Promoting a shift from using cars towards walking and cycling (a modal shift) has the potential to improve population health by reducing the adverse health effects associated with exposure to motor traffic and increasing the population level of physical activity through active travel. However, little is known about the effects of interventions which might achieve this by changing urban design, transport infrastructure or other putative determinants of population travel behaviour. I conducted a systematic review of the best available evidence about the effects of interventions to promote a modal shift. I searched twenty electronic literature databases as well as websites, bibliographies and reference lists and invited experts to contribute additional references. I identified 69 relevant studies and devised a two-dimensional hierarchy of study utility based on study design and study population with which I selected a subset of studies for inclusion. I appraised the quality of these studies; extracted data on the effects of interventions on choice of mode of transport, how these effects were distributed in the population, and associated effects on measures of individual and population health and wellbeing; and produced a narrative synthesis of the findings. Twenty-two studies were included. These comprised three randomised controlled trials, seven non-randomised controlled prospective studies, 11 uncontrolled prospective studies, and one controlled retrospective study of interventions applied to urban populations or areas in which outcomes were assessed in a sample of local people. I found some evidence that targeted behaviour change programmes could change the behaviour of motivated subgroups, resulting (in the largest study) in a modal shift of around 5% of all trips at a population level. Single studies of commuter subsidies and a new railway station also showed positive effects. The balance of best available evidence about other types of intervention such as publicity campaigns, traffic calming and cycling infrastructure suggested that they had not been effective. Participants in trials of active commuting experienced short term improvements in certain measures of health and fitness, but I found no good evidence about health effects associated with any effective intervention at population level. Most relevant studies were not found in mainstream health or social science literature databases. Further analysis of the 47 excluded studies did not change the overall conclusions about effectiveness, but did identify additional categories of intervention that merit further research and provided evidence to challenge assumptions about the actual effects of progressive urban transport policies. The contributions of internet publications, serendipitous discoveries and the initially-excluded studies to the total set of relevant evidence suggested that undertaking a comprehensive search may have provided unique evidence and insights that would not have been obtained using a more focused search. I identified an evaluative bias whereby the effects of population-level interventions were less likely than those of individual-level interventions to have been studied using the most rigorous study designs. Understanding of how environmental and policy factors may influence active travel and physical activity currently relies heavily on evidence from cross-sectional studies of correlates rather than intervention studies. I therefore took advantage of the opportunity presented by a local ‘natural experiment’ — the construction of a new urban section of the M74 motorway in Glasgow — to design, develop and complete the cross-sectional (baseline) phase of a new primary study of the effects of a major environmental intervention. Using a combination of census data, geographical data and field visits, I delineated an intervention study area close to the proposed route of the new motorway and two matched control areas elsewhere in Glasgow. I collected and described data from residents in the three study areas (n=1322) on socioeconomic status, the local environment, travel behaviour, physical activity and general health and wellbeing using a postal questionnaire incorporating two established instruments (the SF-8 and the short-form International Physical Activity Questionnaire), a travel diary and a new 14-item neighbourhood rating scale whose test–retest reliability I established in a subset of respondents (n=125). I then analysed the correlates of active travel and physical activity using logistic regression. Using travel diary data from Scottish Household Survey respondents (n=39067), I also compared the characteristics and travel behaviour of residents living close to the proposed route with those living in the rest of Scotland and analysed the correlates of active travel using logistic regression. Overall data quality and the test–retest reliability of the new neighbourhood scale appeared acceptable. Local residents reported less car travel than expected from national data. In the local study area, active travel was associated with being younger, being an owner-occupier, not having to travel a long distance to work and not having access to a car, whereas overall physical activity was associated with living in social-rented accommodation and not being overweight. After adjusting for individual and household characteristics, neither perceptions of the local environment nor the objective proximity of respondents’ homes to motorway or major road infrastructure appeared to explain much of the variance in active travel or overall physical activity, although I did find a significant positive association between active travel and perceived proximity to shops. Apart from access to local amenities, therefore, environmental characteristics may be of limited relevance as explanatory factors for active travel in this comparatively deprived urban population which has a low level of car ownership and may therefore have less capacity for making discretionary travel choices than the populations studied in most published research on the environmental correlates of physical activity. The design and baseline data for the M74 study now provide the basis for a controlled longitudinal study, which could not otherwise have been carried out, of changes in perceptions of the local environment, active travel, physical activity, and general health and wellbeing associated with a major intervention in the built environment. This will, in time, contribute to addressing calls to produce better evidence about the health impacts of natural experiments in public policy.

The overall objective of the study was to identify factors which play a key role in diet and exercise behaviour for migrant and Danish bus drivers in a workplace setting. The aim was to develop a framework to illustrate how the individual, contextual and cultural influences on health behaviour (diet and physical activity) interplay in an everyday perspective. Data was collected using a qualitative approach. Methods applied consisted of contextual based observations and semi structured interviews with sixteen (n=16) bus drivers. Four interviews were conducted with Danish, four with Somali, four with Turkish and four with participants with a Pakistani ethnic origin. The data was analysed using grounded theory. The core category which emerged from the data was „impact of individual, contextual and cultural influences on health behaviours‟. The core category was supported by five higher order categories. These were as follows: (1) Meanings of health (2) health behaviour and the potential to change, (3) Maintaining Balance (4) Workplace influences on health (5) Positioning in the social context. Each of the higher order categories was further supported with categories and sub-categories. The analysis illustrated findings on different levels. As a result of the impact of individual, contextual and cultural findings, strive for balance through a process of equilibrium was core to well-being and health in an everyday perspective. A collection of factors from the different levels of influence played a key role on diet and physical activity in an everyday work-day context. These have been illustrated through the use of quotes and frameworks. Based on the findings of the study, future research and practice recommendations are outlined.

The Scottish Executive (SE) commissioned the first phase of a National Coronary Heart Disease (CHD) Demonstration Project, Have a Heart Paisley (HaHP), in 2000. HaHP was a complex community-based partnership intervention. An independent evaluation of HaHP (phase one) was commissioned by the SE in 2001. This thesis presents the learning from the evaluation. The first aim is to identify the key implementation, evaluation and policy lessons to result from the evaluation. The second is to contribute to learning about how best to evaluate complex community-based interventions. The evaluation consisted of four approaches: a theory-based approach (the Theories of Change); the mapping of the context; a quasi-experimental survey; and, a range of integrated case studies. This thesis uses the programme logic (the intervention’s Theories of Change) articulated by the HaHP stakeholders to integrate the results from each of the evaluation approaches. HaHP (phase one) did not achieve significant changes in population level CHD risk factors, behaviours, morbidity or mortality. Like many previous community-based CHD interventions HaHP did not fully implement its intended Theories of Change. HaHP’s activities were not consistently based on best practice. It did not articulate or implement clear strategies for addressing health inequalities. The project delivered mainly individually focussed, ‘downstream’ interventions and struggled to achieve wide-scale local service, policy and agenda changes. It did, however, make progress with regard to improving partnerships and jointly delivering interventions. The findings from HaHP add to existing evidence that large-scale behaviour and cultural change will only be achieved through national action and the increasing use of ‘upstream’, legislative, or policy solutions, or changes in mainstream services and organisations. Activity in localised demonstration projects can add to such change rather than create it. The Theories of Change approach claims to improve planning and implementation, enhance evaluation, and address attribution. The approach (as applied within this evaluation) provided substantial amounts of formative feedback that was of use for improving programme implementation. This learning, however, was not always acted upon.

Tackling health inequalities is a policy priority. Research on cancer and particularly oral cancer aetiology has somewhat overlooked this area, in favour of pursuing genetic and 'lifestyle' risk factors. The over-arching aim of this thesis was to investigate the epidemiology of oral cancer in relation to individual socioeconomic status (SES), area-based socioeconomic circumstances, and socioeconomic inequalities. Descriptive epidemiology studies undertaken demonstrated that the burden of oral cancer was increasing across the UK, especially in Scotland, and a socioeconomic gap was widening with those from more deprived communities having significantly greater and increasing incidence of the disease. A systematic review and meta-analysis of the world literature showed that low compared to high SES was associated with significantly elevated risk of oral cancer independent of behavioural factors. A local case-control study provided unclear findings when individual- and area-based socioeconomic factors were explored together; however, a framework for future analyses was developed. In totality, this thesis suggests that public health policy to address the overall rising incidence and widening inequalities of oral cancer needs to acknowledge the complexity of the risk factors; in addition, the findings provide evidence to steer policy, which focus on lifestyles factors towards an integrated approach incorporating measures designed to tackle the root causes of disadvantage.

Background: The increase in the number of people living with HIV (PLHIV), especially in sub-Saharan Africa, is a major public health concern. To date, most attention has been paid to prevention strategies and clinical trials of therapy. In comparison, there have been very few studies of care and support programmes. The ‘HOPE’ programme is a major community-based care and support programme in Ghana. ‘HOPE’ provides nutritional support, skills training for employment, health education and psychological support for PLHIV and for those orphaned through AIDS. Therefore, it was seen by policy makers in the country as desirable that it should be evaluated. A PhD scholarship was funded and the researcher presenting this thesis was appointed. Broad Aims The overall aim was to carry out an evaluation of the ‘HOPE’ programme in Ghana in order to make wider recommendations for evaluation of community-based interventions (CBIs) in Ghana and Africa generally. The timing was less than ideal as many of the major decisions about the intervention had already been made and baseline data had been collected. Therefore, the preliminary aim was to explore a range of possible evaluation methods so that the most suitable approach could be selected. Thereafter, a range of more specific aims, objectives and research questions was identified. Methods: A ‘mixed methods’ approach was adopted. The first component was a desk-based analysis of the literature on the various evaluation approaches that might, at least in theory, be applied to an HIV/AIDS intervention like ‘HOPE’. From this, a decision was made to evaluate ‘HOPE’ in terms of structure, process and outcome. The second component operationalised this decision by reviewing HOPE’s working documents and conducting two pieces of field work: a quantitative and a qualitative study. The quantitative study was a structured questionnaire administered to 200 PLHIV on the ‘HOPE’ programme. The qualitative study consisted of 14 interviews with stakeholders directly involved in the programme implementation and 8 focus group discussions with the programme beneficiaries. Results: The desk-based analysis achieved three main outcomes. First, it set out in a systematic manner the different approaches to evaluation that could in theory have been applied to ‘HOPE’. It identified strengths and weaknesses and the perspectives behind each approach. Second, it set out and then summarised a detailed description of the ‘HOPE’ programme and the national context in which it operated. Third, it set the above within the context of global literature on HIV, community-based interventions and nutritional support programmes. The analysis of the quantitative data showed that beneficiaries were being provided with soy-fortified wheat and vegetable fortified oil at the time of the evaluation. On average, beneficiaries gained weight (Mean difference in weight was 2kg with 95% CI (1.1, 2.9), p-value < 0.001) and increased Body Mass Index (BMI) (Mean difference in BMI was 0.8units with 95% CI (0.4, 1.2), P-value < 0.001). Over a third of the beneficiaries (37.5%) was currently unemployed and only one in five of the beneficiaries had been trained in a skill that might have been useful to find employment: this, despite skills training for all being a programme goal. Multivariate analysis showed that the support group to which the beneficiary belonged was the most important determinant of a positive outcome. Qualitative components demonstrated perceived successes and challenges. Beneficiaries indicated that the anti-retroviral drugs were making them hungry and the food helped to alleviate that effect. They further indicated that the food was nutritious and contributed to their weight gain. Support groups have been sustained and membership increased. Some indicated that food should be more varied and some mentioned selling food to earn money to pay for their medications. Most of the beneficiaries indicated they were unemployed having lost their jobs as a result of stigmatisation. Only a few benefited from skills training leading to employment because of inadequate budgeting. Some who had been trained could not use their newly acquired skills because of lack of capital to start a business. To compound these weaknesses, most reported that they preferred petty trading to the skills offered. The monthly education and the training workshops generated hope, and improved knowledge of HIV/AIDS, promoted drug adherence and helped to reduce stigmatisation. The training of the PLHIV as peer educators is an effective method for HIV education and counselling since PLHIV listen to their peers more than health workers. Respondees predicted dissolution of the support groups when the programme ends. This is because they were not adequately involved in the decision making. Beneficiaries identified participation and cooperation as key prerequisites for sustainability but they also identified important weaknesses in ‘HOPE’ with respect to these criteria. Discussion: Despite the challenges presented by the timing and context of this study, it has been possible to carry out an evaluation that provides important learning. A mixed methods approach was appropriate and is likely to be useful in many similar evaluations. Beneficial outcomes were identified but these cannot be attributed, without qualification, to the intervention. Nonetheless, the findings indicated that participants were highly satisfied with the food support and monthly education. They were dissatisfied with the numbers trained in new skills and in other aspects of the skills training components. Also, the sustainability of the food component when the funding stops was a concern. However, the educational component could be sustained because peer educators could continue at very low cost. Most importantly, community involvement, using locally available resources, inter-sectoral collaboration and harnessing the motivation of local people were seen as key but underutilised ingredients. So, the results of the evaluation are encouraging but not conclusive. Nonetheless, care for people living with HIV is such an important problem that the desirability of conducting a cluster randomised controlled trial among a large number of support groups to assess the programme effectiveness on health, nutrition and economic status should be seriously considered despite the practical and ethical challenges implicit in such a recommendation.

Ethnic differences in the prevalence of diseases are known but the underlying causes and mechanisms remain unclear. The field of ethnic inequalities in health is relatively young in the UK, compromised by the lack of relevant data. It is, nevertheless, curious that while the UK has long provided some of the best empirical evidence and theoretical understanding of social inequalities in health, the exploration of ethnicity as an alternative dimension of social inequality is relatively recent. It was not until 1984 that first national study of ethnic differences in mortality was published. Between 1984 and 1996 the epidemiological knowledge base increased rapidly but weaknesses in these studies were evident. They were cross-sectional, small, based mainly on migrants of working ages from the Caribbean and the Indian subcontinent and tended to focus on CHD in South Asians and hypertension in Black Caribbeans. The use of ethnicity was linked to a biological or cultural concept, and the examination of the role of socio-economic environmental factors was cursory. The ten papers that I am submitting for this thesis were published between 1996 and 2004 and are located within this developing context of research in ethnic differences in health. At a time when there were no other national longitudinal studies of ethnic minorities, these papers were among the first to exploit the potential of the Office for National Statistics Longitudinal Study to examine ethnic differences in health. The findings of my submitted papers enhance the understanding of mortality and morbidity patterns in migrant groups and their children. Briefly, Papers I-III show that, in spite of the progressive improvement in socio-economic circumstances across three generations (grandparents, parents and children), Irish people living in England and Wales continued to show adverse mortality and cancer incidence patterns; Paper IV signals that addressing the risk of cancers is a public health priority for all minority groups, even though rates may be lower than the national average in some groups; Paper V shows the continuity of limiting long-term illness patterns across most migrant and UK-born minority groups; Papers VI and VII show that cumulative disadvantage was more common in South Asian and Caribbean migrants and that downward social mobility is associated with a disproportionate impact on limiting long-term illness in migrants; Papers VIII and IX show that the duration of residence in England and Wales and age at migration are important influences on the mortality of South Asian and Caribbean migrants in England and Wales; Paper X shows that there was little shift in mean birth weight between babies of migrant mothers and babies of UK-born minority mothers in the same ethnic group, which may have a continuing legacy on ethnic health inequalities, notably in cardiovascular disease. In summary, these published papers shed light on the social patterning of ethnic differences in health. This work stimulated the development of my current research programme. The papers included in the submission for the degree of PhD by published work are I. Harding S, Balarajan R. Patterns of mortality in second generation Irish living in England and Wales: longitudinal study. British Medical Journal 1996;312(7043):1389-1392. II. Harding S, Balarajan R. Mortality of third generation Irish people living in England and Wales: longitudinal study. British Medical Journal 2001;322(7284):466-467. III. Harding S. The incidence of cancers among second generation Irish living in England and Wales. British Journal of Cancer 1998;78(7):958-961. IV. Harding S, Rosato M. Cancer incidence among first generation Scottish, Irish, West Indian and South Asian migrants living in England and Wales. Ethnicity and Health 1999;4(1-2):83-92. V. Harding S, Balarajan R. Limiting long-term illness among Black Caribbeans, Black Africans, Indians, Pakistanis, Bangladeshis and Chinese born in the UK. Ethnicity and Health 2000;5(1):41-46. VI. Harding S, Balarajan R. Longitudinal Study of Socio-economic Differences in Mortality Among South Asian and West Indian Migrants. Ethnicity and Health 2001;6(2):121-128. VII. Harding S. Social mobility and self-reported limiting long-term illness among West Indian and South Asian migrants living in England and Wales. Social Science & Medicine 2003;56(2):355-361. VIII. Harding S. Mortality of migrants from the Indian subcontinent to England and Wales: Effect of duration of residence. Epidemiology 2003;14(3):287-292. IX. Harding S. Mortality of migrants from the Caribbean to England and Wales: effect of duration of residence. Int. J. Epidemiol. 2004;33(2):382-386. X. Harding S, Rosato M, Cruickshank JK. Lack of change in birthweights of infants by generational status among Indian, Pakistani, Bangladeshi, Black Caribbean, and Black African mothers in a British cohort study. Int. J. Epidemiol. 2004;33(6):1279-1285.

The aims of this PhD study were to assess the feasibility of accessing non-medical settings within which to offer chlamydia screening, to ascertain the knowledge of chlamydia and young men’s and women’s views towards non-medical screening, and to assess relative willingness to be screened for chlamydia by young men and women. Results: Eighty-four percent of age eligible users approached participated in education, health and fitness and workplace settings (n=126, n=133 and n=104, respectively). Of all sexually active people 113 (32%) were willing to be tested for chlamydia in non-medical settings. Uptake of testing was highest in the health and fitness setting (50% uptake for both women and men compared with 20% in education and 30% in workplace settings). In each setting young men were more willing than women to accept the offer of a chlamydia test. Overall, 40% of men approached provided a sample compared with 27% of all women. Disease prevalence was 4.4% (4.9% in men; 3.8% in women). Interview data suggests young men’s willingness to be tested for chlamydia in non-medical settings is due to convenience and raised awareness of the largely asymptomatic nature of chlamydia infection. Whilst 94% of men screened had never been tested for chlamydia before, one in three young women screened had previous screening experience. Women’s lower uptake of screening was due to concerns about the public nature of the settings leading to stigma. Conclusions: Increasing opportunities for the take-up of screening in non-medical settings could be an effective approach to reaching young men and have a significant impact on the incidence and prevalence of this easily treated STI, thereby reducing the future burden of unwanted reproductive health sequelae.

This thesis analyses the findings of empirical research carried out in three case study UK health authorities in 1996-97, using repeat interviewing of senior managers. It aimed to test three competing hypotheses: i. Markets are one possible system for allocating scarce resources. The process of contract specification in a complex quasi-market is likely to make rationing more explicit than it would be in a hierarchical system ii. In the complex context of the NHS the quasi-market may fail to produce clear contracts and unambiguous allocations, because of prohibitive transaction costs, political costs and ethical costs of greater explicitness iii. Other pressures in favour of explicitness (e.g. rising expenditure, effectiveness evidence and the Patient's Charter) may be irresistible, whatever structural form the NHS takes. The complex relationship between explicit rationing, the internal market and other factors is discussed. Results suggest the quasi-market has contributed to the growth in explicit rationing, notably by decoupling purchasers and providers from their previously shared responsibility to manage resources. In other respects the market has speeded up or magnified the effect of other factors which would or could have happened anyway. Concern to control rising expenditure has led to more explicit decisions but is now rekindling interest in the value of fixed budgets for providers and implicit clinical decision-making. Factors such as the Patient's Charter have also had an independent effect on greater explicitness. Implicit rationing remains significant. The implications for health care rationing of government proposals to abolish the internal market are examined. The results suggest that explicit rationing will probably continue to grow, but with a greater emphasis on explicit criteria to guide clinicians in determining who gets treatment, rather than the exclusion of whole services. The retention of some form of commissioner provider split may also exercise continuing pressure towards explicitness.

Introduction There exists a ‘Scottish effect’, a residue of excess mortality that remains for Scotland relative to England and Wales after standardising for age, sex and local area deprivation status. This residue is largest for the most deprived segments of the Scottish population. Most Scottish areas that can be classified as deprived are located in West Central Scotland and, in particular, the City of Glasgow. Therefore the central aim of this thesis is to establish the existence of a similar ‘Glasgow effect’ and identify if the relationship between deprivation and all cause mortality is different in Glasgow to what is in other, comparable cities in the UK. Methods A method to compare the deprivation status of several UK cities was devised using the deprivation score first calculated by Carstairs and Morris. The population of mainland UK was broken into deciles according to the Carstairs score of Scottish postcode sectors and English wards. Deprivation profiles for particular cities were drawn according to the percentage of the local population that lived in each Carstairs decile. Using data from the three censuses since 1981, longitudinal trends in relative deprivation status for each city could be observed. Analysis of death rates in cities was also undertaken. Two methods were used to compare death rates in cities. Indirect standardisation was used to compare death rates adjusting for the categorical variables of age group, sex and Carstairs decile of postcode sector or ward of residence. Negative binomial models of death counts in small areas using local population as the exposure variable were also created; such models allow the calculation of SMRs with adjustment for continuous variables. Covariates used in these models included city of residence, age group, sex, Carstairs z-score and also the z-scores for each of the four variables from which the Carstairs score is comprised (lack of car ownership, low social class, household overcrowding and unemployment). Results The deprivation profiles confirmed that all UK cities have a high proportion of deprived residents, although some cities have far higher proportions than others. Some cities appeared to show relative improvement in deprivation status over time whilst others seemed resistant to change. Glasgow was the most deprived city at all census time points and the Clydeside conurbation was also more deprived than all other conurbations. SMRs calculated by indirect standardisation indicated that many cities have excess mortality compared to the whole of the UK when adjusting for age group and sex only. Three cities, Glasgow, Liverpool and Manchester, had SMRs that were significantly higher than all other cities at every census time point. Adjusting SMRs for Carstairs deprivation decile diminished the magnitude of this excess mortality in most cities. However, adjusting for Carstairs decile did not diminish the excess mortality in Glasgow sufficiently and there remained a significant, unexplained residue of excess mortality in Glasgow. SMRs generated by regression models adjusting for continuous variables were able to reduce the size of the excess mortality in most cities, though the model producing the lowest SMR varied from place to place and from time to time. In Glasgow, a regression model including age group, sex and lack of car ownership as covariates explained most of the excess mortality at all three time points. Discussion and Conclusion The relationship between deprivation (as measured by the Carstairs index) and death rates in Glasgow did appear to be different to other cities, and there seems to be evidence of a Glasgow effect. There are several reasons why this might be the case, including; the Glasgow effect may be apparent rather than real – an artefact of the Carstairs measure of deprivation failing to capture the complex nature of multiple deprivation; The effect may be the result of migration patterns to and from the city; the effect may be the result of historical levels of deprivation; or the effect may result from different behavioural patterns among Glasgow residents compared to residents of other UK cities. In conclusion, the results show that continued efforts by public health professionals, politicians and residents have failed to produce a step change in the city’s relative health status and Glasgow continues to lag some way behind other cities in the UK. The ability of the Carstairs measure to describe multiple deprivation is called into question. Future research should focus on identifying specific causes of mortality that contribute to the Glasgow effect; on qualitative work to identify if there is a distinct set of social norms in deprived neighbourhoods of Glasgow that contribute to unhealthy patterns of behaviour; and on creating a deprivation index that can be used on equivalent units of geographical area in both Scotland and England.

Background Homelessness shares many similarities with other socio-economically deprived circumstances. It was not known whether the health of homeless people was similar to that of other deprived non-homeless populations. Aims To describe hospital admissions and deaths in a cohort of homeless Glasgow adults and to compare these to socio-economically deprived groups within a matched sample of the non-homeless local population. Methods A retrospective 5-year cohort study was conducted comparing an exposed (homeless) cohort of adults with an age and sex matched unexposed (non-homeless) cohort from the local general population. All participants’ linked hospitalisation and death records were identified. Survival was analysed using comparisons of rates, Kaplan-Meier plots and Cox proportional hazards models. Hospitalisation rate ratios were compared using an exact Poisson method. Additional proportional hazards models were produced to adjust for morbidity, which was identified in hospital records up to 5 years before death. Results 6323 homeless and 12 625 non-homeless adults were studied. The mean ages of men and women in both cohorts at entry were 33 and 30 years, respectively, and 65% were men. After 5 years 1.7% of the general population and 7.2% of the homeless population had died. Age and sex adjusted hazards of death, compared with residents of the most affluent areas, were 2.6 (95% CI 1.5 – 4.4) for residents of the most deprived areas and 8.7 (95% CI 5.2 – 14.5) for homeless individuals. Men were at twice the risk of death as women. Homelessness was associated with death on average 12 years younger than the matched general population (41 versus 53 years). A third of deaths in the homeless were caused by drugs and a further 16% by alcohol. In the homeless, adjusted hazards ratios for deaths by drugs were 20.4 (95% CI 12.0 – 34.7), for suicide were 8.4 (95% CI 3.9 – 18.2), for assault were 7.0 (95% CI 2.6 – 19.0) and for alcohol were 4.7 (95% CI 3.1 – 7.1) compared with the non-homeless population. Homelessness remained an independent risk factor for death after adjustment for morbidities, with a hazard ratio of 2.4 (95% CI 1.3 – 4.3) compared with living in the most affluent non-homeless circumstances. Hospitalisation for alcohol related conditions increased the risk of death from alcohol by 42-fold but homelessness added no further hazard. In contrast, hospitalisation for drug-related causes raised the risk of death from them by 4-fold and homelessness added a further 7-fold risk. The risk ratio for emergency hospitalisation in the homeless was 6.4 compared with the non-homeless. Admission rates were higher in the homeless for all conditions except cancers. Risk ratios in the homeless compared to the most affluent non-homeless cohorts were highest for cellulitis (risk ratio 112.9, 95% CI 20.2 – 4472.0), drug poisoning (risk ratio 90.0, 95% CI 16.0 – 3565.9) and convulsions (risk ratio 71.5, 95% CI 12.7 – 2834.1) In men, lengths of stay were longest in patients from the most affluent areas and shortest in the homeless. In women, lengths of stay increased with greater socio-economic deprivation but homeless women had stays that were typical of the general population. There was little difference in elective admission rates across different socio-economic strata. Homelessness was associated with a small reduction in risk of elective hospitalisation in men and a small increase in women compared with the general population. Admissions for treatment of infectious and parasitic disease were 9 times more common in the homeless. Admissions for injuries, poisonings, mental and behavioural disorders, and maternity related diagnoses were around 2-3 more common in the homeless. Homelessness was associated with almost 3-fold increases in elective admissions for abortions but an 80% lower risk of vasectomy. Lengths of stay for elective admissions increased with deprivation and were longest in the homeless. Conclusions The morbidity and mortality of homeless adults is significantly worse than that of the most deprived non-homeless populations of Glasgow. Hospital inpatients who are homeless are at greater risk of death for a number of conditions and may benefit from more intensive treatment and follow-up.