https://orcid.org/0009-0009-1407-3511
Figures
Abstract
Background
People with concurrent mental health and substance use problems are among the most socially excluded groups in our society, yet little attention has been paid to what socially excluded people see as central to promoting their social inclusion. The aim of this qualitative scoping review is to provide an overview of barriers and facilitators for social inclusion among people with concurrent mental health and substance use problems, based on first-person perspectives, to help guide future research, policies, and practice.
Methods
We explored first-person perspectives on social inclusion among people with concurrent mental health and substance use problems, employing Arksey and O’Malleys framework. We searched Medline, PsycINFO, Embase, Scopus, Cinahl, and other sources for studies published between January 2000 and September 2023. We employed content analysis and followed the PRISMA checklist.
Results
We included 55 articles included in our review and identified sub themes of: Intrapersonal baseline (identity, belonging), Components of social inclusion (relationships, meaningful activities, employment, economy), and Systemic failure or success (housing, public health and welfare services, the criminal justice system).
Conclusion
Social inclusion is rarely studied outside the context of direct services. Our results point to knowledge gaps in addressing social inclusion in a broad, societal context; implementing gaps in services; and developing policies to assure the fundamental needs and human rights of socially excluded persons.
Citation: Nord-Baade S, Ness O, Jensen CB, Rowe M, Opheim E, Landheim A (2024) Barriers and facilitators for social inclusion among people with concurrent mental health and substance use problems. A qualitative scoping review. PLoS ONE 19(12): e0315758. https://doi.org/10.1371/journal.pone.0315758
Editor: Andrea Cioffi, University of Foggia: Universita degli Studi di Foggia, ITALY
Received: June 3, 2024; Accepted: November 30, 2024; Published: December 16, 2024
Copyright: © 2024 Nord-Baade et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Data Availability: All relevant data are within the manuscript and its Supporting Information files.
Funding: Funder: Innlandet Hospital Trust www.sykehuset-innlandet.no Project number: 150928 SNB & AL The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
Competing interests: The authors have declared that no competing interests exist.
Introduction
People with concurrent mental health and substance use problems are among the most socially excluded groups in our society [1, 2]. In short, addressing social inclusion is essential to promote their well-being and quality of life [1]. Measuring the prevalence of dual disorders, or concurrent mental health and substance use disorders, is a complicated matter. One study found concurrent substance use disorders in approximately 30% of all patients diagnosed with severe mental illness [3]. Another study reported a lifetime prevalence of a psychiatric disorder in up to 89% of people with substance use disorders [4]. The complexity of these disorders and their prevalence supports the need to address marginalization in this group, with probability of providing transferable knowledge to other marginalized groups such as immigrants and refugees, people with LGBTQ+ sexual orientations, and people with other physical or mental disabilities [5].
Social exclusion has been defined as “a state in which individuals are unable to participate fully in economic, social, political and cultural life, as well as the process leading to and sustaining such a state” [5 p. 18]. It is linked to mental and physical illness, lower quality of life, and higher morbidity and mortality [6]. We endorse an understanding of social inclusion as both a process and a goal, that is, as “the process of improving the terms of participation in society for people who are disadvantaged on the basis of age, sex, disability, race, ethnicity, origin, religion, or economic or other status, through enhanced opportunities, access to resources, voice and respect for rights” [5 p. 20]. These definitions provide a broad understanding of the concepts, enabling us to explore the complexity of the matter. However, the measurement and definitions of social inclusion and exclusion is dependent on systemic, social, cultural, material, subjective and psychological factors [7–9]. Addressing social inclusion among people with concurrent mental health and substance problems is especially important in a time of increasing social inequality and a difficult global economy that disproportionately affects those with limited resources. Organizations such as the United Nations [5] highlight the importance of addressing mental health and substance use issues and associated social inequity that may constitute violations of human rights.
Experiencing social inclusion (e.g. through relationships, activities, work, housing and a sense of belonging) facilitates recovery. It also has preventive effects against mental health problems and substance use via the experience of receiving social support, engaging and participating in activities, maintaining and developing social skills, and of a sense of belonging and empowerment [10, 11]. Yet despite acknowledging the benefits of social inclusion, service providers often overlook the community aspects of patients’ lives [12]. Even though the recovery approach has improved service quality, critiques of mental health and substance use services suggest an overemphasis on individual responsibility. Further, service providers are critiqued for not addressing structural factors and societal influences that function as barriers for social inclusion for the individual [10, 13]. In addition, efforts have been made to implement knowledge-based service models with social inclusion as an essential component. However, such models, e.g. Assertive Community Treatment Teams (ACT), Flexible Assertive Community Treatment (FACT), Individual Placement and Support (IPS), Integrated Dual Disorders Treatment (IDDT), and Housing First are not implemented systematically. This has leadto disparate treatments and services available to the target group [14–16].
When addressing social inclusion and exclusion, there is a tendency to focus on objective measures related to work, education, housing, and economy. The individuals’ subjective experiences of promoting social inclusion are understudied [9]. This study seeks to complement the knowledge on objective measures and emphasize the person-oriented approach, aimed at improving the services’ ability to promote social inclusion and inform future research and policies. The research question of this qualitative scoping review is: what are the barriers and facilitators for social inclusion as experienced by people with concurrent mental health and substance use problems?
Materials and methods
A scoping review was chosen as it is suitable for broad, complex, and multidisciplinary research questions, and for exploring key characteristics or factors related to the research topic. It enables mapping of existing literature and knowledge gaps, hence providing guidance and directions for future research, practice and policy efforts [17–19]. The study employed Arksey and O´Malley’s [17] five-stage framework for scoping reviews: (1) identifying the research questions, (2) searching for relevant studies, (3) selecting studies, (4) charting the data, and (5) collating and summarizing the studies. In this section, the conduction of the first four phases is presented while covering the fifth stage in the results section, following the PRISMA checklist for scoping reviews [20] (see S1 Checklist).
Stage 1 –Identifying the research question
Little is known about promoting social inclusion based on the experience of marginalized groups, including people with concurrent mental health and substance use problems. Focusing on the voices of this group can support their empowerment and help us bridge the gap between research and practice. The aim in this study was to present current knowledge status regarding the question: What are the barriers and facilitators for social inclusion as experienced by people with concurrent mental health and substance use problems?
Stage 2 –Searching for relevant studies
The search was conducted in two phases (see S1 File and Fig 1). First, SNB and EO conducted a broad exploratory search for both quantitative and qualitative research through Medline (OVID), PsycINFO (OVID), Embase (OVID), Scopus (Elsevier) and Cinahl (Ebsco) in February and March 2023. After screening the results, discussions among all authors led to a decision to include articles with first-person perspectives only, as these best reflected the wisdom that persons in the target group could offer. Second, in September 2023, EO conducted a search in the same databases as above, including the following text words and subject terms, aimed at discovering research with first-person perspectives: (1) concurrent mental health and substance use, (2) mental illness in combination with (3) substance/alcohol use, (4) social inclusion, and (5) first-person experiences (second search only). Third, supplementary searches were conducted through searching reference lists manually and contacting experts in the field to identify additional studies. The supplementary search uncovered few references that the database search had not.
Stage 3 –Selecting studies
SNB and ON developed a screening guide that included qualitative peer reviewed empirical research articles with first-person experiences of social inclusion in the target group, published in the years 2000–2023, and written in English or Scandinavian languages (Norwegian, Swedish, Danish). Included articles originated in similar countries according to criteria outlined by Esping Andersen [21] and Bambra [22]. All Nordic countries were included. Exclusion criteria in addition to not meeting the inclusion criteria were articles not addressing barriers and facilitators for social inclusion.
Eligibility criteria.
2628 articles were screened by title, abstracts, and keywords in the first phase. Of these, 263 met criteria for full text screening, and of these 39 were included in the final analysis. In a second search 585 articles were screened by title, abstracts, and keywords. 101 qualified for full text screening; of these, 42 articles met the inclusion criteria; and of these, 13 articles were included after de-deduplicating articles from the first search using EndNote. A total of 52 articles were included from the searches. Three additional articles were retrieved from reference lists and through experts, leading to a total of 55 articles for the scoping review (see Fig 1).
SNB and CBJ, a peer researcher, read all abstracts in the first search (n = 2628). In this phase, studies that did not highlight the target group were included because they included relevant information on, or discussion of high numbers of concurrent mental health and substance use problems. Studies that noted but did not highlight social inclusion, focusing instead on recovery or other themes, were also included. Non-empirical articles were excluded, and those that fell under other exclusion criteria. Several other articles were excluded in this phase, often connected to the search words ‘co-occurring’ and ‘concurrent’. This led the databases to include studies on other comorbid conditions and diagnoses in the results. Consensus was reached on included articles for full text screening after consulting with ON. SNB read 100% of the articles included for full text screening (n = 263). MR and AL each read 20% and 10% of the articles randomly selected. In the second search, SNB read all abstracts (n = 585) and conducted the full text screening (n = 101), following the same principles as described above. Of the finally included articles (n = 55), ON, MR and AL read 10 percent each, randomly.
Stage 4 –Charting the data
SNB coded included articles by author, year published, title, journal, country of origin, methods, context and sample, main research focus, and subthemes (see Tables 1 and 2).
Stage 5 –Collating and summarizing the results
SNB employed an explorative and inductive content analysis approach including the stages of preparation, organizing and reporting [23], following recommendations for analysis in qualitative scoping reviews [24]. After collecting and reading through the data, the material was coded and categorized both by facilitators and barriers, before identifying overarching themes and subthemes, and interpreting these. All authors were consulted in this process. The software F4analyse [25] was used for analysis. Results are shown in Table 2, followed by narrative descriptions in the section below, in line with recommendations for reporting in scoping reviews [24].
Results
The results concern barriers to and facilitators of social inclusion as experienced by people with concurrent mental health and substance use problems. Our analysis yielded three main themes: (1) The intrapersonal baseline, (2) Components of social inclusion, and (3) Systemic failure or success, with subthemes for each (see Table 1 for main themes and subthemes, and Table 2 for included articles and results).
The intrapersonal baseline
This theme highlights the importance of including processes rooted in the individual when making efforts to promote social inclusion, as related to two subthemes: (1) Identity, and (2) Belonging.
Identity.
Identity affects social inclusion via self-perception of being someone who is, or is not, socially capable, of value, or desirable to others. Participants in the included studies often perceived themselves as worthless and unwanted. This was often due to loss of social roles, connected with a sense of hopelessness or a wish “to be normal” or “fit in”. They experienced this as creating a distance between themselves and others.
A negative identity was described as a barrier to social inclusion via its effect on behavior, with others’ reactions to out-of-norm behavior confirming self-perception as an unwanted and ‘second-class citizen’. Trying to change or control this behavior was by some experienced as challenging, lacking knowledge or resources to adjust it. These negative reactions came not only from people in the mainstream community, but from service providers as well. Some perceived treatment or hospitalization as confirming their “disturbed identity,” being someone who is not normal. Receiving kindness could be confusing for some if it went against their established identity of being unworthy.
To facilitate social inclusion through redefining self-perception, some pointed to the importance of skill building to increase a sense of self-efficacy. Others spoke of the importance of having socially valuable roles through working or engaging in meaningful activities, and having satisfactory housing. Some said receiving flexible help and being treated with dignity through person-oriented services helped them redefine themselves more positively and counteract the sense of being a burden to society. They also spoke of establishing new, healthy identities that promote their social inclusion through gaining greater knowledge of mental health and substance use problems, practicing self-forgiveness, being recipients of acts of kindness, offering it to others, and internalizing these experiences, thus creating identities outside of illness.
Belonging.
A sense of belonging supports social inclusion, as evident in the material. Many people reported a lifelong sense of not belonging, related to negative experiences in their families, school, or community giving them conflicting feelings of both wanting and not wanting to belong in mainstream community. Stigma and racism, often experienced as worse in rural areas, were described as barriers to belonging. Other barriers were homelessness, housing, lack of an educational degree, family connections, network, or jobs, and having lived a different life from others, making it difficult to connect. Some preferred finding a sense of belonging among other outsiders who also had problems and saw themselves as having limited possibilities to connect with people outside of this. Some spoke of a desire to start over, being given a clean slate from society, avoiding the stigma and the barrier that come with it.
People spoke of achieving a sense of belonging and inclusion through participating in meaningful activities, therapeutic groups, or self-help groups, where they shared common interests, challenges, and experiences. Some, however, wondered if participation in arranged activities and charities with peers functioned as a barrier to belonging into the mainstream community. Others spoke of working or receiving support from family and friends as a facilitator. A few emphasized collective community efforts done for their benefit to help them achieve a sense of belonging, pointing to the role of other people in the community, and the importance of acting on one’s healthy values and being met with them by others.
Components of social inclusion
This theme involves components of social inclusion, with the subthemes of (1) Relationships, (2) Meaningful activities, (3) Employment, and (4) Economy. These components are crucial for social inclusion as they address both subjective and objective aspects.
Relationships.
For many of the participants in the included studies, challenging relationships with family or partners, or multiple relational traumas through losing contact with family, partners, friends, and children or due to deaths, created a lasting sense of disconnectedness and a barrier to social inclusion. Many found it difficult to establish new relationships or re-connect with people due to bad experiences, including with service providers. This was associated with lack of support, confidence, or knowledge as to how to go about it, leading to greater isolation and exclusion. Others avoided starting relationships out of preference, fear of relapse, self-protection in hostile environments, estrangement, or fear of rejection. People also found building relationships difficult due to their mental health or substance use related problems, feeling they had nothing to offer.
Some found it easier to establish healthy relationships with peers though participating in activities or peer groups supported by a mutual understanding and non-judgmental acceptance. These relationships helped build confidence and social skills and were starting points for connecting with others. Ending unhealthy relationships, overcoming a lack of trust in others and experiences with not being trusted was necessary to facilitate connection. For some, reconnection with family depended on creating a sphere in which struggles could be addressed and understood by family members. Involving family members and other significant people in treatment could further support social inclusion.
Meaningful activities.
Engaging in meaningful activities was often described as a starting point for promoting social inclusion. Through participating in different activities, especially with peer support, people experienced increased self-confidence, social skills, coping mechanisms for illness, and motivation to participate in other activities such as voluntary work. This functioned as a gateway to employment for some. In addition, it could create a sense of normalcy, better quality of life and belonging via offering access to valuable social roles and an expanded social network.
Barriers to social participation were associated with insecurities about social skills, lack of money, transportation problems, and limited choice of activities, the last especially for people in rural areas. Feeling forced to participate in activities that one was not interested in could be a barrier to participating in other arranged activities. Related to this, focusing on activities themselves rather than the social aspects of them helped some people overcome social insecurities and engage. Receiving information and advice about relevant activities and motivational support through professionals, peer-staff and peers also facilitated participation and social inclusion.
Employment.
Employment supported achievement of self-respect, restoration of relationships with family, provision for children, being a good role model, and contributing to society. Most of the barriers and facilitators mentioned in relation to participating in meaningful activities also applied to employment, such as insecurities about social and practical skills.
Other barriers mentioned were stigma, racism, side effects of medications, poor physical health, criminal records, and lack of social and familial support. Some people spoke of not finding satisfactory work because of not having kept up with changes in the workplace, while others feared losing benefits and not earning enough to cover their loss. Others avoided work because of a lack of perceived ability, lack of hope, finding increased contact with others too stressful, or wanting to focus on other activities, family, or children.
People spoke of paid work, not training programs, along with support to maintain financial safety, as supporting their self-confidence. Finding the ‘right job,’ receiving positive support privately and from professionals, and gaining a distance from substance use, was improving their work performance and facilitated social inclusion.
Economy.
Economic status is important to promote social inclusion and prevent social exclusion seen as poverty and lacking financial security pushed many toward homelessness and the underground economy. This worsened their marginalization and lack of engagement with their community. Benefits were the main income for many, but these could be hard to get and easy to lose. For women especially, financial solvency affected their opportunities to provide for their children, an important factor in staying connected to society.
Doing better economically facilitated social inclusion, helping people choose safe places to live. Having money helped people engage with others, participate in social gatherings and establish reciprocal relationships by making it possible for them to contribute to them. Having money also supported people’s improved quality of life and ability to maintain their health through stabilizing their living situations.
System failure or success
Systems of care could support or inhibit people’s social inclusion through the sub-themes of (1) housing, (2) public health and welfare services, and (3) the criminal justice system.
Housing.
Housing, along with autonomy, a sense of dignity, safety, and stability, undercut people’s feeling of living on the outskirts of society and promote social inclusion. Some preferred living in supervised housing, others wanted independent housing. Some preferred to live among the general population, others among peers.
Supervised housing may impede social inclusion if not adapted to the person’s needs. Some preferred homelessness to unsafe, undignified housing. Others self-isolated in supportive housing due to stigmatizing encounters with staff or easy access to substances challenging their recovery. On the other hand, some experienced a sense of community in supported housing, with peer and staff support. This was often enhanced by collaboration between mental health and substance use service providers and housing staff, and enforcement of housing rules supporting positive social interaction. When housed in a functioning program, people often found increased hope for the future, and this sometimes led to reconnection with family, returning to school, and engagement in meaningful activities including voluntary work or paid work.
Some people spoke of procuring independent apartments after tackling barriers such as financial issues, rejection of housing vouchers, criminal history, and stigma. Maintaining independent housing could be overwhelming, too, and tempt people to return to homelessness. Experiencing mental health problems when stably housed, sometimes influenced by reduced substance use, point to the importance of continued professional support.
Public health and welfare services.
People cited problems in their contacts with public health and welfare services as a barrier to social inclusion. Problems included difficulties gaining access to mental health and substance use services and lack of integration of care for those who needed both. Some felt disempowered after negative encounters with service providers across years of seeking services, leading them to distrust the system and avoid engaging in treatment. When seeking treatment, bureaucratic delays and challenges, and issues with health insurance and finances were other reported barriers, the latter more pronounced in non-Nordic countries. Difficulties gaining access to treatment, a lack of person-centered care and limited involvement in decision-making, the perceived dominance of the medical model, coercion, and lack of expertise with treating concurrent conditions, often led people to end their treatment prematurely. In addition, many reported feeling stigmatized and mistrusted by staff due to their previous histories, or experienced low expectations from staff regarding their potential to contribute to society.
People also spoke of facilitating experiences. Receiving integrated and person-centered care, they said, supported their engagement in treatment. They cited being involved, experiencing collaboration and support in meetings with service providers across agencies, focusing on resources, personal skills, and on emotional and practical coping skills relevant to daily life as especially helpful. Staff whom they saw as being trusting and trustworthy, supportive, and respectful facilitated recovery and social inclusion, in addition to them having a sense of humor, patience and a non-judgmental attitude. Peer support, vocational and recreational activities, and outreach work also helped some gain access and stay connected to services, and could be steppingstones to connection with others. Having staff acknowledge their alienation from society helped them become engaged in services, some said, and supported their efforts to achieve social inclusion.
The criminal justice system.
Some people reported experiences with the criminal justice system, and for some of these, court requirements to seek treatment or prison terms supported their rehabilitation and social reintegration. Others, though, said the legal system can’t provide treatment and that substance use should be decriminalized to help the overall chances of living a decent life. Some simply did not have faith in the criminal justice system, leaving them feeling disempowered with little hope of social reintegration.
People offered few facilitating factors. Some spoke of support from treatment programs while others spoke of familial support. Non-judgmental support from staff was helpful, albeit mostly compared to the draconian practice of isolation. For women, same-gender support was important, both from people not using substances and from peers who were. Some spoke of being able to establish a supporting network while imprisoned and re-connecting with supportive people.
People said continued substance use or relapse following release were barriers to social reintegration. Rehabilitation in jail, they said, was difficult due to easy access to substances and lack of treatment. These factors were worsened by experiences of stigma and being poorly treated by staff and the system. Longer prison terms also created a barrier because of estrangement in family relationships.
People spoke of insufficient support from public services for transition back to their communities, including a lack of emotional and practical support for securing financing, housing, and work. The mainstream community, they said, refused to give them a second chance, thus limiting contact with people outside their old networks.
Discussion
Our study of first-person experiences among people with concurrent mental health and substance use problems guides us in the implications and recommendations we discuss in this section. Most of the included studies were conducted in the U.S., Great Britain, and Nordic countries, suggesting caution regarding their relevance to other settings. Why research is more prevalent in these countries compared to others raises questions as to how social inclusion is experienced and addressed in other countries, pointing to the need for further investigation. Additionally, most studies did not investigate potential differences in subsamples by factors such as gender, age, or context. Therefore, we cannot differentiate among subgroups, in turn challenging their implications for practice. Further, social inclusion was largely studied indirectly as part of general recovery processes, revealing a lack of holistic investigation of social inclusion. Finally, many studies were conducted within treatment or housing programs, therefore it should come as no surprise that our results point to experiences with health and welfare systems as a main barrier or facilitator of social inclusion.
The results show barriers on all levels from the individual to the societal, with barriers often clearer than facilitators. Participants often had lifelong experiences with social exclusion, often related to people’s mental health and substance use problems, lack of resources, and worldviews stemming from a life at the margins of society. These were often accompanied by relational trauma, stigma, and lack of trust that followed the persons in meetings with service providers, who sometimes validated people’s lack of trust in others and their internalized stigma. Societal barriers included limited access to and over-dependence on services, while access to services and dignified treatment while receiving them were facilitators of inclusion. However, people saw support from peers or peer staff as equally, or more important than support from professionals.
Implications for research
Our finding points to the importance of further exploration of how factors such as age, gender, type of problems, generational and sociodemographic characteristics influence social inclusion. Such findings could promote person- and context oriented and socially acceptable services. Additionally, future research should investigate the overarching societal structures in addition to systemic, supporting efforts to create practical solutions. Action research including participation of people with lived experience and aimed at improving support and service provision may help to close the gap between research and practice.
Implications for practice
It is striking that so much knowledge can be gained through talking to people who are socially excluded, and that there is so little capacity, at present, to implement this knowledge. There is an urgent call for systemic change and more robust implementation of socially oriented, knowledge-based treatment models. This is important considering people’s negative experiences with the current fragmented services and system of care, which undermined their access to social inclusion and participation in the society. We need to transform current systems of care, but we also need to support people’s transition to participation in mainstream society, with the critical involvement of people with lived experience in these efforts. The Citizenship framework [81, 82] is receiving attention as a way of addressing exclusion for marginalized groups, e.g. in Scotland [83], Spain [84] Norway [32, 85], and the U.S [81, 82], and serves as a good example of practice.
Implications for policies
Our findings seem to indicate violations and lack of enforcement of human rights in relation to social exclusion. There is a need to develop policies that secure fundamental human rights and promote mental health and social inclusion through improving living conditions such as economy, housing, and treatment, and ensuring that legal policies do good, not harm. Societal structures and attitudes build upon the creation of parallel communities, excluding the target group from mainstream society. Parallel overarching societal processes may be significant points of interest in addressing policies for social inclusion for this target group, and others. These processes include deinstitutionalization, the construction of fragmented and often inaccessible health and welfare systems, increasing inequities in health, economy and social welfare, and the current financial political climate including the promotion of individualistically oriented culture. Such processes negatively affect societal attitudes and sense of responsibility towards those less fortunate and influence the target group’s access to mainstream society. Such processes and statuses, combined with excluded persons learned mistrust in services which, to further complicate matters, are subject to cutbacks in financial challenging times, are a cause for worry.
The role of civic society in promoting social inclusion is rarely explored but should be. Possible starting points to address these issues are Prilleltensky´s [86] proposals for a shift from a “me-culture” to a “we-culture” to promote mattering, wellbeing, and connectedness, the work of Davidson [87] pointing to the importance of “simply being let in” as opposed to “fitting in”, and Prilleltensky et al.’s [88] work on the conditions (distributive, procedural and corrective justice) to promote mattering and well-being. Given the barriers related to our main themes, as seen in association with effects of “me-cultures”, it would be interesting to explore how civil society could facilitate social inclusion for socially excluded people with complex problems. Such explorations should and must involve individuals with lived experience.
Strengths and limitations
Our study has some methodological limitations. In general, the different steps and processes that result in a scoping review are not linear. In conducting a scoping review, a sensitive search is of great importance. Our search strategy is a combination of a sensitive search, and a more specific search performed some weeks apart. We consider this to be a strength of our review, as it incorporates the iterative nature of searching for relevant literature. We have not hand searched key journals as suggested in the framework but consider our research question to be of an interdisciplinary character, and as such identification of key journals is difficult. This fact is also reflected in the large number of unique journals included in the review. The analyses showed high levels of common experiences expressed across different study populations, pointing to high internal validity in the study. Another strength is our team-based approach with complementary perspectives, including the peer researcher’s, enhancing the quality of review process. However, there are some limitations on generalizability, as most of the studies were conducted in the USA, UK, and Nordic countries, mostly seen as high-income countries. In addition, few studies addressed potential differences in subsamples by factors such as gender, age, or context, demanding precautions.
Conclusion
Promoting social inclusion for persons with mental health and substance use problems is a complex matter demanding multidisciplinary approaches and actions. Massive research, practice and policy efforts must be undertaken to address social inclusion both directly and in a broad social context, aimed at breaking down barriers and building facilitators. More effort to include the social context in individual treatment and follow-up-care is needed as well. We challenge researchers, practitioners, and policy makers to take further steps in addressing, implementing knowledge, and handling the matter of social inclusion among people with concurrent mental health and substance use problems, as it is not only a societal concern but also a fundamental human right.
Supporting information
S1 Checklist. Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) checklist.
https://doi.org/10.1371/journal.pone.0315758.s001
(PDF)
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