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.

Negative consequences of conflict-related sexual violence on survivors: a systematic review of qualitative evidence.

BACKGROUND: Conflicts exacerbate dynamics of power and inequalities through violence normalization, which acts as a facilitator for conflict-related sexual violence. Literature addressing its negative outcomes on survivors is scant. The aim of this systematic review was to analyze the qualitative evidence reported in scientific literature and focusing on the negative consequences of conflict-related sexual violence on victims' physical, psychological, and social dimensions of health in a gender-inclusive and disaggregated form. METHODS: A literature search was conducted on January 13, 2023 on Pubmed, Scopus, and PsychArticles. The search strings combined two blocks of terms related to sexual violence and conflict. A time filter was applied, limiting the search to studies published in the last ten years. Information regarding the main characteristics and design of the study, survivors and their experience, and about conflict-related sexual violence was collected. The negative consequences of conflict-related sexual violence on the physical, psychological, and social dimension of victims were extracted according to the Biopsychosocial model of health. The review followed the Joanna Briggs Institute methodology for systematic reviews and relied on the Preferred Reporting Items for Systematic reviews and Meta-Analyses. RESULTS: After full text review, 23 articles met the inclusion criteria, with 18 of them reporting negative repercussions on physical health, all of them highlighting adverse psychological outcomes, and 21 disclosing unfavorable social consequences. The negative outcomes described in multiple studies were sexual and reproductive health issues, the most mentioned being pregnancy, manifestations of symptoms attributable to post-traumatic stress disorder, and stigma. A number of barriers to access to care were presented as emerging findings. CONCLUSIONS: This review provided an analysis of the negative consequences of conflict-related sexual violence on survivors, thus highlighting the importance of qualitative evidence in understanding these outcomes and addressing barriers to access to care. Conflict-related sexual violence is a sexual and reproductive health issue. Sexuality education is needed at individual, community, and provider level, challenging gender norms and roles and encompassing gender-based violence. Gender-inclusive protocols and services need to be implemented to address the specific needs of all victims. Governments should advocate for SRHRs and translate health policies into services targeting survivors of CRSV.

Vulnerability of migrant women during disasters: a scoping review of the literature.

BACKGROUND: Disasters have an unequal impact on the population because of differences in conditions of vulnerability, exposure, and capacity. Migrants and women are among the groups that are at greater risk for and disproportionately affected by disasters. However, despite the large body of evidence that analyzes their vulnerability separately, disaster research that targets migrant women is scant. The aim of this scoping review was to analyze the published scientific literature concerning the vulnerability of migrant women and the consequent negative impact they experience during disasters. METHODS: A literature search was conducted on December 15th, 2021 on Pubmed, Scopus, and Web of Science databases. No time filter was applied to the search. Information regarding the article's main characteristics and design, migrant women and their migration experience, as well as about the type of disaster was collected. The factors responsible for the vulnerability of migrant women and the negative outcomes experienced during a disaster were extracted and inductively clustered in main themes reflecting several vulnerability pathways. The review followed the Joanna Briggs Institute methodology for scoping reviews and relied on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR). RESULTS: After full text review, 14 articles met the inclusion criteria. All of them adopted a qualitative methodology and focused on COVID-19. The pandemic negatively affected migrant women, by triggering numerous drivers that increased their level of exposure and vulnerability. Overall, six vulnerability factors have been identified: legal status, poverty conditions, pre-existing health conditions, limited agency, gender inequality and language and cultural barriers. These resulted in nine impacts: worsening of mental health status, poor access to care, worsening of physical health conditions, fraud, exacerbation of poverty, gender-based violence, jeopardization of educational path, and unfulfillment of their religious needs. CONCLUSIONS: This review provided an analysis of the vulnerability factors of migrant women and the pathways leading to negative outcomes during a disaster. Overall, the COVID-19 pandemic demonstrated that health equity is a goal that is still far to reach. The post-pandemic era should constitute the momentum for thoroughly addressing the social determinants of health that systematically marginalize the most vulnerable groups.

Real requirements of nursing activities and patient-related factors related to nursing overload in an internal medicine department.

Adequate nursing care can be decisive for the outcome of a patient admitted to an internal medicine ward. Individual prediction of nursing activity at the time of a patient's admission could improve the work process. This study aimed to assess the objectively assessed nursing requirements of patients admitted to a medical setting and to identify clinical factors that correlate with high demands. This is a prospective and pragmatic observational study that enrolled patients admitted to the Internal Medicine ward at the Altovicentino Civil Hospital (Italy) between September 1 and December 31, 2022. Nursing activities were recorded for the first 3 days of hospitalization and standardized as performance/5 min/patient. Patients requiring more than the 75th percentile of performance/5 min/patient were considered nursing over-activities. Multivariable models were used to assess patient-related risk factors associated with nursing over-activity. This study enrolled 333 patients (mean age: 74.2; 55.6% male). Their mean Charlson Comorbidity Index (CCI), Clinical Frailty Scale (CFS), Chronic Barthel Index, and Sistema Informtativo della Performance Infermieristica (SIPI) scores were 5.3, 4.2, 62.4, and 53.7, respectively. Mean National Early Warning System (NEWS) on admission was 3.9 (standard deviation: 2.8). A median of 73 (interquartile range [IQR]: 54-109) nursing care activities/5 min/patient were performed. NEWS score (odds ratio [OR]: 1.372, 95% confidence interval [95%CI]: 1.216-1.547, p < 0.001) and Acute Barthel Index (OR: 0.983, 95%CI: 0.967-0.999, p = 0.041) were independent risk factors for nursing over-activities. NEWS and the Acute Barthel Index could help reorganize nursing resources within internal medicine wards, allowing for an equal distribution between patients who require more resources and those who require less.

Is the National Early Warning Score able to identify nursing activity load? A prospective observational study.

BACKGROUND: The National Early Warning Score scale correlates well with the intensity of the patient's acute condition. It could also correlate with the nursing activity load and prove useful in defining and redistributing nursing resources based on the acuity of patients. AIM: To assess whether patients' National Early Warning Score at hospital admission correlates with objective nursing demands and can be used to optimize the distribution of available care resources. METHODS: This single-center prospective study included patients admitted to the Department of Internal Medicine at the Civil Hospital in Altovicentino (Italy) between September 1 and December 31, 2022. Nursing activities were recorded for the first three days after admission and standardized to the daily mean as performance/5 min/patient/day. Linear regression was used to assess the correlation between nursing demands for different National Early Warning Scores. RESULTS: This study included 333 patients. Their mean National Early Warning Score was 3.9 (standard deviation: 2.9), with 61 % (203/333) in the National Early Warning Score <5 category, 19.5 % (65/333) in the National Early Warning Score 5-6 category, and 19.5 % (65/333) in the National Early Warning Score >6 category. Their average daily care requirements increased from 22 (16-30) activities/5 min/patient/day in the low National Early Warning Score category to 30 (20-39) activities/5 min/patient/day in the intermediate National Early Warning Score category (p < 0.001) and 35 (23-45) activities/5 min/patient/day in the high National Early Warning Score category (p < 0.001). CONCLUSION: The National Early Warning Score correlates with nursing care activities for patients with an acute condition and can be used to optimize the distribution of available care resources.

Access to care in Afghanistan after august 2021: a cross-sectional study exploring Afghans' perspectives in 10 provinces.

BACKGROUND: The Taliban takeover in August 2021 ended a decades-long conflict in Afghanistan. Yet, along with improved security, there have been collateral changes, such as the exacerbation of the economic crisis and brain drain. Although these changes have altered the lives of Afghans in many ways, it is unclear whether they have affected access to care. This study aimed to analyse Afghans' access to care and how this access has changed after August 2021. METHODS: The study relied on the collaboration with the non-governmental organisation EMERGENCY, running a network of three hospitals and 41 First Aid Posts in 10 Afghan provinces. A 67-item questionnaire about access to care changes after August 2021 was developed and disseminated at EMERGENCY facilities. Ordinal logistic regression was used to evaluate whether access to care changes were associated with participants' characteristics. RESULTS: In total, 1807 valid responses were returned. Most respondents (54.34%) reported improved security when visiting healthcare facilities, while the ability to reach facilities has remained stable for the majority of them (50.28%). Care is less affordable for the majority of respondents (45.82%). Female respondents, those who are unmarried and not engaged, and patients in the Panjshir province were less likely to perceive improvements in access to care. CONCLUSIONS: Findings outline which dimensions of access to care need resource allocation. The inability to pay for care is the most relevant barrier to access care after August 2021 and must therefore be prioritised. Women and people from the Panjshir province may require ad hoc interventions to improve their access to care.

Exploring barriers to access to care following the 2021 socio-political changes in Afghanistan: a qualitative study.

BACKGROUND: Following the change of government in August 2021, the social and economic landscape of Afghanistan deteriorated into an economic and humanitarian crisis. Afghans continue to struggle to access basic healthcare services, making Universal Health Coverage (UHC) in the country a major challenge. The aim of this study was to perform a qualitative investigation into the main access to care challenges in Afghanistan and whether these challenges have been influenced by the recent socio-political developments, by examining the perspectives of health professionals and hospital directors working in the country. METHODS: Health professionals working in facilities run by an international non-government organisation, which has maintained continuous operations since 1999 and has become a key health reference point for the population, alongside the public health system, and hospital directors working in government hospitals were recruited to participate in an in-depth qualitative study using semi-structured interviews. RESULTS: A total of 43 participants from ten provinces were interviewed in this study. Four issues were identified as critical barriers to achieving UHC in Afghanistan: (1) the lack of quality human resources; (2) the suboptimal management of chronic diseases and trauma; (3) the inaccessibility of necessary health services due to financial hardship; (4) the unequal accessibility of care for different demographic groups. CONCLUSIONS: Health professionals and hospital directors shed light on weaknesses in the Afghan health system highlighting chronic issues and issues that have deteriorated as a result of the 2021 socio-political changes. In order to improve access to care, future healthcare system reforms should consider the perspectives of Afghan professionals working in the country, who are in close contact with Afghan patients and communities.

Development and Validation of a New Tool to Improve the Accuracy of the Hospital Mass-Casualty Incident Response Plan Activation: The PEMAAF Score.

INTRODUCTION: Effective response to a mass-casualty incident (MCI) entails the activation of hospital MCI plans. Unfortunately, there are no tools available in the literature to support hospital responders in predicting the proper level of MCI plan activation. This manuscript describes the scientific-based approach used to develop, test, and validate the PEMAAF score (Proximity, Event, Multitude, Overcrowding, Temporary Ward Reduction Capacity, Time Shift Slot [Prossimità, Evento, Moltitudine, Affollamento, Accorpamento, Fascia Oraria], a tool able to predict the required level of hospital MCI plan activation and to facilitate a coordinated activation of a multi-hospital network. METHODS: Three study phases were performed within the Metropolitan City of Milan, Italy: (1) retrospective analysis of past MCI after action reports (AARs); (2) PEMAAF score development; and (3) PEMAAF score validation. The validation phase entailed a multi-step process including two retrospective analyses of past MCIs using the score, a focus group discussion (FGD), and a prospective simulation-based study. Sensitivity and specificity of the score were analyzed using a regression model, Spearman's Rho test, and receiver operating characteristic/ROC analysis curves. RESULTS: Results of the retrospective analysis and FGD were used to refine the PEMAAF score, which included six items-Proximity, Event, Multitude, Emergency Department (ED) Overcrowding, Temporary Ward Reduction Capacity, and Time Shift Slot-allowing for the identification of three priority levels (score of 5-6: green alert; score of 7-9: yellow alert; and score of 10-12: red alert). When prospectively analyzed, the PEMAAF score determined most frequent hospital MCI plan activation (>10) during night and holiday shifts, with a score of 11 being associated with a higher sensitivity system and a score of 12 with higher specificity. CONCLUSIONS: The PEMAAF score allowed for a balanced and adequately distributed response in case of MCI, prompting hospital MCI plan activation according to real needs, taking into consideration the whole hospital response network.

The Correlation of Arterial Stiffness Parameters with Aging and Comorbidity Burden.

The aim of the study was to evaluate the relationships between carotid-femoral pulse wave velocity (PVW-cf), cardio-ankle vascular index (CAVI) and CAVI0 (which is a mathematical elaboration of CAVI, theoretically less dependent on blood pressure), age and comorbidity burden. Furthermore, 183 patients (119 female, mean age 67.5 ± 14.3 years) referred to the Geriatric Ward and Outpatient Clinic at Verona University Hospital were included; demographic, clinical and blood analysis data were collected. Charlson Comorbidity Index (CCI), PVW-cf, CAVI and CAVI 0 were obtained. Significant correlations were found between CAVI, CAVI0, PVW-cf and both age (r = 0.698, r = 0.717, r = 0.410, respectively p < 0.001 for all) and CCI, (r = 0.654; r = 0.658; r = 0.448 respectively and p < 0.001 for all), still significant after adjustment for several variables. In a stepwise multiple regression model, considering several variables, CCI was the only predictor of PWV-cf, whereas age and CCI were significant predictors of both CAVI and CAVI 0. In conclusion, all arterial stiffness indexes are associated with CCI and aging; the latter correlation is more evident for CAVI and CAVI 0 than for PVW-cf. Arterial stiffness parameters can complement the characterization of patients affected by a remarkable comorbidity burden across aging; arterial stiffening might mirror the complexity of these individuals.

Availability and Characteristics of Humanitarian Health Education and Training Programs: A Web-Based Review.

INTRODUCTION: Education and training programs are critical to achieve personnel capacity building and professionalization in the rapidly growing humanitarian health sector. Thus, this study aimed to describe the status of humanitarian health education and training programs world-wide. METHODS: A web-based analysis was conducted to identify the available humanitarian health programs. The following characteristics of the training programs were described: geographical location, target audience, prerequisite, qualification, curriculum, content, length, modality of delivery, teaching and assessment methods, and tuition fee. RESULTS: The search identified a total number of 142 training programs, most of them available in few countries of the global North. Only seven percent of the identified programs qualified for a master's degree in humanitarian health. Public health was the most identified content (47.2%). Approximately one-half of the training programs (50.7%) were delivered face-to-face. Theoretical knowledge was the most common method used for teaching and assessment. The duration of the training and tuition fees were different for different programs and qualifications, while target audience, prerequisite, and curriculum design were often vaguely described or missing. CONCLUSIONS: The study shows a global inequality in access to humanitarian health training programs due to financial and geographical constraints. The study also reveals gaps in program contents, as well as teaching and assessment methods, all issues that could be addressed by developing cost-effective e-learning and online simulation programs. Lastly, the data from this study provide a learning tool that can be used by humanitarian health educators and training centers to further define and standardize the requirements and competencies of humanitarian health professionals.