Improving TB infection control in a regional hospital in the Eastern Cape, South Africa

This quality improvement (QI) work was carried out in Cecilia Makiwane Hospital (CMH), a regional public hospital in the Eastern Cape, South Africa (SA). SA has among the highest incidence of tuberculosis (TB) in the world and this is a leading cause of death in SA. Nosocomial infection is an important source of TB transmission. Adherence to TB infection prevention control (IPC) measures in the medical inpatient department was suboptimal at CMH. The overall aim of this QI project was to make sustainable improvements in TB IPC. A multidisciplinary team was formed to undertake a root cause analysis and develop a strategy for change. The main barriers to adherence to IPC measures were limited knowledge of IPC methods and stigma associated with TB. Specifically, the project aimed to increase the number of: ‘airborne precaution’ signs placed above patients’ beds, patients correctly isolated and patients wearing surgical face masks. Four Plan Do-Study-Act cycles were used. The strategy for change involved education and awareness-raising in different formats, including formal in-service training delivered to nurses and doctors, a hospital-wide TB awareness week with engaging activities and competitions, and a World TB Day provincial solidarity march. Data on adherence to the three IPC measures were collected over an 8-month period. Pre-intervention (October 2016), a mean of 2 percent of patients wore face masks, 22 percent were correctly isolated and 12 percent had an airborne precaution sign. Postintervention (May 2017), the compliance improved to 17 percent, 50 percent and 25 percent, respectively. There was a large variation in compliance to each measure. Improvement was greatest in the number of patients correctly isolated. We learnt it is important to work with, not in parallel to, existing teams or structures during QI work. On-the-ground training of nurses and clinicians should be undertaken alongside engagement of senior staff members and managers. This improves the chance of change being adopted into hospital policy

Impact of COVID-19 on migrants' access to primary care and implications for vaccine roll-out: a national qualitative study.

BACKGROUND: COVID-19 has led to big changes in UK primary care, including rapid digitalisation, with unknown impact on migrant groups. AIM: To understand the pandemic's impact on recently-arrived migrants and their access to primary health care, and implications for vaccine roll-out. DESIGN AND SETTING: Qualitative study involving semi-structured interviews with primary care professionals (PCPs) and migrants in urban, suburban, and rural settings across England. METHOD: Sixty-four PCPs and administrative staff, and 17 recently-arrived migrants were recruited using purposive, convenience, and snowball sampling. In-depth, semi-structured interviews were conducted by telephone. Data were analysed iteratively, informed by thematic analysis. RESULTS: PCPs and migrants concurred that digitalisation and virtual consultations have amplified existing inequalities in access to health care for many migrants, due to a lack of digital literacy and access to technology, compounded by language barriers. PCPs were concerned that virtual consultations resulted in difficulties building trust and risked missing safeguarding cues. Both PCPs and migrants highlighted challenges around registering and accessing health care due to physical closure of surgeries, as well as indirect discrimination, language and communication barriers, and a lack of access to targeted and tailored COVID-19 information or interventions. Migrants reported a range of specific beliefs, from acceptance to mistrust, around COVID-19 and potential COVID-19 vaccines, often influenced by misinformation. Innovative opportunities were suggested, including translated digital health advice using text templates and YouTube; these merit further exploration. CONCLUSION: Pandemic-related changes to primary care delivery may become permanent; some migrant groups are at risk of digital exclusion and may need targeted additional support to access services. Solutions are needed to address vaccine hesitancy in marginalised groups to ensure equitable COVID-19 vaccine uptake

Defining the determinants of vaccine uptake and undervaccination in migrant populations in Europe to improve routine and COVID-19 vaccine uptake: a systematic review

Understanding why some migrants in Europe are at risk of underimmunisation and show lower vaccination uptake for routine and COVID-19 vaccines is critical if we are to address vaccination inequities and meet the goals of WHO's new Immunisation Agenda 2030. We did a systematic review (PROSPERO: CRD42020219214) exploring barriers and facilitators of vaccine uptake (categorised using the 5As taxonomy: access, awareness, affordability, acceptance, activation) and sociodemographic determinants of undervaccination among migrants in the EU and European Economic Area, the UK, and Switzerland. We searched MEDLINE, CINAHL, and PsycINFO from 2000 to 2021 for primary research, with no restrictions on language. 5259 data sources were screened, with 67 studies included from 16 countries, representing 366 529 migrants. We identified multiple access barriers-including language, literacy, and communication barriers, practical and legal barriers to accessing and delivering vaccination services, and service barriers such as lack of specific guidelines and knowledge of health-care professionals-for key vaccines including measles-mumps-rubella, diphtheria-pertussis-tetanus, human papillomavirus, influenza, polio, and COVID-19 vaccines. Acceptance barriers were mostly reported in eastern European and Muslim migrants for human papillomavirus, measles, and influenza vaccines. We identified 23 significant determinants of undervaccination in migrants (p<0·05), including African origin, recent migration, and being a refugee or asylum seeker. We did not identify a strong overall association with gender or age. Tailored vaccination messaging, community outreach, and behavioural nudges facilitated uptake. Migrants' barriers to accessing health care are already well documented, and this Review confirms their role in limiting vaccine uptake. These findings hold immediate relevance to strengthening vaccination programmes in high-income countries, including for COVID-19, and suggest that tailored, culturally sensitive, and evidence-informed strategies, unambiguous public health messaging, and health system strengthening are needed to address access and acceptance barriers to vaccination in migrants and create opportunities and pathways for offering catch-up vaccinations to migrants

Use of social media platforms by migrant and ethnic minority populations during the COVID-19 pandemic: a systematic review

OBJECTIVE: Migrants and ethnic minority groups have been disproportionately impacted by COVID-19 and have lower levels of vaccine uptake in some contexts. We aimed to determine the extent and nature of social media use in migrant and ethnic minority communities for COVID-19 information, and implications for preventative health measures including vaccination intent and uptake. DESIGN: A systematic review of published and grey literature following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched databases including Embase, Web of Science, PubMed NIH, CINAHL, facilitated through the WHO Global Research on COVID-19 database from 31 December 2019 to 9 June 2021. ELIGIBILITY CRITERIA FOR STUDY SELECTION: Research reporting the use of social media by migrants and/or ethnic minority groups in relation to COVID-19. DATA EXTRACTION: We extracted data on key outcomes, study design, country, population under study and sample size. RESULTS: 1849 unique records were screened, and 21 data sources were included, including populations in the UK, USA, China, Jordan, Qatar and Turkey. We found evidence of consistent use of a range of social media platforms for COVID-19 information in some migrant and ethnic minority populations (including WeChat, Facebook, WhatsApp, Instagram, Twitter, YouTube), which may stem from difficulty in accessing COVID-19 information in their native languages or from trusted sources. Some evidence suggested circulating misinformation and social media use may be associated with lower participation in preventative health measures, including vaccine intent and uptake, findings which are likely relevant to multiple population groups. CONCLUSIONS: Social media platforms are an important source of information about COVID-19 for some migrant and ethnic minority populations. Urgent actions and further research are now needed to better understand effective approaches to tackling circulating misinformation, and to seize on opportunities to better use social media platforms to support public health communication and improve vaccine uptake. REGISTRATION: This study has been registered with PROSPERO (CRD42021259190)

Migration and outbreaks of vaccine-preventable disease in Europe: a systematic review.

Migrant populations are one of several underimmunised groups in the EU or European Economic Area (EU/EEA), yet little is known about their involvement in outbreaks of vaccine-preventable diseases. This information is vital to develop targeted strategies to improve the health of diverse migrant communities. We did a systematic review (PROSPERO CRD42019157473; Jan 1, 2000, to May 22, 2020) adhering to PRISMA guidelines, to identify studies on vaccine-preventable disease outbreaks (measles, mumps, rubella, diphtheria, pertussis, polio, hepatitis A, varicella, Neisseria meningitidis, and Haemophilus influenzae) involving migrants residing in the EU/EEA and Switzerland. We identified 45 studies, reporting on 47 distinct vaccine-preventable disease outbreaks across 13 countries. Most reported outbreaks involving migrants were of measles (n=24; 6496 cases), followed by varicella (n=11; 505 cases), hepatitis A (n=7; 1356 cases), rubella (n=3; 487 cases), and mumps (n=2; 293 cases). 19 (40%) outbreaks, predominantly varicella and measles, were reported in temporary refugee camps or shelters. Of 11 varicella outbreaks, nine (82%) were associated with adult migrants. Half of measles outbreaks (n=11) were associated with migrants from eastern European countries. In conclusion, migrants are involved in vaccine-preventable disease outbreaks in Europe, with adult and child refugees residing in shelters or temporary camps at particular risk, alongside specific nationality groups. Vulnerability varies by disease, setting, and demographics, highlighting the importance of tailoring catch-up vaccination interventions to specific groups in order to meet regional and global vaccination targets as recommended by the new Immunisation Agenda 2030 framework for action. A better understanding of vaccine access and intent in migrant groups and a greater focus on co-designing interventions is urgently needed, with direct implications for COVID-19 vaccine delivery

Safety Culture and the Positive Association of Being a Primary Care Training Practice during COVID-19: The Results of the Multi-Country European PRICOV-19 Study.

The day-to-day work of primary care (PC) was substantially changed by the COVID-19 pandemic. Teaching practices needed to adapt both clinical work and teaching in a way that enabled the teaching process to continue, while maintaining safe and high-quality care. Our study aims to investigate the effect of being a training practice on a number of different outcomes related to the safety culture of PC practices. PRICOV-19 is a multi-country cross-sectional study that researches how PC practices were organized in 38 countries during the pandemic. Data was collected from November 2020 to December 2021. We categorized practices into training and non-training and selected outcomes relating to safety culture: safe practice management, community outreach, professional well-being and adherence to protocols. Mixed-effects regression models were built to analyze the effect of being a training practice for each of the outcomes, while controlling for relevant confounders. Of the participating practices, 2886 (56%) were non-training practices and 2272 (44%) were training practices. Being a training practice was significantly associated with a lower risk for adverse mental health events (OR: 0.83; CI: 0.70–0.99), a higher number of safety measures related to patient flow (Beta: 0.17; CI: 0.07–0.28), a higher number of safety incidents reported (RR: 1.12; CI: 1.06–1.19) and more protected time for meetings (Beta: 0.08; CI: 0.01–0.15). No significant associations were found for outreach initiatives, availability of triage information, use of a phone protocol or infection prevention measures and equipment availability. Training practices were found to have a stronger safety culture than non-training practices. These results have important policy implications, since involving more PC practices in education may be an effective way to improve quality and safety in general practice

'Please make comfortable': prescribing opioids in the wake of Gosport.

The latest crisis concerning UK end of life care arose in June 2018 with the publication of the Jones inquiry into opioid related excess mortality at Gosport War Memorial Hospital in the 1990s. Hundreds of premature deaths resulted from misuse of diamorphine and syringe drivers, which often followed the clinical instruction ‘please make comfortable’. It is hard to overstate this scandal, one of many in the NHS. The report highlights patient safety failures at multiple levels, concerns about institutional culture, insufficient challenging and investigation of poor practice, and poor support of whistleblowers. Pocock et al’s editorial considers whether this was the result of a rogue clinician or systemic failures, while assessing the effect on palliative care provision. What merits further discussion is the complexity surrounding opioid prescribing in palliative and end-of-life care, with its repercussions on both public and political discourse in the UK and further afield.Non

Do health partnerships with organisations in lower income countries benefit the UK partner? A review of the literature

BACKGROUND: Health partnerships between institutions in the UK and Low or Lower- middle Income Countries are an increasingly important model of development, yet analysis of partnerships has focused on benefits and costs to the Low and Lower- Middle Income partner. We reviewed the evidence on benefits and costs of health partnerships to UK individuals, institutions & the NHS and sought to understand how volunteering within partnerships might impact on workforce development and service delivery. METHODS: A systematic review of both published literature and grey literature was conducted. Content relating to costs or benefits to the UK at an individual, institutional or system level was extracted and analysed by thematic synthesis. The benefits of volunteering described were mapped to the key outcome indicators for five different UK professional development structures. A framework was developed to demonstrate the link between volunteer experience within partnerships and improved UK service delivery outcomes. RESULTS: The literature review (including citation mapping) returned 9 published papers and 32 pieces of grey literature that met all inclusion criteria. 95% of sources cited benefits and 32% cited costs. Most literature does not meet high standards of formal academic rigor. Forty initial individual benefits codes were elicited. These were then grouped into 7 key domains: clinical skills; management skills; communication & teamwork; patient experience & dignity; policy; academic skills; and personal satisfaction & interest. A high degree of concordance was shown between professional benefits cited and professional development indicators within UK work force development frameworks. A theoretical trajectory from volunteer experience to UK service delivery outcomes was demonstrated in most areas, but not all. 32% of sources cited costs, yielding 15 initial codes which were grouped into 5 domains: financial; reputational; health & security; loss of staff; and opportunity costs. CONCLUSIONS: There is little published or unpublished literature on the impact of volunteering within health partnerships to British individuals, institutions or the UK. The existing evidence base is descriptive and focuses on the benefits of volunteering. More work is required to quantify the costs and benefits of volunteering within health partnerships for individuals and institutions, and the associated challenges and barriers. Despite these limitations our analysis suggests that there is a strong theoretical argument that the skills acquired through volunteering are transferable to service delivery within the NHS and that the benefits to individuals and institutions could be maximised when volunteering is formally embedded within continuing professional development processes