'Challenging but ultimately rewarding' - lived experiences of Deep End Northern Ireland GPs: a qualitative study.

BACKGROUND: Living in socioeconomically deprived areas is associated with shorter lives and worse health. GPs working in these areas face additional challenges compared with those in more affluent locations. AIM: To establish GPs' motivation for working in these areas, to discover the challenges that GPs face, and to gain insights from GPs on potential improvements and changes. DESIGN AND SETTING: An interpretative phenomenological analysis was undertaken of GPs' lived experiences of working in the most socioeconomically deprived practices in Northern Ireland (NI), which is the most deprived country within the UK. METHOD: Interviews were carried out with nine GPs to find out the challenges facing them, why they work in a Deep End area, and what suggestions, ideas, and solutions they have to improve patient care and GP experience at NI's Deep End. RESULTS: The challenges related to wider health service failures including the increased demand on GPs and feelings of powerlessness. Patient population challenges included 'missingness', late or crisis presentations, alongside the clinical difficulties of a highly 'medicalised' patient population, as well as the high prevalence of mental health problems. However, GPs choose to work in Deep End areas because the environments were seen as clinically stimulating and rewarding, as well as giving them feelings of belonging and fulfilling a duty to 'their' area. Improvements focused on providing more flexible access, increased mental health provision, and future training and recruitment, particularly around widening participation in medical school. CONCLUSION: Improving the environmental conditions, empowering individuals, and investing in communities are essential factors to achieving health. The current model of providing reactionary acute care is leading to GPs experiencing powerlessness and feelings of helplessness at the Deep End.

Countering social exclusion through inclusive homecare provision: Utilising a participatory life-course approach to influence policy.

Homecare models can be effective mechanisms in securing wellbeing and ageing-in-place goals prevalent in health policy agendas. However, the relevance and utility of these models for those living in socially and environmentally insecure conditions has rarely been considered. This is marked by an assumption of in-situ care delivery in private dwellings, and the absence of such groups from homecare development processes. This study aims to harnesses the experiences and preferences of older people in homelessness (OH), older Irish Travellers (OT), and professional stakeholders in an evidence-based co-production of policy recommendations for inclusive homecare provision. The study employed a participatory approach involving the integration of lived experience evidence in a multistakeholder co-production process. Methods comprised: five separate focus groups with OH, OT and service providers (n = 30); two consultative forums involving focus group participants together; and 49 life-course interviews with OH (n = 27) and OT (n = 22) and adults. Findings demonstrate that sizeable gaps in care remain for these groups, and that resource constraints and legislative restrictions prevail for professional stakeholders. Co-produced policy recommendations for inclusive homecare provision based on these experiences and group preferences are presented and discussed.

Positive health and ageing policies for older Irish travellers and older people who have experienced homelessness in Ireland: Life-course meanings and determinants.

Marginalised groups of older people remain neglected in positive health and ageing (PHA) agendas, whether they concern healthy or active ageing concepts. Questions exist around the meaning of such constructs and the factors that enable disadvantaged populations to achieve equitable later-life experiences. Focusing on two such groups in Ireland, this study investigates the constituent dimensions of PHA for older Irish Travellers and older people who have experienced homelessness and the role of life-course and structural determinants in constructing PHA trajectories for these groups. The study involves a qualitative, participatory voice-led methodology, with analysis based on 49 in-depth life-course interviews with people aged 50 years and over from the two populations. Five interconnected dimensions of PHA are identified and presented. Four determinants related to life-course experiences and structural factors are identified as contributing to these dimensions: social relations, material and accommodation circumstances, formal supports and systems, and critical transitions and resilience. While illustrating the validity of PHA agendas for these groups when understood through their lived experiences, the findings highlight the significant deprivations and risks to rights that must be accounted for to secure meaningful gains in PHA for the groups.

Predictors and consequences of homelessness in whole-population observational studies that used administrative data: a systematic review.

BACKGROUND: Homelessness is a complex societal and public health challenge. Limited information exists about the population-level health and social care-related predictors and consequences of persons with lived experience of homelessness (PEH). Studies that focus on population subgroups or ad hoc questionnaires to gather data are of relatively limited generalisability to whole-population health surveillance and planning. The aim of this study was to find and synthesise information about the risk factors for, and consequences of, experiencing homelessness in whole-population studies that used routine administrative data. METHOD: We performed a systematic search using EMBASE, MEDLINE, the Cochrane Library, Cumulative Index to Nursing and Allied Health Literature (CINAHL) and PsycINFO research databases for English-language studies published from inception until February 2023 that reported analyses of administrative data about homelessness and health and social care-related predictors and consequences. We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. RESULTS: Of the 1224 articles reviewed, 30 publications met the inclusion criteria. The included studies examined a wide range of topic areas, and the homelessness definitions used in each varied considerably. Studies were categorised into several topic areas: Mortality, morbidity and COVID-19; health care usage and hospital re-admission; care home admission and shelter stay; and other (e.g. employment, crime victimisation). The studies reported that that the physical and mental health of people who experience homelessness was worse than that of the general population. Homeless individuals were more likely to have higher risk of hospitalisation, more likely to use emergency departments, have higher mortality rates and were at greater risk of needing intensive care or of dying from COVID-19 compared with general population. Additionally, homeless individuals were more likely to be incarcerated or unemployed. The effects were strongest for those who experienced being homeless as a child compared to those who experienced being homeless later on in life. CONCLUSIONS: This is the first systematic review of whole-population observational studies that used administrative data to identify causes and consequences associated with individuals who are experiencing homelessness. While the scientific literature provides evidence on some of the possible risk factors associated with being homeless, research into this research topic has been limited and gaps still remain. There is a need for more standardised best practice approaches to understand better the causes and consequences associated with being homeless.

Predictors and Consequences of Homelessness: Protocol for a Cohort Study Design Using Linked Routine Data.

BACKGROUND: Homelessness is a global burden, estimated to impact more than 100 million people worldwide. Individuals and families experiencing homelessness are more likely to have poorer physical and mental health than the general population. Administrative data is being increasingly used in homelessness research. OBJECTIVE: The objective of this study is to combine administrative health care data and social housing data to better understand the consequences and predictors associated with being homeless. METHODS: We will be linking health and social care administrative databases from Northern Ireland, United Kingdom. We will conduct descriptive analyses to examine trends in homelessness and investigate risk factors for key outcomes. RESULTS: The results of our analyses will be shared with stakeholders, reported at conferences and in academic journals, and summarized in policy briefing notes for policymakers. CONCLUSIONS: This study will aim to identify predictors and consequences of homelessness in Northern Ireland using linked housing, health, and social care data. The findings of this study will examine trends and outcomes in this vulnerable population using routinely collected health and social care administrative data. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/42404.

Adolescent binge drinking in the West of Ireland: associated risk and protective factors.

BACKGROUND: Alcohol is a leading cause of morbidity and mortality worldwide. Adolescence is when alcohol use typically begins. Harmful patterns of alcohol consumption, such as binge drinking, may emerge during adolescence and become established. This study aimed to examine potential risk and protective factors for binge drinking among 15-16-year-old adolescents in the West of Ireland. METHODS: This was a cross-sectional secondary analysis of 4473 participants from the Planet Youth 2020 Survey. The outcome was ever binge drinking, defined as ever consumption of five or more drinks in a two-hour period or less. Independent variables were selected a priori following review of peer-reviewed literature and were grouped as individual, parents and family, peer group, school, leisure time and local community factors. Statistical analysis was completed using SPSS version 27. Differences in medians and means for continuous variables were examined using the Mann-Whitney U test and Independent Samples t-test respectively. Multivariable logistic regression was used to examine independent associations between potential risk and protective factors and ever binge drinking. A p-value of < 0.05 was deemed statistically significant. RESULTS: The prevalence of ever binge drinking was 34.1%. Self-rated 'bad/very bad' mental health (adjusted Odds Ratio (aOR) 1.61, 95% CI 1.26-2.06, p < 0.001), current cigarette use (aOR 4.06, 95% CI 3.01-5.47, p < 0.001) and current cannabis use (aOR 2.79, 95% CI 1.80-4.31, p < 0.001) increased odds of ever binge drinking. Parental supervision (aOR 0.80, 95% CI 0.73-0.88, p < 0.001) and negative parental reaction to adolescent drunkenness (aOR 0.51, 95% CI 0.42-0.61, p < 0.001) reduced odds of ever binge drinking. Getting alcohol from parents increased odds of ever binge drinking (aOR 1.79, 95% CI 1.42-2.25, p < 0.001). Adolescents with friends who drink alcohol had almost five times higher odds of ever binge drinking (aOR 4.59, 95% CI 2.65-7.94, p < 0.001). Participating in team/club sports also increased odds of ever binge drinking (aOR 1.30, 95% CI 1.07-1.57, p = 0.008 for 1-4 times/week, aOR 1.52, 95% CI 1.07-2.16, p = 0.020 for ≥ 5 times/week). CONCLUSION: This study identifies individual and social environment factors associated with adolescent binge drinking in the West of Ireland. This can inform intersectoral action to protect adolescents from alcohol-related harm.

Are GP training opportunities in Northern Ireland widening or closing the gap on health inequalities? An analysis of Northern Ireland deprivation data.

BACKGROUND: Increasing the GP workforce will not necessarily level up healthcare provision. Instead, increasing GP training numbers could worsen health inequity and inequalities. This is especially true if there are fewer opportunities to learn, train, and build confidence in underserved, socioeconomically deprived areas. AIM: To investigate the representation of socioeconomic deprivation in postgraduate GP training practices in Northern Ireland (NI). DESIGN & SETTING: An analysis of socioeconomic deprivation indices and scores of GP practices in NI involved in postgraudate GP training. METHOD: The socioeconomic deprivation indices and scores of GP postgraduate training practices were compared against general practice in NI by examining the representation of practices whose patients live in areas of blanket deprivation, higher deprivation, and higher affluence. RESULTS: Of 319 practices in NI, 195 (61%) were registered as postgraduate training practices and had a statistically significantly lower deprivation score (3.02±0.21) compared with non-training practices (3.2±0.32), t(255) -2.02, P = 0.041. The proportion of training practices with blanket deprivation and higher levels of deprivation was underrepresented, with the current postgraduate GP training practices having more affluent populations. CONCLUSION: Postgraduate training practices had a statistically significant lower deprivation score and did not fully reflect the socioeconomic make-up of wider NI general practice. The results, however, are more favourable than in other areas of the UK and better than undergraduate teaching opportunities in general practice. Health inequalities will worsen if the representation of general practice training in areas of greater socioeconomic deprivation is not increased.

Factors influencing compliance with Hepatitis C treatment in patients transitioning from prison to community-A summary scoping review.

It is well-established that prevalence of Hepatitis C (HCV) infection in prisoners is disproportionately higher than in the general population. While developments in screening and treatment for HCV have enabled greater detection and treatment in prison, release is a high-risk time for HCV infected prisoners returning to the challenges of community living. A scoping review was conducted to examine the evidence on individual, provider and system level factors that influence compliance with HCV treatment in patients transitioning from prison to community. Retrieved articles were screened and those eligible were selected for data extraction. Quantitative and qualitative studies were included. Electronic peer-reviewed databases were searched in February 2022: 140 articles were initially identified of which seven were included in the final review. Six key themes characterized the literature: education, case management and discharge planning, hepatology in-reach nurses, transition clinics, primary care providers and system wide approach. This summary scoping review highlights the paucity of research in this area. There is a need for experimental research to investigate specific interventions, and to understand HCV care-specific barriers and facilitators. A multi-pronged approach is needed to address barriers to healthcare services in general but also specific barriers relating to HCV. Factors that facilitate compliance should also be recognized and amplified across regional HCV elimination strategies.

The Specialist Anesthesiology Workforce in East, Central, and Southern Africa: A Cross-Sectional Study.

BACKGROUND: The populations of the East, Central, and Southern African regions receive only a fraction of the surgical procedures they require, and patients are more likely to die after surgery than the global average. An insufficient anesthetic workforce is a key barrier to safe surgery. The anesthetic workforce in this region includes anesthesiologists and nonphysician anesthesia providers. A detailed understanding of the anesthesiologist workforce in East, Central, and Southern Africa is required to devise strategies for the training, retention, and distribution of the workforce. METHODS: A cross-sectional study of the anesthesiologist workforce of the 8 member countries of the College of Anaesthesiologists of East, Central, and Southern Africa (CANECSA) was undertaken. Data collection took place between May 2020 and September 2020 using existing databases and was validated through direct contact with anesthesiologists and other hospital staff. Primary outcomes were: total number of anesthesiologists in the region and their demographics, including gender, age, country of practice, current work location, country of origin, and country where they received their initial anesthesia qualification. RESULTS: Within the CANECSA member countries, 411 qualified anesthesiologists were identified (0.19 per 100,000 population). The median age was 41 years, and one-third were women. The majority (67.5%) were based in urban areas with a population >1 million people, and most are used by government institutions (61.6%). Most anesthesiologists in the region were trained (89.1%) and currently work (95.1%) in their home country. CONCLUSIONS: The numbers of anesthesiologists in CANECSA member countries are extremely low-about 5% of the minimum recommended figures-and poorly distributed relative to the population. Strategies are required to expand the anesthesia workforce and address maldistribution.

Access to healthcare for people experiencing homelessness in the UK and Ireland: a scoping review.

BACKGROUND: People experiencing homelessness (PEH) have poorer physical and mental health than the general population. They are also more likely to have less access to healthcare. These processes of access can be better understood using Levesque's access framework which addresses both supply (service provision) and demand (user abilities). METHODS: Following the Joanna Briggs Institute (JBI) guidelines, electronic peer-reviewed databases were searched in February 2022 for studies published since 2000 related to access to healthcare for PEH ages 16 and older in the United Kingdom (UK) and Ireland. Retrieved articles were screened and those eligible were selected for data extraction. Qualitative and quantitative studies were included. RESULTS: Fifty-six papers out of 538 identified were selected and aliased. Six main themes were identified: staff education, flexibility of systems, service coordination, patient preparedness, complex health needs and holistic care. These relate to the Levesque access framework. CONCLUSIONS: Improving access to healthcare for PEH requires changes to how services are provided and how service-user abilities are supported.

Do undergraduate general practice placements propagate the 'inverse care law'?

INTRODUCTION: Fifty years since Dr Tudor-Hart's publication of the 'Inverse Care Law', all-cause mortality rates and COVID-19 mortality rates are higher in more deprived areas. Part of the solution is to increase access and availability to healthcare in underserved and deprived areas. This paper examined how socio-economically representative the undergraduate general practice placements are in Northern Ireland (NI). METHODS: A quantitative study of general practices involved in undergraduate medical placements through Queen's University Belfast, comparing practice lists by deprivation indices, examining both blanket deprivation and deprivation quintile trends for teaching and non-teaching practices. RESULTS: Deprivation data for 135 teaching practices were compared against the 323 NI practices. Teaching practices had fewer patients living in the most deprived quintiles compared with non-teaching practices. Fewer practices with blanket deprivation were involved in undergraduate medical education, 32% compared with 42% without blanket deprivation. Practices in areas of blanket deprivation were under-represented as teaching practices, 10%, compared to 14% of NI general practices that met this criterion. CONCLUSION: Practices with blanket deprivation were under-represented as teaching practices. Exposure to general practice in deprived areas is an essential step to improving future workforce recruitment and ultimately to closing the health inequalities gap. Ensuring practices in high-need areas are proportionately represented in undergraduate placements is one way to direct action in addressing the 'Inverse Care Law'. This study is limited to NI and further work is required to compare institutions across the UK and Ireland.

Life-Course Marginalities of Positive Health and Aging: A Participatory Approach Integrating the Lived Experiences of Older Irish Travelers and Older Homeless Adults in Multistakeholder Research Processes.

There is increased emphasis on adopting positive health and aging policy goals for heterogeneous older populations, and recognition of the role that participatory research approaches can play in supporting their implementation. However, questions remain about how to represent the marginalized experiences of some older populations within such processes. With a focus on older Irish ethnic Travelers and older homeless adults as two vulnerable populations in Ireland, this article presents and critically discusses a participatory approach developed to integrate marginalized older adult perspectives on positive health and aging in a multistakeholder research and development process. The qualitative methodology is first detailed, incorporating methods that harness collaboratively derived views and individual narratives (e.g., focus groups; consultation forums; in-depth interviews). Critical reflections on research implementation and specific considerations relevant to these populations are presented (e.g., trust building; one-to-one facilitation), with lessons then drawn for the design of multistakeholder participatory approaches with marginalized older populations.

Demographic characteristics and ocular needs of children attending child eye clinics in Cross River State, Nigeria: a retrospective analysis of clinical records.

OBJECTIVES: To describe the demographic characteristics and ocular needs of children attending four child eye clinics in Cross River State, Nigeria, to inform the development of a sustainable spectacle cross-subsidisation scheme. DESIGN: Retrospective analysis of clinic records. SETTING: Four child eye clinics in Calabar, Ogoja, Ikom and Ugep, Cross River State, Nigeria, from 1 May 2017 to 30 June 2019. PARTICIPANTS: Children who failed the vision screening in schools and visited assigned child eye clinics, and self-referred children from the community. MAIN OUTCOME MEASURES: Children's age, sex, residence, diagnosis, disease management, presenting and corrected visual acuity, history of spectacle wear and magnitude of refractive errors in spherical equivalent in the worse eye. RESULTS: Of all the 3799 records reviewed, data were available for 3774 children (mean age 10.6±4.35 years; 61.6% girls; 69.1% from urban settings); 30.8% (n=1162) of them had vision impairment. Of those children, 71.2% (n=827) were diagnosed with refractive error. For management, 48.6% (n=1833) were prescribed spectacles and 40.5% (n=1527) were prescribed ocular medications. Children prescribed spectacles were significantly more likely to be girls (68.0%, p<0.001), and older than 13 years of age (53.6%, p<0.001). The most common range of spherical equivalent (in the worse eye) was <-0.50 DS to +1.75 DS (51.6%, n=945), followed by >-0.25 DS to -3.00DS (39.7%, n=727). Non-refractive eye conditions such as cataract (33.3%) and corneal disorders (14.1%) contributed to almost half of the total blindness. CONCLUSION: The findings show that spectacles provisions and ocular medications are the primary and secondary needs for children who attended child eye clinics seeking eye care services. Further research is needed to understand parents' willingness to pay for spectacles to set strategic multitier pricing for a sustainable cross-subsidisation scheme.

Establishing a Deep End GP group: a scoping review.

BACKGROUND: GPs working in deprived areas, where all-cause mortality rates are higher compared to less deprived areas, face unique challenges. Despite 50 years passing since Tudor Hart's seminal 'inverse care law' paper, the health inequities gap remains wide. Deep End GP groups are frontline GP-led initiatives working to close this gap and improve the health and lives of those most in need. AIM: To use scoping methodology to map out the process of creating a Deep End GP group. DESIGN & SETTING: A scoping review using Arksey and O'Malley's framework. METHOD: MEDLINE, Embase, Web of Science, and CINAHL databases, as well as non-peer reviewed publications, were searched and articles extracted, reviewed, and analysed according to iterative inclusion criteria. RESULTS: From an initial search number of 35 articles, 16 articles were included in the final analysis. Key steps in starting a Deep End GP group were: quantifying patients and practices in areas of deprivation; establishing GP-led objectives at an initial meeting; regular steering group meetings with close collaboration between academic and frontline general practice, as well as the wider multidisciplinary team; and adopting a local Deep End logo. CONCLUSION: Deep End GP groups have made advances to reduce health impacts of systemic health inequities. Starting a Deep End GP group involves a multidisciplinary approach, beginning with the identification of patients and practices in areas of highest need. The findings and key themes identified in this scoping review will guide interested parties to start the journey to do the same in their locality and to join the Deep End movement.

Developing a tool for the measurement of social exclusion in healthcare settings.

BACKGROUND: Social exclusion is a complex concept that is recognised as a key determinant of health. Many measurement tools developed looked at people from single excluded groups in isolation. We know from experience and literature that exclusion is often intersectional and multi-layered. Therefore, the aim of this research was to develop a social exclusion measurement tool for use in healthcare settings with individuals from any excluded group that would include questions to investigate socioeconomic elements and subjective experiences in their lives. METHODS: Inductive and deductive methods were used to develop the tool. Early drafts were tested with experts (both academic and experts by experience) and modified in line with feedback received. The tool was then piloted with people in the community, and this allowed us to assess the internal consistency and validity of the tool. Exploratory factor analysis was carried out as part of this evaluation. RESULTS: The measurement tool was initially evaluated by 17 academic and 'real world' experts. It was then piloted with seven experts by experience, two gatekeepers and two participants who were presumed not to be excluded, resulting in the development of the final tool. This was then tested with 276 participants (127 presumed excluded, 149 presumed not excluded). The socioeconomic characteristics of these participants were documented, and exploratory factor analysis was carried out on data relating to subjective items. A four-factor structure emerged comprising 22 items. Internal consistency of the factors was high, and their ability to discriminate between the two groups was notable. CONCLUSIONS: A tool for measuring the social exclusion of individuals has been developed by engaging with people from a variety of excluded groups. Socioeconomic indicators were combined with subjective items. The input of experts by experience, academics and others was sought to enhance the tool. The tool was applied to two distinct samples, showing obvious differences both in the socioeconomic items, and the items included in the factor analysis. The potential use of this tool could have positive implications for people who are excluded.

A review of the inclusion of equity stratifiers for the measurement of health inequalities within health and social care data collections in Ireland.

BACKGROUND: Health equity differs from the concept of health inequality by taking into consideration the fairness of an inequality. Inequities may be culturally specific, based on social relations within a society. Measuring these inequities often requires grouping individuals. These groupings can be termed equity stratifiers. The most common groupings affected by health inequalities are summarised by the acronym PROGRESS (Place of residence, Race, Occupation, Gender, Religion, Education, Socioeconomic status, Social capital). The aim of this review was to examine the use of equity stratifiers in routinely collected health and social care data collections in Ireland. METHODS: One hundred and twenty data collections were identified from the Health Information and Quality Authority (HIQA) document, "Catalogue of national health and social care data collections: Version 3.0". Managers of all the data collections included were contacted and a data dictionary was requested where one was not available via the HIQA website. Each of the data dictionaries available was reviewed to identify the equity stratifiers recorded. RESULTS: Eighty-three of the 120 data collections were considered eligible to be included for review. Twenty-nine data dictionaries were made available. There was neither a data dictionary available nor a response to our query from data collection managers for twenty-three (27.7%) of the data collections eligible for inclusion. Data dictionaries were from national data collections, regional data collections and national surveys. All data dictionaries contained at least one of the PROGRESS equity stratifiers. National surveys included more equity stratifiers compared with national and regional data collections. Definitions used for recording social groups for the stratifiers examined lacked consistency. CONCLUSIONS: While there has been much discussion on tackling health inequalities in Ireland in recent years, health and social care data collections do not always record the social groupings that are most commonly affected. In order to address this, it is necessary to consider which equity stratifiers should be used for the Irish population and, subsequently, for agreed stratifiers to be incorporated into routine health data collection. These are lessons that can be shared internationally as other countries begin to address deficits in their use of equity stratifiers.