BackgroundThe involvement of patients and the public in healthcare has grown significantly in recent decades and is documented in health policy documents internationally. Many benefits of involving these groups in primary care planning have been reported. However, these benefits are rarely felt by those considered marginalised in society and they are often excluded from participating in the process of planning primary care. It has been recommended to employ suitable approaches, such as co-operative and participatory initiatives, to enable marginalised groups to highlight their priorities for care.MethodsThis Participatory Learning and Action (PLA) research study involved 21 members of various marginalised groups who contributed their views about access to primary care. Using a series of PLA techniques for data generation and co-analysis, we explored barriers and facilitators to primary healthcare access from the perspective of migrants, Irish Travellers, homeless people, drug users, sex workers and people living in deprivation, and identified their priorities for action with regard to primary care provision.ResultsFour overarching themes were identified: the home environment, the effects of the ‘two-tier’ healthcare system on engagement, healthcare encounters, and the complex health needs of many in those groups. The study demonstrates that there are many complicated personal and structural barriers to accessing primary healthcare for marginalised groups. There were shared and differential experiences across the groups. Participants also expressed shared priorities for action in the planning and running of primary care services.ConclusionsMembers of marginalised groups have shared priorities for action to improve their access to primary care. If steps are taken to address these, there is scope to impact on more than one marginalised group and to address the existing health inequities.Electronic supplementary materialThe online version of this article (doi:10.1186/s12939-016-0487-5) contains supplementary material, which is available to authorized users.

BackgroundHomeless populations experience poorer physical and mental health, and more barriers to accessing adequate healthcare. This study investigates the health of this population, following the provision of a free to access primary care service for homeless people in Dublin (Safetynet). The health of this group will be compared to previous studies on homelessness conducted in Dublin prior to the establishment of this service (in 1997 and 2005).MethodsParticipants were recruited through Safetynet clinics. A 133-item questionnaire was administered to determine participants’ physical and mental well-being, use of health services and healthcare needs. Prescription data was extracted from participants’ electronic health records.ResultsA total of 105 participants were recruited. The majority were < 45 years of age (69%), male (75%), single (52%), Irish (74%) and had children (52%). Multimorbidity was common; with 5.3 ± 2.7 (mean ± SD) physical conditions reported per person. A large proportion of participants had at some point received a formal diagnosis of a mental health condition (70%; 73/105), including depression (50%; 52/105), addiction disorder (39%), anxiety (36%; 38/105), schizophrenia (13%; 14/105) and bipolar disorder (6%; 6/105). With regards to illicit drug use, 60% (63/105) of participants reported ever using drugs, while 33% (35/105) reported being active drug users. Based on AUDIT C criteria, 53% had an alcohol problem. Compared to previous studies, participants reported more positive ratings of health (70% vs. 57% in 1997 and 46% in 2005). The proportion of participants on one or more prescription medication was higher than in previous studies (81% vs. 32% in 1997 and 49% in 2005) and there was a decrease in attendance at outpatients departments (17% vs. 27% in 2005) and a trend towards a decrease in attendance at Accident and Emergency departments (A & E) (29% vs. 37% in 2005).ConclusionsThis vulnerable population has many physical and mental health problems. Use of drugs, alcohol and smoking is common. Following the establishment of Safetynet, self-reported health was rated more positively, there was also a decrease in the use of A & E and outpatient services and an increase in prescription medicines.Electronic supplementary materialThe online version of this article (doi:10.1186/s12913-015-0716-4) contains supplementary material, which is available to authorized users.

ObjectivesHomeless people lack a secure, stable place to live and experience higher rates of serious illness than the housed population. Studies, mainly from the USA, have reported increased use of unscheduled healthcare by homeless individuals.We sought to compare the use of unscheduled emergency department (ED) and inpatient care between housed and homeless hospital patients in a high-income European setting in Dublin, Ireland.SettingA large university teaching hospital serving the south inner city in Dublin, Ireland. Patient data are collected on an electronic patient record within the hospital.ParticipantsWe carried out an observational cross-sectional study using data on all ED visits (n=47 174) and all unscheduled admissions under the general medical take (n=7031) in 2015.Primary and secondary outcome measuresThe address field of the hospital’s electronic patient record was used to identify patients living in emergency accommodation or rough sleeping (hereafter referred to as homeless). Data on demographic details, length of stay and diagnoses were extracted.ResultsIn comparison with housed individuals in the hospital catchment area, homeless individuals had higher rates of ED attendance (0.16 attendances per person/annum vs 3.0 attendances per person/annum, respectively) and inpatient bed days (0.3 vs 4.4 bed days/person/annum). The rate of leaving ED before assessment was higher in homeless individuals (40% of ED attendances vs 15% of ED attendances in housed individuals). The mean age of homeless medical inpatients was 44.19 years (95% CI 42.98 to 45.40), whereas that of housed patients was 61.20 years (95% CI 60.72 to 61.68). Homeless patients were more likely to terminate an inpatient admission against medical advice (15% of admissions vs 2% of admissions in homeless individuals).ConclusionHomeless patients represent a significant proportion of ED attendees and medical inpatients. In contrast to housed patients, the bulk of usage of unscheduled care by homeless people occurs in individuals aged 25–65 years.

Background Homeless people have poor health and mortality indices. Despite this they make poor usage of health services. This study sought to understand why they use health services differently from the domiciled population. Methods Ethnographic observations were conducted at several homeless services, in Dublin. This was supplemented with 47 semi-structured interviews with homeless people and two focus groups of homeless people and hospital doctors. A critical-realist approach was adopted for interpretation of the data. Results Homeless people tended to present late in their illness; default early from treatment; have low usage of primary-care, preventative and outpatient services; have high usage of Emergency and Inpatient services; and poor compliance with medication. They tended to avoid psychiatric services. A number of external barriers were identified. These were classified as physical (distance) administrative (application process for medical care; appointments; queues; the management of addiction in hospital; rules of service; and information providing processes); and attitudinal (stigma; differing attitudes as to appropriate use of services. A new form of barrier, Conversations of Exclusion was identified and described. Internalised barriers were identified which were in nature, either cognitive (fatalistic, denial, deferral to future, presumption of poor treatment or discrimination, self blame and survival cognitions) or emotional (fear; embarrassment, hopelessness and poor self-esteem). Generative mechanisms for these factors were identified which either affected participants prior to homelessness (marginalization causing hopelessness, familial dysfunction, substance misuse, fear of authority, illiteracy; mental health; and poor English) or after becoming homeless (homelessness; ubiquity of premature death; substance misuse; prioritization of survival over health; threat of violence; chaotic nature of homelessness; negative experiences of authority; and stigma. Conclusions An explanatory critical realist model integrating the identified generative mechanisms, external and internalised barriers was developed to explain why the Health service Utilization of homeless people differs from the domiciled populations. This new model has implications for health service policy makers and providers in how they design and deliver accessible health services to homeless people.

BackgroundVaccination against influenza and pertussis in pregnancy can reduce the significant morbidity and mortality associated with these infections. Despite this, there is poor uptake of both vaccines in pregnancy.AimTo explore women’s perception of vaccination in pregnancy and thereby determine the reasons behind such low vaccination rates.Design & settingThis is a qualitative study undertaken at a large maternity hospital.MethodSeventeen post-partum women completed a semi-structured interview discussing vaccination. They were recruited from a quantitative study looking at vaccination rates in pregnancy. The interview transcripts were discussed among three researchers and underwent thematic analysis.ResultsThree themes emerged. The first theme explored the influencing factors that shaped the women’s decision to vaccinate in pregnancy. The recommendation of a healthcare provider was the most important influencing factor for this study's cohort of women. The second theme highlighted the deficiency in knowledge women had regarding vaccine safety. The last theme related to the pertussis vaccine, and the reluctance of healthcare providers to discuss and offer this vaccine in pregnancy.ConclusionThe qualitative approach gives voice to the thoughts and concerns of women as they make the complex decision to vaccinate in pregnancy. Clinicians must be cognizant of the important role they play in advising women to vaccinate in pregnancy. They must advise women that the vaccine is safe and address any of their concerns. Lastly, a message on vaccine safety should be included in future public health campaigns to promote vaccination in pregnancy.