Medicine on the margins: learning opportunities for undergraduates within inclusion health.

Marginalised groups, including the homeless, refugees and asylum seekers, often experience extremely poor health and present unique challenges to health systems. Undergraduate medical placements with specialist primary care services for these groups can be an insightful learning opportunity within 'inclusion health', a field committed to improving health of these populations. The aim of this project was to showcase organisations for students to gain further exposure and evaluate students' elective experiences at a specialist primary care service for marginalised groups. Students created a mind map to identify organisations in Norwich that were valuable for future students to explore. Five elective students were asked to complete qualitative questionnaires about their experiences. Approximately 10 organisations accommodated participating medical students. Three of five participants responded to the questionnaire, reporting a beneficial learning experience, enabling students to understand complex needs of marginalised groups. The findings offer creative suggestions of where students can gain further exposure. Evaluation of this elective suggests there is unique value in offering placements with a diverse range of organisations that support marginalised groups. Educators should consider integrating opportunities for debriefing and a structured curriculum. Greater support and resources must be provided to include these services for regular teaching and training.

Prevalence and health effects of communicable and non-communicable disease comorbidity in rural KwaZulu-Natal, South Africa.

OBJECTIVES: To describe changes in prevalence of hypertension, diabetes, HIV and tuberculosis, and prevalence of comorbidity, and to investigate associations between each condition, and combinations of conditions, with self-reported general health and hospital admission. METHODS: This study used data from a longitudinal population-based HIV and health surveillance cohort, conducted by the Africa Health Research Institute in Umkhanyakude district of rural KwaZulu-Natal, South Africa. RESULTS: Prevalence of hypertension, HIV and diabetes increased from 2009 to 2015, and prevalence of tuberculosis decreased. 81% of the 47 334 participants were female; hypertension and diabetes were the commonest conditions in people over age 50, whereas HIV was most common in those younger than 50 years. Comorbidity of communicable and non-communicable conditions was commonest in 40- to 60-year-olds. The adjusted odd ratios (OR) for better self-reported general health with multimorbidity were 0.53 (95% CI 0.51-0.56), 0.29 (95% CI 0.27-0.29), 0.25 (95% CI 0.21-0.37) and 0.21 (95% CI 0.12-0.37) for one, two, three and four conditions, respectively, vs. no conditions. Tuberculosis was most strongly and inversely associated with better general health (OR 0.34 (0.31-0.37) and most strongly associated with hospital admission (OR 3.26 (2.32-2.99)). CONCLUSION: The high prevalence of communicable and non-communicable conditions in this rural South African population is giving rise to a burden of multimorbidity, as increased access to antiretroviral treatment has reduced mortality in people with HIV. Healthcare systems must adapt by working towards integrated primary care for HIV/AIDS and non-communicable diseases.

OBJECTIFS: Décrire l'évolution de la prévalence de l'hypertension, du diabète, du VIH et de la tuberculose et de la prévalence de la comorbidité, et étudier les associations entre chaque affection et les combinaisons d'affections avec l'état de santé général et l'hospitalisation rapportés. MÉTHODES: Cette étude a utilisé les données d'une cohorte longitudinale de surveillance du VIH et de la santé basée sur la population, menée par l'Institut de Recherche sur la Santé en Afrique dans le district de Umkhanyakude, en zone rurale du KwaZulu-Natal, en Afrique du Sud. RÉSULTATS: La prévalence de l'hypertension, du VIH et du diabète a augmenté de 2009 à 2015 et la prévalence de la tuberculose a diminué. 81% des 47.334 participants étaient des femmes; l'hypertension et le diabète étaient les affections les plus courantes chez les personnes de plus de 50 ans, tandis que le VIH était plus répandu chez celles de moins de 50 ans. La comorbidité des maladies transmissibles et non transmissibles était plus fréquente chez les 40 à 60 ans. Les rapports de cotes ajustés (OR) pour une meilleure santé générale auto-déclarée avec une multimorbidité étaient de 0,53 (IC95%: 0,51-0,56), 0,29 (IC95%: 0,27-0,29), 0,25 (IC95%: 0,21-0,37) et 0,21 (IC95%: 0,12-0,37) pour une, deux, trois et quatre affections, respectivement, par rapport à l'absence d'affection. La tuberculose était le plus fortement et inversement associée à une meilleure santé générale (OR: 0,34 (0,31-0,37) et plus fortement associée à l'hospitalisation (OR: 3,26 (2,32-2,99)). CONCLUSION: La prévalence élevée des maladies transmissibles et non transmissibles dans cette population sud-africaine rurale entraine une augmentation de la charge de la multimorbidité,l'accès accru au traitement antirétroviral ayant réduit la mortalité chez les personnes vivant avec le VIH. Les systèmes de santé doivent s'adapter en œuvrant pour des soins primaires intégrés pour le VIH/SIDA et les maladies non transmissibles.

Scarred survivors: gate keepers and gate openers to healthcare for migrants in vulnerable circumstances.

Background: The main barriers to 'vulnerable migrants' receiving good quality primary care are language and administration barriers. Little is known about the experiences of healthcare discrimination faced by migrants from different cultural groups. The aim was to explore vulnerable migrants' perspectives on primary healthcare in a UK city. Methods: Three focus groups and two semi-structured interviews were aided by interpreters. These were analysed against a pre-developed framework based on national standards of care for vulnerable migrants. Recruitment was facilitated via a community organisation. Results: In total, 13 participants took part, six women and seven men. There were five Arabic speakers, four Farsi speakers and four English speakers. Themes included access to primary care, mental health, use of interpreters, post-migration stressors and cultural competency. Conclusion: Vulnerable migrants perceived high levels of discrimination and reported the value of a respectful attitude from health professionals. Appointment booking systems and re-ordering medication are key areas where language barriers cause the most disruption to patient care. Medication-only treatment plans have limitations for mental distress for this population. Community-based therapies which manage post-migration stressors are likely to enhance recovery.