethical approval: Dulwich Research Ethics Committee (Integrated Research Application System 271312). Setting:London, United Kingdom (2019-23) coinciding with COVID-19 and disruptions to the National Health Service, Homeless Health Peer Advocacy and housing services. Participants:Homeless Health Peer Advocacy clients and non-clients (A-C); Homeless Health Peer Advocacy staff, volunteers and homelessness-sector stakeholders (A). Intervention:Peer advocates accompany clients to healthcare appointments and provide support to address barriers to access. Main outcome measures:Primary: probability of 'did not attend' at a scheduled outpatient appointment within 12 months of cohort enrolment. Secondary: number of inpatient admissions and accident and emergency visits. Data sources:(A) In-depth interviews and focus groups; (B) Structured questionnaires and National Health Service Hospital Episode Statistics; (C) Groundswell programme data and cohort findings. Results:Qualitative (A): Peer advocacy empowered clients by building cultural health capitals (skills and communication that support healthcare interactions) and strengthening social and economic resources. Advocates themselves gained social, cultural, human and physical resources, though benefits were greatest for those with some pre-existing stability. Cohort (B): Compared with non-clients, Homeless Health Peer Advocacy clients showed no difference in did not attend rates (rate ratio 0.97, 95% confidence interval 0.67 to 1.42) or accident and emergency visits (mean difference 0.86, 95% confidence interval -0.06 to 1.79) for the other pre-specified outcomes. Clients had 1.14 more inpatient admissions (95% confidence interval 0.52 to 1.75). Sensitivity analyses with imputed data suggested higher numbers of outpatient attendances, outpatient 'did not attends', accident and emergency visits and admissions among clients. Secondary analyses suggested differences by levels of anxiety and depression. Cost-consequence (C): Median annual cost per client was £353 (£176 per scheduled engagement). Evidence of National Health Service cost saving was inconclusive. Limitations:The COVID-19 disrupted both Homeless Health Peer Advocacy delivery and National Health Service services. Non-randomised design may have introduced bias. Conclusions:Homeless Health Peer Advocacy enhances clients' cultural health capital and helps peer advocates achieve their goals. We cannot state whether peer advocacy reduces 'did not attends' or demonstrate cost savings, but it was associated with more inpatient admissions and, in sensitivity analyses, more outpatient appointments. Future work:Research should explore how peer advocacy addresses stigma in health care and hostel settings and develop outcome measures that capture wider systemic change. Funding:This synopsis presents independent research funded by the National Institute for Health and Care Research (NIHR) Public Health Research programme as award number 17/44/40.

While the impact of social restrictions on sexual and romantic life early in the COVID-19 pandemic has been widely studied, little is known about impacts beyond the initial months. We analyzed responses from 2,098 British adults (aged 18-59) taking part in the Natsal-COVID study (Waves 1 and 2). Participants were recruited via a web panel and surveyed twice: four months and one year after the start of the UK's first national lockdown (July 2020 and March 2021). Changes in the prevalence and frequency of participants' physical and virtual sexual behaviors between the two surveys were analyzed using multinomial logistic regression. Changes in the quality of intimate relationships were modeled using logistic regression for the 1,407 participants in steady relationships, adjusting for age, gender, and relationship status. The reported prevalence of any sexual activity amongst the full sample increased over the study period (from 88.1% to 91.5%, aOR = 1.50, 95% CI 1.23-1.84). Increases were observed for physical (aOR = 1.41, 95% CI 1.15-1.74) and virtual (aOR = 1.20, 95% CI 1.07-1.34) activities, particularly masturbation (aOR 1.53, 95% CI 1.37-1.72). Increases were larger for men than women. The proportion of participants in steady relationships whose relationship scored as "lower quality" increased (from 23.9% to 26.9%, aOR = 1.28, 95% CI 1.10-1.49). These findings have implications for understanding sexual health needs during disasters and planning sexual health service priorities following the pandemic.

Background: Differential barriers to accessing healthcare contribute to inequitable health outcomes. This study aims to describe the characteristics of individuals who experienced barriers, and what those barriers were, during the COVID-19 pandemic. Methods: We analysed data from Virus Watch: an online survey-based community study of households in England and Wales. The primary outcome was reported difficulty accessing healthcare in the previous year. Results: Minority ethnic participants reported difficulty accessing healthcare more than White British participants (41.6% vs 37%), while for migrants this was at broadly similar levels to non-migrants. Those living in the most deprived areas reported difficulty more than those living in the least deprived quintile (45.5% vs. 35.5%). The most frequently reported barrier was cancellation/disruption of services due to the COVID-19 pandemic (72.0%) followed by problems with digital or telephone access (21.8%). Ethnic minority participants, migrants, and those from deprived areas more commonly described 'insufficient flexibility of appointments' and 'not enough time to explain complex needs' as barriers. Conclusions: Minority ethnic individuals and those living in deprived areas were more likely to experience barriers to healthcare during the COVID-19 pandemic, and it is essential they are addressed as services seek to manage backlogs of care.

Background Tuberculosis in the UK is more prevalent in people with social risk factors– e.g. previous incarceration, homelessness - and in migrants from TB endemic countries. The management of TB infection is part of TB elimination strategies, but is challenging to provide to socially excluded groups and the evidence base for effective interventions is small. Methods We evaluated a TB infection screening and treatment programme provided by a peer-led service (Find&Treat) working in inclusion health settings (e.g. homeless hostels) in London. IGRA (interferon-gamma release assay) testing and TB infection treatment were offered to eligible adults using a community-based model. The primary outcome was successful progression through the cascade of care. We also evaluated socio-demographic characteristics associated with a positive IGRA. Results 42/312 (13.5%) participants had a positive IGRA and no one had evidence of active TB. 35/42 completed a medical evaluation; 22 started treatment, and 17 completed treatment. Having a positive IGRA was associated with previous incarceration and being born outside of the UK. Discussion Provision of TB infection diagnosis and management to this socially excluded population has several challenges including maintaining people in care and drug-drug interactions. Peer-support workers provided this service safely and effectively with appropriate support. Further work to generate data to inform risks and benefits of treatment for TB infection in this group is needed to facilitate joint decision making.

Background:Evidence on the sexual and reproductive health and rights (SRHR) of migrants is lacking globally. We describe SRHR healthcare resource use and long-acting reversible contraceptives (LARCs) prescriptions for migrant versus non-migrant women attending primary care in England (2009-2018).Methods:This population-based observational cohort study, using Clinical Practice Research Datalink (CPRD) GOLD, included females living in England aged 15 to 49. Migration was defined using a validated codelist. Rates per 100 person years at risk (pyar) and adjusted rate ratios (RRs) were measured in migrants versus non-migrants for consultations related to all-causes, six exemplar SRHR outcomes, and LARC prescriptions. Proportions of migrants and non-migrants ever prescribed LARC were calculated.Findings:There were 25,112,116 consultations across 1,246,353 eligible individuals. 98,214 (7.9 %) individuals were migrants. All-cause consultation rates were lower in migrants versus non-migrants (509 vs 583/100pyar;RR 0.9;95 %CI 0.9-0.9), as were consultations rates for emergency contraception (RR 0.7;95 %CI 0.7-0.7) and cervical screening (RR 0.96;95 %CI 0.95-0.97). Higher rates of consultations were found in migrants for abortion (RR 1.2;95 %CI 1.1-1.2) and management of fertility problems (RR 1.39;95 %CI 1.08-1.79). No significant difference was observed for chlamydia testing and domestic violence. Of 1,205,258 individuals eligible for contraception, the proportion of non-migrants ever prescribed LARC (12.2 %;135,047/1,107,894) was almost double that of migrants (6.91 %;6,728/97,364). Higher copper intrauterine devices prescription rates were found in migrants (RR 1.53;95 %CI 1.45-1.61), whilst hormonal LARC rates were lower for migrants: levonorgestrel intrauterine device (RR 0.63;95 %CI 0.60-0.66), subdermal implant (RR 0.72;95 %CI 0.69-0.75), and progesterone-only injection (RR 0.35;95 %CI 0.34-0.36).Interpretation:Healthcare resource use differs between migrant and non-migrant women of reproductive age. Opportunities identified for tailored interventions include access to primary care, LARCs, emergency contraception and cervical screening. An inclusive approach to examining health needs is essential to actualise sexual and reproductive health as a human right.

Government controls over intimate relationships, imposed to limit the spread of Sars-CoV-2, were unprecedented in modern times. This study draws on data from qualitative interviews with 18 participants in Natsal-COVID, a quasi-representative web-panel survey of the British population (n = 6,654 people), reporting that they had sex with someone from outside their household in the preceding four weeks; a period in which contact between households was restricted in the UK. Whilst only 10% of people reported sexual contact outside their household, among single people and those in non-cohabiting relationships, rates were much higher (Natsal-COVID). Our findings show that individuals did not take decisions to meet up with sexual partners lightly. Participants were motivated by needs-for connection, security, intimacy and a sense of normality. People balanced risks-of catching COVID-19, social judgement and punishment for rule-breaking-against other perceived risks, including to their mental health or relationships. We used situated rationality and social action theories of risk to demonstrate that people weighed up risk in socially situated ways and exhibited complex decision-making when deciding not to comply with restrictions. Understanding motivations for non-compliance is crucial to informing future public health messaging which accounts for the needs and circumstances of all population members.

Background The World Health Organization End TB Strategy emphasises screening for early diagnosis of tuberculosis (TB) in high-risk groups, including migrants. We analysed key drivers of TB yield differences in four large migrant TB screening programmes to inform TB control planning and feasibility of a European approach. Methods We pooled individual TB screening episode data from Italy, the Netherlands, Sweden and the UK, and analysed predictors and interactions for TB case yield using multivariable logistic regression models. Results Between 2005 and 2018 in 2 302 260 screening episodes among 2 107 016 migrants to four countries, the programmes identified 1658 TB cases (yield 72.0 (95% CI 68.6–75.6) per 100 000). In logistic regression analysis, we found associations between TB screening yield and age (≥55 years: OR 2.91 (95% CI 2.24–3.78)), being an asylum seeker (OR 3.19 (95% CI 1.03–9.83)) or on a settlement visa (OR 1.78 (95% CI 1.57–2.01)), close TB contact (OR 12.25 (95% CI 11.73–12.79)) and higher TB incidence in the country of origin. We demonstrated interactions between migrant typology and age, as well as country of origin. For asylum seekers, the elevated TB risk remained similar above country of origin incidence thresholds of 100 per 100 000. Conclusions Key determinants of TB yield included close contact, increasing age, incidence in country of origin and specific migrant groups, including asylum seekers and refugees. For most migrants such as UK students and workers, TB yield significantly increased with levels of incidence in the country of origin. The high, country of origin-independent TB risk in asylum seekers above a 100 per 100 000 threshold could reflect higher transmission and re-activation risk of migration routes, with implications for selecting populations for TB screening. Tweetable abstract Factors associated with TB screening yield included increasing age, migrant typology, TB incidence in country of origin, TB case contact and period of screening. The TB yield among asylum seekers was higher than for other migrant categories. https://bit.ly/3VMLwFp

Introduction Evidence shows that people identifying as a sexual minority experience worse health compared to heterosexual people. We estimated health inequalities by sexual identity in the first year of the COVID-19 pandemic in the general British population. Methods Our analysis included 6,016 sexually-experienced participants (18–59 years) participating in Natsal-COVID, a quasi-representative webpanel survey conducted 1-year following Britain’s first lockdown. We report age-adjusted odds ratios (aOR) and age and relationship status-adjusted ORs (aAOR) for general, mental, and sexual health outcomes among sexual minorities compared to their heterosexual-identifying counterparts. Results Altogether, 96.2% participants identified as heterosexual, 1.8% as gay/lesbian, 1.4% as bisexual, and 0.7% as other. Sexual minorities were more likely to report their general health as ‘bad/very bad’. There were differences by subgroups; sexual minority women (aOR:2.5, 95% CI 1.5–3.7) and bisexual participants (aOR:2.6, 1.6–4.1) had the highest odds of reporting poor general health. Sexual minority participants were more likely to report poor mental health, with bisexual participants most like to screen positive for anxiety (GAD-2) (aOR:2.3, 1.7–3.0) and depression (PHQ-2) (aOR:1.7, 1.3–2.2), while gay/lesbian participants were most likely to report ‘always/often’ feeling lonely (aOR:1.5, 1.1–2.2). Sexual minority men (aAOR 1.7, 1.2–2.3), gay/lesbian (aAOR:1.4, 1.1–1.9) and bisexual participants (aAOR:1.6, 1.1–2.1) had highest odds of reporting dissatisfaction with their sex life. Sexual minority men (aAOR:4.1, 2.6–6.4) were more likely to report successfully accessing STI services, and twice as likely to report having tried but failed to access STI services (aAOR:2.1, 1.1–3.9), both in the past year. Discussion These data, from a national general population survey, suggest that in the year following Britain’s first lockdown, sexual minorities experienced worse health than heterosexual-identifying people, and among men, an unmet need for STI services. Whether these findings reflect existing inequalities or were exacerbated by the pandemic is unknown, but mitigation is needed.

Introduction: The WHO End-TB Strategy emphasises early diagnosis and screening of tuberculosis (TB) in high-risk groups, including migrants. We analysed key drivers behind differences in TB yield in four large migrant TB screening programmes to inform TB control planning. Methods: We pooled routinely collected individual TB screening episode data from Italy, the Netherlands, Sweden, and the UK under the EU Commission E-DETECT. TB grant. We analysed predictors and interactions for TB case yield using multivariable logistic regression models. Results: We collected data gathered between 2005-2018 on 2,302,260 screening episodes among 2,107,016 migrants to four countries; the programmes identified 1,658 TB cases (yield 72.0 per 100,000; 95% confidence interval, CI 68.6-75.6). In the logistic regression analysis, we found significant associations between TB screening yield and increasing age, migrant typology, higher TB incidence in the country of origin (CoO), TB case contact, period of screening, and additional programmatic effects. We demonstrated interactions between migrant typology and age, as well as CoO. For asylum seekers, the elevated TB risk (aOR 4.64, CI 3.17-6.8) remained similar above CoO incidence thresholds of 50 per 100,000. Conclusions: Contrary to previous studies we demonstrated that the risk of TB detection among asylum seekers is not significantly influenced by incidence in their CoO if it is above 50 per 100,000, possibly reflecting the higher transmission and reactivation risk of migration routes. This key finding may help better determining eligible populations for TB screening programmes.

INTRODUCTION The WHO End TB Strategy emphasises early diagnosis and screening of TB in high-risk groups, including migrants. We analysed TB yield data from four large migrant TB screening programmes to inform TB policy.METHODS We pooled routinely collected individual TB screening episode data from Italy, the Netherlands, Sweden and the United Kingdom under the European Union Commission E-DETECT.TB grant, described characteristics of the screened population, and analysed TB case yield.RESULTS We collected data on 2,302,260 screening episodes among 2,107,016 migrants, mostly young adults aged 18-44 years (77.8%) from Asia (78%) and Africa (18%). There were 1,658 TB cases detected through screening, with substantial yield variation (per 100,000): 201.1 for Sweden (95% confidence intervals CI 111.4-362.7), 68.9 (95% CI 65.4-72.7) for the United Kingdom, 83.2 (95% CI 73.3-94.4) for the Netherlands and 653.6 (95% CI 445.4-958.2) in Italy. Most TB cases were notified among migrants from Asia (n = 1,206, 75/100,000) or Africa (n = 370, 76.4/100,000), and among asylum seekers (n = 174, 131.5/100,000), migrants to the Netherlands (n = 101, 61.9/100,000) and settlement visa migrants to the United Kingdom (n = 590, 120.3/100,000).CONCLUSIONS We found considerable variations in yield across programmes, types of migrants and country of origin. These variations may be partly explained by differences in migration patterns and programmatic characteristics.

Introduction Public engagement throughout the research lifecycle can help improve research quality and ensure it reaches audiences effectively. Where the perspective of the ‘general population’, rather than service users or community groups, is sought, there are no clear means of engaging those with no particular interest in the topic. Natsal, large-scale probability-sample surveys of sexual behaviour in Britain, seeks to develop a general population engagement panel to address this. Here we report on the lessons learned to date. Methods We undertook qualitative interviews with 20 participants aged 16-59 from the Natsal-4 pilot survey to explore: interest in research engagement; types of activities of interest; motivations for participating; communications approaches. We then trialled engagement with pilot participants who had agreed to recontact (n=93/131) on a real research decision: Selecting a sample for Natsal-4 using administrative records vs current address-based sampling. Results There was general interest in further engagement with research, particularly around interpreting results and designing future studies. Participants preferred flexibility regarding which activities they participated in. Financial incentives were viewed as important, but other motivating factors were also raised. Communications should clearly state what is required including whether specific skills are needed. In our trial engagement project, 15/93 participants responded with their views on changing Natsal-4’s sampling methodology (each were emailed a £10 gift voucher). Discussion Natsal-4 participants’ feedback helped inform methodological decision-making, suggesting a participant panel can provide a valuable lay perspective on research. This may be useful to other projects seeking to work with those not engaged with services or community groups.

ObjectivesPhysical distancing as a non-pharmaceutical intervention aims to reduce interactions between people to prevent SARS-CoV-2 transmission. Intimate physical contact outside the household (IPCOH) may expand transmission networks by connecting households. We aimed to explore whether intimacy needs impacted adherence to physical distancing following lockdown in Britain in March 2020.MethodsThe Natsal-COVID web-panel survey (July–August 2020) used quota-sampling and weighting to achieve a quasi-representative population sample. We estimate reporting of IPCOH with a romantic/sexual partner in the 4 weeks prior to interview, describe the type of contact, identify demographic and behavioural factors associated with IPCOH and present age-adjusted ORs (aORs). Qualitative interviews (n=18) were conducted to understand the context, reasons and decision making around IPCOH.ResultsOf 6654 participants aged 18–59 years, 9.9% (95% CI 9.1% to 10.6%) reported IPCOH. IPCOH was highest in those aged 18–24 (17.7%), identifying as gay or lesbian (19.5%), and in steady non-cohabiting relationships (56.3%). IPCOH was associated with reporting risk behaviours (eg, condomless sex, higher alcohol consumption). IPCOH was less likely among those reporting bad/very bad health (aOR 0.54; 95% CI 0.32 to 0.93) but more likely among those with COVID-19 symptoms and/or diagnosis (aOR 1.34; 95% CI 1.10 to 1.65). Two-thirds (64.4%) of IPCOH was reported as being within a support bubble. Qualitative interviews found that people reporting IPCOH deliberated over, and made efforts to mitigate, the risks.ConclusionsGiven 90% of people did not report IPCOH, this contact may not be a large additional contributor to SARS-CoV-2 transmission, although heterogeneity exists within the population. Public health messages need to recognise how single people and partners living apart balance sexual intimacy and relationship needs with adherence to control measures.

Background Inpatients experiencing homelessness are often discharged to unstable accommodation or the street, which may increase the risk of readmission. Methods We conducted a cohort study of 2772 homeless patients discharged after an emergency admission at 78 hospitals across England between November 2013 and November 2016. For each individual, we selected a housed patient who lived in a socioeconomically deprived area, matched on age, sex, hospital, and year of discharge. Counts of emergency readmissions, planned readmissions, and Accident and Emergency (A&E) visits post-discharge were derived from national hospital databases, with a median of 2.8 years of follow-up. We estimated the cumulative incidence of readmission over 12 months, and used negative binomial regression to estimate rate ratios. Results After adjusting for health measured at the index admission, homeless patients had 2.49 (95% CI 2.29 to 2.70) times the rate of emergency readmission, 0.60 (95% CI 0.53 to 0.68) times the rate of planned readmission and 2.57 (95% CI 2.41 to 2.73) times the rate of A&E visits compared with housed patients. The 12-month risk of emergency readmission was higher for homeless patients (61%, 95% CI 59% to 64%) than housed patients (33%, 95% CI 30% to 36%); and the risk of planned readmission was lower for homeless patients (17%, 95% CI 14% to 19%) than for housed patients (30%, 95% CI 28% to 32%). While the risk of emergency readmission varied with the reason for admission for housed patients, for example being higher for admissions due to cancers than for those due to accidents, the risk was high across all causes for homeless patients. Conclusions Hospital patients experiencing homelessness have high rates of emergency readmission that are not explained by health. This highlights the need for discharge arrangements that address their health, housing and social care needs.

Background Physical distancing as a non-pharmaceutical intervention (NPI) to prevent SARS-CoV-2 transmission aims to reduce interactions between people, including between different households. We explored whether sexual intimacy needs impacted on compliance with physical distancing at a population level in Britain following the initial national lockdown on 23 March 2020. Methods We undertook the Natsal-COVID web-panel survey between 29 July-10 August 2020. Quota-based sampling and weighting were used to obtain a quasi-representative sample of the British population. We estimated reporting of physical contact outside of the household (PCOH) with a romantic/sexual partner in the four weeks prior to interview, described the type of contact, identified demographic and behavioural factors associated with PCOH and present age-adjusted odds ratios (aORs). Results Of the 6,654 participants aged 18–59 years, 9.9% (95%CI:9.9–10.6%) reported PCOH. Of these, 86.1% reported oral/anal/vaginal sex or genital contact, while the remaining reported kissing (10.4%) or only holding hands/hugging/cuddling (3.4%). PCOH varied by age and gender and was highest in those aged 18–24 (20.6% of women and 15.6% of men). PCOH was more likely in participants identifying as gay/lesbian (aOR 2.5; 1.82–3.45) or bisexual (aOR 1.52; 1.12–2.05) and those reporting >1 partner (aOR 1.71; 3.77–5.88) or condomless sex with a new partner (OR 5.03; 1.07–6.21) in the past year. PCOH was less likely in those reporting a steady or cohabiting relationship (aOR 0.66; 0.55–0.79 and aOR 0.11; 0.08–0.14 respectively), and in those reporting bad/very bad health (aOR 0.54; 0.32–0.93). Conclusion The intimate nature of sexual contact is high-risk for SARS-CoV-2 transmission and PCOH may expand transmission networks by connecting households. Mathematical models of NPIs might consider age- and gender-specific PCOH in the context of other mixing patterns. Public health messaging needs to recognise the importance of sexual and romantic contact in people's decision-making and adherence to control measures.