Interventions to improve access to primary care for inclusion health groups in England: a scoping review.

BACKGROUND: Everyone in England has the right to primary care without financial charges. Nevertheless, evidence shows that barriers remain for inclusion health populations such as vulnerable migrants, people experiencing homelessness, Gypsy, Roma, and Traveller (GRT) communities, and people who sell sex. There is little evidence for what works to improve access. This study was a scoping review of interventions to improve access to mainstream primary care for inclusion health groups in England. METHODS: In this scoping review, we searched databases (Embase, Medline, APA PsychInfo, the Cochrane Collaboration Library, Web of Science and CINAHL) and grey literature sources, including the National Health Service and National Institute for Clinical Excellence, for articles published in English between Jan 1, 2010, and Dec 31, 2020, with no limit on study design. Data were extracted according to inclusion criteria, including interventions taking place in England and targeting people with insecure immigration status, people who sell sex, people experiencing homelessness, and GRT communities. Results were presented in a narrative synthesis. FINDINGS: 39 studies describing one or more interventions were included: four peer-reviewed articles (one randomised trial, two quality improvement projects, and one mixed-methods study protocol) and 25 grey literature items (38 interventions in total). Interventions mostly targeted people with insecure immigration status (17/38, 45%), and a majority (12/38, 32%) took place in London. The most common types of intervention were training, education, and resources (such as leaflets or websites) for patients or staff (25/38, 66%), and most interventions targeted GP registration processes (28/38, 74%). Interventions commonly involved voluntary and community sector organisations (16/38, 42%). Most interventions were not evaluated to understand their effectiveness (23/38, 61%). Sources with evaluations identified staff training, direct patient advocacy, and involvement of people with lived experience as effective elements. INTERPRETATION: Interventions to improve access to primary care for inclusion health groups in England were heterogeneous, commonly undertaken at community level, and developed to serve local inclusion health groups. Considerations for policymakers and practitioners include groups and geographical areas less commonly included in interventions, the elements of positive practice identified in evaluations, and the need for evaluation of future interventions. FUNDING: National Institute for Health and Care Research (NIHR 202050).

Perspectives on registration to primary care from inclusion health groups in England: a mixed-method study.

BACKGROUND: Although everyone living in the UK is entitled to access free primary care within the National Health Service (NHS), evidence shows that people in need of health care are wrongly being refused access. This study aimed to explore the perspectives of individuals from inclusion health groups on primary care registration and accessibility. METHODS: This was a mixed-methods study. From Oct 5, 2022, to Feb 20, 2023, we surveyed 49 people (36 [73%] men; 12 [24%] women) and interviewed 25 other (14 [56%] men; 11 [44%] women) who were service users of the University College London Hospital Find & Treat mobile service. This service included people with lived experience of homelessness, asylum seeking, addiction, selling sex, and irregular immigration. We recruited these participants through hostels for people with ongoing addiction and complex needs, initial asylum accommodation centres, and day shelters. Our research team included two peer researchers. FINDINGS: Of those surveyed, 25 (51%) perceived their access to primary health-care services as good, and 17 (35%) reported obstacles to going to the general practitioner (GP). Participants described multiple barriers to registering for GP surgeries, including a lack of understanding and poor communication with NHS services, a fear of discrimination, and a lack of digital access that prevents information seeking and access to services. Respondents also reported using emergency services instead of primary care because they were more immediately accessible without previous registration. Facilitators to GP registration included one-on-one support and outreach work that helps people navigate into services and know their rights, and the use of specialist GP services, which are perceived as more accepting, especially for people experiencing homelessness. INTERPRETATION: The barriers to registration identified are related to both individual and group level characteristics and produce both similar and divergent needs between different inclusion health groups. The need for additional support during registration was clear, and our work highlights the requirement for interventions to improve access to primary care for underserved groups, as well as coordinated policy action. One-on-one support in particular, either outreach or provided in services where inclusion health groups spend time, appears to be a key facilitator to ensuring comprehensive and fast access to GP services. FUNDING: National Institute for Health and Care Research (NIHR).

The impact of the COVID-19 pandemic on refugees and asylum seekers in Greece: A retrospective analysis of national surveillance data from 2020.

BACKGROUND: Migrants globally, including refugees and asylum seekers, have experienced adverse clinical and socioeconomic impacts of the COVID-19 pandemic. For approximately 56,000 refugees and asylum seekers in Reception and Identification Centers (RICs) and Reception Sites (RS) in Greece, living in severely substandard living conditions, prevention measures have been impossible with limited provision in terms of routine testing, surveillance, and access to healthcare. These migrant populations have experienced prolonged lockdowns and restricted movement since the pandemic began. We aimed to assess the impact of COVID-19 on refugees and asylum seekers in reception facilities in Greece and explore implications for policy and practice. METHODS: A retrospective analysis of policy documents and national surveillance data was conducted to identify COVID-19 outbreaks and estimate incidence among asylum seekers and refugees residing in these camps during the first 9 months of the epidemic in Greece (26th February - 15th November 2020). Incidence proportion (IP) of COVID-19 confirmed cases was calculated for three population groups (refugees and asylum seekers in RICs, refugees and asylum seekers in RSs, and the general population in Greece) during three time periods (first wave, second wave, and overall across the 9-month period). FINDINGS: Twenty-five COVID-19 outbreaks were identified in refugee and asylum seeker reception facilities, with 6 (85.7%) of 7 RICs and 18 (56.3%) of 32 RSs reporting at least one outbreak during the study period. The overall 9-month COVID-19 IP among refugee and asylum seeker populations residing in RSs on the Greek mainland was 1758 cases per 100,000 population; in RICs the incidence was 2052 cases per 100,000 population. Compared to the general population the risk of COVID-19 infection among refugees and asylum seekers in reception facilities was 2.5 to 3 times higher (p-value<0.001). The risk of acquiring COVID-19 infection was higher among refugee and asylum seeker populations in RSs on the Greek mainland (IP ratio: 2.45; 95% CI: 2.25-2.68) but higher still among refugee and asylum seeker populations in RICs in the Greek islands and the land border with Turkey (IP ratio: 2.86; 95% CI: 2.64-3.10), where living conditions are particularly poor. INTERPRETATION: We identified high levels of COVID-19 transmission among refugees and asylum seekers in reception facilities in Greece. The risk of COVID-19 infection among these enclosed population groups has been significantly higher than the general population of Greece, and risk increases as living conditions deteriorate. These data have immediate implications for policy and practice. Strategies are now needed to ensure refugee and asylum seeker populations are included in national response plans to reduce transmission in at-risk groups for COVID-19, alongside inclusion in plans for COVID-19 vaccine roll out.

The current state of immunization against Gram-negative bacteria in children: a review of the literature.

PURPOSE OF REVIEW: Gram-negative bacteria (GNB) are a major cause of infection worldwide and multidrug resistance in infants and children. The major pathogens include Klebsiella pneumoniae, Escherichia coli, Enterobacter spp., Pseudomonas aeruginosa and Acinetobacter baumannii. With new antibiotic options limited, immunization is likely to play a critical role in prevention. This review discusses their epidemiology, the current state of vaccine research and potential immunization strategies to protect children. A comprehensive review of the literature, conference abstracts along with web searches was performed to identify current and investigational vaccines against the major GNB in children. RECENT FINDINGS: Phase I--III vaccine trials have been undertaken for the major Gram-negative bacteria but not in infants or children. E. coli is a common infection in immune-competent children, including neonatal sepsis. Several vaccines are in late-phase clinical trials, with some already licensed for recurrent urinary tract infections in women. Klebsiella spp. causes community-acquired and hospital-acquired infections, including sepsis in neonates and immunocompromised children although no vaccine trials have extended beyond early phase 2 trials. P. aeruginosa is a common pathogen in patients with cystic fibrosis. Phase 1--3 vaccine and monoclonal antibody trials are in progress, although candidates provide limited coverage against pathogenic strains. Enterobacter spp. and A. baumannii largely cause hospital-acquired infections with experimental vaccines limited to phase 1 research. SUMMARY: The current immunization pipelines for the most prevalent GNB are years away from licensure. Similar to incentives for new antibiotics, global efforts are warranted to expedite the development of effective vaccines.

Refugee and asylum seeker usage of primary care: medical student survey at two inner-city general practices.

Refugees and asylum seekers face a number of barriers in accessing healthcare. However, there is a lack of quantitative research examining healthcare usage by refugees and asylum seekers in the UK. Using EMIS data from two GP practices in South London, all patients who had registered as refugees or asylum seekers were identified (n=35). The following data were extracted: date of registration; number of appointments in the 12 months from registration; reason for appointment; secondary care referrals and whether these were attended; and demographic data (age, sex, ethnicity). The mean number of appointments in 12 months was 5.8, and the median was 4. 60% of patients had 5 or fewer appointments. The most common reasons for appointments were psychiatric, musculoskeletal, and dermatological. 51% had a secondary care referral, of which 72% were attended; the most common referrals were to radiology. Of 35 patients, 20 were male and 15 female; the mean age was 32 and the most common ethnic category was Black African. Comparing this data to UK averages suggests that the survey cohort consulted their GP with roughly the same frequency as the average member of the public. There was a higher frequency of psychiatric symptoms, although referrals to secondary psychiatric care were infrequent. The survey cohort attended fewer secondary care referrals than comparable UK-wide data. This suggests that more work is necessary on identifying barriers to healthcare access for this population, and that they present with complex needs. This has implications for policy and for training GPs.

Mortality data in the age of drones ‡.

Mortality data plays an essential role in shaping humanitarian, legal and ethical responses to conflict situations. The rise of drone warfare poses new questions regarding the accuracy and reliability of mortality data in conflict. This article examines some of the methodological and political challenges to collecting mortality data in drone warfare, and how the way in which drones are framed in public discourse contributes to these challenges.