Making health equity a reality through research, education, policy and practice
Research in Progress
Dr. Patrick O’Donnell is currently undertaking a scoping review related to measuring social exclusion in healthcare settings. This scoping review seeks to address how are social exclusion and social inclusion defined internationally in relation to health, and how are social exclusion and social inclusion measured at the individual level in healthcare settings.
Patrick was recently awarded the inaugural Dr. Jim Slein Research Bursary in Substance Misuse/Health Inequity for this work.
Researchers at the ICGP and SafetyNet recently presented an analysis of the health status of Syrian Refugees on arrival in Ireland at the European General Practice Research Network (EGPRN) Conference in Dublin. This was based on a secondary analysis of data recorded by Safetynet - mobile health unit- on arrival of refugees in Ballaghaderreen accommodation centre.
Safetynet’s Mobile Health and Screening Unit (MHSU) is a new service provided by Safetynet Primary Care in partnership with HSE Social Inclusion that provides health assessments, primary care and supports integration into routine services for vulnerable groups. The unit consists of a vehicle with consultation room and x-ray, a GP, nurse and administrative support. Health assessments were offered to all new arrivals and were conducted by a GP and nurse with interpreters. They included general health questions, mental health, reproductive health, dental needs and bloods for HBsAg, anti HBs, anti HBc, Hep C and HIV antibodies, syphilis and rubella and varicella for women of child bearing age.
Key findings were that on arrival Syrian refugees have a high level of health needs. Providing health assessments and primary care services close to the time of arrival can help prevent local services becoming overwhelmed. Expediating medical cards for this group ensures they can access services in a timely manner. Non communicable diseases are more prevalent in this population than communicable diseases. Dental needs were high and a dental assessment could help prioritise the most urgent cases if local services are stretched. Mental health needs were not higher than expected, but symptoms of trauma in particular are likely to develop later after resettlement and local services need to be prepared.
The PHE group, led by Dr. Claire Collins ICGP are also undertaking further research with Syrian Refugees in Ireland. This consists of self-completed questionnaires to refugees who have recently arrived in the country asking them to self-report their health status. The questionnaire will ask respondents to provide their sociodemographic and migration information, health status, health related quality of life, and unmet health needs. This is a mirror of work currently being carried out in Norway. The results of the GP database will be compared to the results of the IOM health assessment, the DoJ health summary and the questionnaires. The questionnaires will also be compared to data from Syrian refugees in Norway, which will provide context and generalisability.
How do variations in definitions of “migrant” and their application influence the access of migrants to health care services?
This paper seeks to answer two important questions. Who are we talking about when we refer to ‘migrants’? And what if any impact of health care provision is affected by those different definitions and interpretations?
The study reviews 169 studies from 39 of the 53 WHO European Region Countries. Publications in both English and Russian language were examined. The study found that there was no universally accepted definition for migrant at an international level and the heterogeneity of definitions used limits comparability of routinely collected data. Legal status was one of the most significant factors determining access to affordable and adequate health services for migrants in a country.
The authors point out that across the WHO European Region the distinction that States apply to the category of ‘migrant’ impacts the level and quality of statutory health care entitlements and provision. Often referred to as a homogenous group with similar needs, the spectrum of people within the European Region who fall under the umbrella of migrant ranges from unaccompanied minor asylum seekers & trafficked sex workers to highly skilled, educated and mobile IT and health care professionals. These cohorts of people and their health needs can be radically different. The authors conclude that this wide variation in definitions ‘without common criteria for sampling and inclusion of migrants’ makes comparison of migrant health across Member States challenging.
Identifying preferred terms for migrants, seeking consensus on important migration-related variables for collection across health information systems and progressing towards universal access to health care across the WHO European Region are recommended.
Source: Hannigan A, O’Donnell P, O’Keeffe M, MacFarlane A. How do variations in definitions of “migrant” and their application influence the access of migrants to health care services? Copenhagen: WHO Regional Office for Europe; 2016 (Health Evidence Network (HEN) synthesis report 46).
Posted December 2016
Migrant Health - The Health of Asylum Seekers, Refugees and Relocated Individuals
The authors note that the current model of care for many programme refugees is one whereby individual general practitioners have been expected to voluntarily assume responsibility for the care of dozens of newly arrived migrants in a single community, without additional resources or financial support. This model they say lacks foresight, and is not sustainable.
The Faculty’s timely and succinct paper makes recommendations to Government covering;
Screening for chronic and infectious diseases and mental health issues and referral to specialised services as required.
Access to primary care, sexual and reproductive health care and mental health services, which are culturally and linguistically competent.
Ring fenced funding for additional vaccinations for asylum seekers and refugees so that all necessary vaccines can be administered in a timely manner.
Translation services to be readily available in primary care
Specialised services, such as psychotherapy for survivors of torture and other traumas,
The need for a formal assessment of the broader health needs of asylum seekers, refugees, and relocated individuals in Ireland.
Greater investment by the Irish government in health services for asylum seekers, refugees, and relocated individuals.
The acceleration of the processing of asylum applications.
Intersectoral collaboration to ensure the development of health and social policies that promote inclusion and integration of all migrants into Irish society.
Durable solutions for the housing, education, employment and health needs of all asylum seekers
Migrant Health- The Health of Asylum Seekers, Refugees and Relocated Individuals
June 2016. Faculty of Public Health Medicine. Royal College of Physicians Ireland.
Posted December 2016
Transition - from Direct Provision to life in the community.
The experiences of those who have been granted refugee status, subsidiary protection or leave to remain in Ireland.
By Dr Muireann Ni Raghallaigh & Dr Maeve Foreman, June 2016.
This Irish Research Council funded report is a unique and useful collaboration between UCD, TCD, the Irish Refugee Council, regional NGOs and Asylum Seekers. The report describes the range of challenges, hurdles and needs that asylum seekers face. From a health perspective there are repeated references and incidences of the negative impact that the current Direct Provision model has on the on-going mental health of people in the system and the inappropriateness of the system to assist with recovery from traumatic events that occurred in their home country or during their journey to asylum.
The authors note that currently there is only one primary care social worker nationally with the responsibility for providing services to Direct Provision centres and that such professional supports are necessary to facilitate integration.
“These professionals can provide practical and emotional support to individuals and families and can develop essential links between the Direct Provision centre and the local community, thus facilitating integration and easing the transition process”.
The collaborative report makes more than 25 practicable, specific and realistic recommendations to Government in order to assist this vulnerable group from the time they arrive in Ireland as asylum seekers to their transition to permanent residents or citizens.
Posted December 2016
Domestic Violence During Pregnancy – GP Survey Report April 2016.
By Ms Marie T. O’Shea, Dr Claire Collins, Dr Ailis Ni Rhian & Dr Miriam Daly
This survey report was conducted by the Irish College of General Practitioners (ICGP) and funded by Cosc (The National Office for the Prevention of Domestic, Sexual and Gender-based Violence) with input from the HSE Social Inclusion as part of a project whose aim was to raise awareness and increase the recognition of domestic violence against women during pregnancy at primary care level.
Specifically, the objectives of this survey were:
To assess the awareness levels and current practice of General Practitioners (GPs) regarding the prevalence of domestic violence during pregnancy
To identify GP knowledge gaps and related learning needs in relation to domestic violence during pregnancy
To establish GP attitudes and barriers to identifying and discussing with pregnant patients domestic violence during pregnancy.
The response rate from the ICGP membership was 18% amounting to 530 completed surveys. Over half (57%) of the surveys returned were from female GPs a slightly higher representation than among ICGP membership (45%).
The key findings
Of those surveyed, 63% had never asked a pregnant woman about domestic violence and 99% of respondents never did this routinely.
Almost 20% of GPs had treated between one and five women who disclosed instances of domestic abuse during their pregnancy, either spontaneously or as a result of GP questioning.
Just over half of respondents noted improved outcomes for their patient following intervention, while 47% who had intervened noted no change in their patient’s circumstances.
The majority of respondents (84%) had did not receive training or education in managing domestic violence at undergraduate level, during the course of their GP training (57%) or during their continuing medical education (76%).
Approximately 65% of respondents were unaware of any guidance document for GPs on the subject of domestic violence.
The vast majority of respondents indicated that they would welcome further education in the area of domestic violence during pregnancy.
A large portion (63%) of respondents agreed that additional resources would be helpful for improved management of cases in general practice.
Recommendations are made in the report specifically related to guideline awareness and education based on the key findings, which suggest a need for:
Increased GP clinical knowledge of domestic violence during pregnancy.
Improved GPs’ confidence in addressing domestic violence during pregnancy with their patients.
Further promotion of the ICGP Domestic Violence: a guide for general practice Quick Reference Guide (2014).
Further education on, but not limited to:
- Signs and symptoms of domestic violence during pregnancy.
- Appropriate referral options for women who disclose.
- How to respond to a disclosure of domestic violence during pregnancy.
- Legal issues and reporting requirements.
Full report is available at asset.cfm (icgp.ie)
Posted December 2016
Evaluation of the HSE Naloxone Demonstration Project.
by Anne Clarke & Anne Eustace of Eustace Patterson Ltd.
An evaluation report of the Naloxone Project was launched by Minister of State, Catherine Byrne TD on International Overdose Day (31st August 2016).
Naloxone is an opioid antagonist that can temporarily reverse the effects of opioid overdose. This can provide a window of opportunity to prolong a life while waiting for emergency services to arrive and medically treat a person who has overdosed. Naloxone can be administered intramuscularly, intravenously or by nasal spray. The Demonstration Project used the intramuscular version of the product. This project has been implemented in four locations, Dublin, Cork, Limerick and Waterford/South East since its commencement in February 2015.
During the project, close to 600 people received training and 31 people participated in the ‘Train the Trainers’ component of the project. The evaluation notes that five administrations of naloxone occurred resulting in the prevention of five potentially fatal overdoses.
A total of 95 prescriptions of Naloxone were issued during the demonstration project. This involved six GPs in Dublin and Limerick. No prescriptions were issued from the two other project locations.
Feedback from stakeholders points to the need to adopt a more measured and strategic approach to consultation in the next phase. The drawing in of the full suite of stakeholders, especially organisations and/or stakeholder with reservations about the Project was seen as an important success determinant. Involvement of service users’ networks and organisations could be strengthened as could consultation pre implementation through formal and structured engagement with specific groups, e.g. service users, family members, GPs, trainers, etc. This would benefit from the support of a centre point of communication to manage on-going consultation, briefings and PR during implementation.
This initiative was led by the HSE National Social Inclusion Office, in partnership with key stakeholders, including Ana Liffey Drugs Project, Merchants Quay Ireland, National Family Support Network and UISCE. The launch of the evaluation report was also linked with an innovative photo exhibition in Temple Bar showing strong images of families and services users and was hosted by the HSE
The full version of the evaluation is at; www.hse.ie/eng/services/publications/SocialInclusion/addiction/Naloxonedemoproject.pdf
Posted December 2016
Hard Edges Mapping – Mapping Severe and Multiple Disadvantage in England.
By Glen Bramley & Suzanne Fitzpatrick with Jenny Edwards, David Ford, Sarah Johnsen, Filip Sosenko & David Watkins.
This report by the Langly Chase Foundation draws together previously separate datasets from homelessness, offending and substance misuse treatment systems. It also takes into account available data around mental health and poverty. The report delivers the latest and most comprehensive statistics on people facing severe and multiple disadvantage: where they live, what their lives are like, how effectively they are supported by services, and the economic implications of the disadvantages they face.
The report finds there is a huge overlap between the offender, substance misusing and homeless populations. For example, two thirds of people using homeless services are also either in the criminal justice system or in drug treatment in the same year.
Other interesting findings include;
Severe and multiple disadvantage predominately affects white males aged 25 – 44.
42% off people facing severe and multiple disadvantages had run away as children.
Only 16% of people facing severe and multiple disadvantages consider their quality of life as good, compared to over 70% of the general population.
Local authorities which report the highest rates of people facing severe and multiple disadvantages are mainly in the North of England, seaside towns and certain central London boroughs. However, even in the richest areas, there is no part of England that is untouched by the issue of severe and multiple disadvantages.
The report calls for far-reaching changes to address this issue from Government, local authorities and the voluntary sector.
Full report is accessible on;
Posted December 2016
A new report on HIV and migrants in Ireland produced by a sub-group of the Public Health Medicine HIV/STI Special Interest Group.
Summary by Dr Sarah Doyle
Some of the main findings include the following:
During the period from 2002 to 2013, there were 4,331 new HIV diagnoses reported in Ireland. Of these, 49% were among migrants. The majority of new diagnoses among migrants (32%) originated from sub-Saharan Africa. The rate of new HIV diagnoses among male migrants from Latin America has increased, around twentyfold, between 2005 (25/100,000) and 2013 (506/100,000).
Among migrants, the male-to-female ratio has varied considerably, from 0.5 among migrants from sub-Saharan Africa to 8.0 among migrants originating from Latin America and North America. While the rates among females born in sub-Saharan Africa have decreased, they remain very high (170 per 100,000 in 2013). Heterosexual transmission was the most commonly reported route of transmission for migrant cases from sub-Saharan Africa and Eastern Europe. Sex between men was the most frequent route of transmission reported among migrants from Latin America, Western Europe and Central Europe. The proportion of cases diagnosed late and with advanced disease is highest among migrants born in sub-Saharan Africa.
From the literature it is reported that, across the lifecourse, migrants are often diagnosed or present at a later stage for healthcare than those born in Ireland (or the UK). Many opportunities for testing are missed in the year prior to diagnosis because of low awareness among health care professionals. For women in the UK and Ireland with HIV, the risk of late booking in pregnancy is higher in those of black African or other black ethnicity, than it is for those of white ethnicity. HIV infected children in the UK and Ireland are more likely to be the offspring of African mothers, and to be diagnosed later in the course of their disease.
The prevalence of HIV among migrants in Ireland is not known, but a couple of studies report on prevalence in screened populations of asylum seeking and refugee women, respectively. The percentage of asylum seekers tested for HIV in Balseskin reception centre who test positive is 1.7%. In one study of refugee women attending a maternity hospital 3% tested positive for HIV.
There are a variety of structural, cultural and personal constraints to HIV testing among migrants in Ireland. In addition, cost, location and organisation of testing and treatment services and waiting times for treatment have been identified, by migrants, as barriers to accessing and utilising services. Migrants perceive social stigma in the wider community to be a hindrance to presenting for HIV testing.
Beyond the period of review in this report (in 2015 and 2016), the marked increase in new notifications of HIV in men who have sex with men (MSM), particularly in those from Latin America, has been sustained, and increased. As you may know, a multi-disciplinary group has been established at a national level to respond to this increase. However, there has been no such focus on migrants from Sub-Saharan Africa.
The recommendations of the report include using the findings to inform HIV prevention programmes for migrants, with two distinct migrant groups that warrant targeted approaches, identified: heterosexuals from sub-Saharan Africa and men who have sex with men. Other recommendations include improving reporting on HIV in migrants; identification of ways to increase testing for HIV in migrants and of ensuring earlier presentation to health services of those with HIV; and improving awareness of national guidance on testing for infectious diseases in migrants among healthcare professionals. Engagement with the HSE Sexual Health and Crisis Pregnancy Programme and relevant NGOs is suggested as a mechanism to do this.
Dr. Sarah Doyle is the Chair, HIV and Migrants subgroup of STI/HIV Special Interest Group.
For further information contact SarahM.Doyle@hse.ie
Posted December 2016
The CAMS Approach to Suicide Risk: Philosophy and Clinical Procedures
By David A. Jobes
CAMS is an evolving therapeutic framework for assessment and management of suicide risk. This article is summarised here because the approach potentially offers a way for clinicians to reduce suicidality among homeless people. Staff in at least one of the Dublin based organisations providing services to homeless are training counsellors to use the approach.
This article published in 2009 by David A Jobes, the designer of the CAMS approach, provides an overview of the approach with particular emphasis on its philosophy and clinical procedure. The central element of the approach is the clinical alliance which is the essential vehicle for delivering a potentially lifesaving series of clinical interventions. The patient is engaged as participant in assessment of risk and in the resulting plan. This is guided by the use of Suicide Status Form (SSF).
The CAMS philosophy asserts that suicidal thinking may be a sensible though worrying response to psychological pain and suffering. The aim is to understand how the thoughts and behaviours work for the person in a non-judgemental way. Once the functional aspects of suicidality are understood the clinician is in a better position to propose alternatives. The patient feels understood respected and appreciated for these often scary ways of thinking and feeling.
While the approach works on an outpatient basis it is not opposed to inpatient treatment if needed. The article describes an example of an engagement between clinician and patient where the clinician encourages the patient to engage in CAMS rather than suicide on a “nothing to lose” basis, the option of suicide would still be there if it didn’t work. Honest, transparent and empathetic engagement acknowledging the clinician’s suicide prevention bias.
Clinical procedures were developed and empirically studied in real world clinical settings. The use of the SSF tool, described in detail in the article, assesses risk, develops a plan, tracks risk and updates the plan and documents clinical outcomes.
The article details the research on which the approach is built and claims they provide encouraging results about the approach and tool.
Levers and barriers to accessing primary care: New Research from the Partnership for Health Equity
Patrick O’Donnell, Edel Tierney, Austin O’Carroll, Diane Nurse and Anne MacFarlane
This participatory research used innovative methods to effectively engage with six marginalised groups who are often considered hard-to-reach and hard-to-research. Local organisations and primary care services acted as gatekeepers for meeting all participants. Four main themes were identified; the home environment, the Irish 'two-tier' healthcare system, healthcare encounters and complex health needs. The research demonstrates that there are many complicated personal and structural barriers to accessing primary healthcare for these groups. Findings of this research are of relevance to primary care professionals and policy makers alike.