Exploring differences in the utilization of the emergency department between migrant and non-migrant populations: a systematic review.

BACKGROUND: Migrants face several barriers when accessing care and tend to rely on emergency services to a greater extent than primary care. Comparing emergency department (ED) utilization by migrants and non-migrants can unveil inequalities affecting the migrant population and pave the way for public health strategies aimed at improving health outcomes. This systematic review aims to investigate differences in ED utilization between migrant and non-migrant populations to ultimately advance research on migrants' access to care and inform health policies addressing health inequalities. METHODS: A systematic literature search was conducted in March 2023 on the Pubmed, Scopus, and Web of Science databases. The included studies were limited to those relying on data collected from 2012 and written in English or Italian. Data extracted included information on the migrant population and the ED visit, the differences in ED utilization between migrants and non-migrants, and the challenges faced by migrants prior to, during, and after the ED visit. The findings of this systematic review are reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines. RESULTS: After full-text review, 23 articles met the inclusion criteria. All but one adopted a quantitative methodology. Some studies reported a higher frequency of ED visits among migrants, while others a higher frequency among non-migrants. Migrants tend to leave the hospital against medical advice more frequently than the native population and present at the ED without consulting a general practitioner (GP). They are also less likely to access the ED via ambulance. Admissions for ambulatory care-sensitive conditions, namely health conditions for which adequate, timely, and effective outpatient care can prevent hospitalization, were higher for migrants, while still being significant for the non-migrant population. CONCLUSIONS: The comparison between migrants' and non-migrants' utilization of the ED did not suggest a clear pattern. There is no consensus on whether migrants access EDs more or less than non-migrants and on whether migrants are hospitalized at a higher or lower extent. However, migrants tend to access EDs for less urgent conditions, lack a referral from a GP and access the ED as walk-ins more frequently. Migrants are also discharged against medical advice more often compared to non-migrants. Findings of this systematic review suggest that migrants' access to care is hindered by language barriers, poor insurance coverage, lack of entitlement to a GP, and lack of knowledge of the local healthcare system.

Impact of Ebola and COVID-19 on maternal, neonatal, and child health care among populations affected by conflicts: a scoping review exploring demand and supply-side barriers and solutions.

INTRODUCTION: Armed conflicts have a severe impact on the health of women and children. Global health emergencies such as pandemics and disease outbreaks further exacerbate the challenges faced by vulnerable populations in accessing maternal, neonatal, and child healthcare (MNCH). There is a lack of evidence that summarizes the challenges faced by conflict-affected pregnant women, mothers, and children in accessing MNCH services during global health emergencies, mainly the Ebola and COVID-19 pandemics. This scoping review aimed to analyze studies evaluating and addressing barriers to accessing comprehensive MNCH services during Ebola and COVID-19 emergencies in populations affected by conflict. METHODS: The search was conducted on PubMed, Scopus, and Web of Science databases using terms related to Ebola and COVID-19, conflicts, and MNCH. Original studies published between 1990 and 2022 were retrieved. Articles addressing the challenges in accessing MNCH-related services during pandemics in conflict-affected settings were included. Thematic analysis was performed to categorize the findings and identify barriers and solutions. RESULTS: Twenty-nine studies met the inclusion criteria. Challenges were identified in various MNCH domains, including antenatal care, intrapartum care, postnatal care, vaccination, family planning, and the management of childhood illnesses. Ebola-related supply-side challenges mainly concerned accessibility issues, health workforce constraints, and the adoption of stringent protocols. COVID-19 has resulted in barriers related to access to care, challenges pertaining to the health workforce, and new service adoption. On the demand-side, Ebola- and COVID-19-related risks and apprehensions were the leading barriers in accessing MNCH care. Community constraints on utilizing services during Ebola were caused by a lack of trust and awareness. Demand-side challenges of COVID-19 included fear of disease, language barriers, and communication difficulties. Strategies such as partnerships, strengthening of health systems, service innovation, and community-based initiatives have been employed to overcome these barriers. CONCLUSION: Global health emergencies amplify the barriers to accessing MNCH services faced by conflict-affected populations. Cultural, linguistic, and supply-side factors are key challenges affecting various MNCH domains. Community-sensitive initiatives enhancing primary health care (PHC), mobile clinics, or outreach programs, and the integration of MNCH into PHC delivery should be implemented. Efforts should prioritize the well-being and empowerment of vulnerable populations. Addressing these barriers is crucial for achieving universal health coverage and the Sustainable Development Goals.

Health systems resilience in fragile and conflict-affected settings: a systematic scoping review.

BACKGROUND: Health systems resilience (HSR) research is a rapidly expanding field, in which key concepts are discussed and theoretical frameworks are emerging with vibrant debate. Fragile and conflict-affected settings (FCAS) are contexts exposed to compounding stressors, for which resilience is an important characteristic. However, only limited evidence has been generated in such settings. We conducted a scoping review to: (a) identify the conceptual frameworks of HSR used in the analysis of shocks and stressors in FCAS; (b) describe the representation of different actors involved in health care governance and service provision in these settings; and (c) identify health systems operations as they relate to absorption, adaptation, and transformation in FCAS. METHODS: We used standard, extensive search methods. The search captured studies published between 2006 and January 2022. We included all peer reviewed and grey literature that adopted a HSR lens in the analysis of health responses to crises. Thematic analysis using both inductive and deductive approaches was conducted, adopting frameworks related to resilience characteristics identified by Kruk et al., and the resilience capacities described by Blanchet et al. RESULTS: Thirty-seven studies met our inclusion criteria. The governance-centred, capacity-oriented framework for HSR emerged as the most frequently used lens of analysis to describe the health responses to conflict and chronic violence specifically. Most studies focused on public health systems' resilience analysis, while the private health sector is only examined in complementarity with the former. Communities are minimally represented, despite their widely acknowledged role in supporting HSR. The documentation of operations enacting HSR in FCAS is focused on absorption and adaptation, while transformation is seldom described. Absorptive, adaptive, and transformative interventions are described across seven different domains: safety and security, society, health system governance, stocks and supplies, built environment, health care workforce, and health care services. CONCLUSIONS: Our review findings suggest that the governance-centred framework can be useful to better understand HSR in FCAS. Future HSR research should document adaptive and transformative strategies that advance HSR, particularly in relation to actions intended to promote the safety and security of health systems, the built environment for health, and the adoption of a social justice lens.

The COVID-19 pandemic response and its impact on post-corona health emergency and disaster risk management in Italy.

Background: The COVID-19 pandemic has profoundly impacted societies, influencing countries' Health Emergency and Disaster Risk Management (H-EDRM) systems. By taking Italy as a case study, this research aimed to investigate the response to the COVID-19 pandemic, focusing on the changes made to the existing H-EDRM system, with an emphasis on human resources, health service delivery, and logistics and the forward-looking strategies for the next health emergencies and disasters. Methods: We performed a retrospective observational case study using qualitative methodology. Data was collected via semi-structured interviews and analyzed considering the World Health Organization (WHO) H-EDRM framework. Multiple interviewees were selected to obtain a holistic perspective on the Italian response to COVID-19. Stakeholders from five different sectors (policy-making, hospital, primary care, third sector, lay community) from three of the most impacted Italian regions (Piemonte, Lombardia, and Veneto) were interviewed, for a total of 15 respondents. Results: Results on human resources revolved around the following main themes: personnel, training, occupational health, and multidisciplinary work; results on health service delivery encompassed the following main themes: public health, hospital, and primary care systems; results on logistics dealt with the following themes: infrastructures, supplies, transports, and communication channels. Lessons learned stressed on the importance of considering pragmatic disaster preparedness strategies and the need for cultural and structural reforms. Stakeholders mentioned several implications for the post-pandemic H-EDRM system in Italy. Conclusions: Findings highlight that the interconnection of sectors is key in overcoming pandemic-related challenges and for future disaster preparedness. The implications for the Italian H-EDRM system can inform advancements in disaster management in Italy and beyond.