Tuberculosis (TB) disproportionally affects hard-to-reach populations,, such as the homeless, migrants, refugees, prisoners, substance misuers, people living with HIV. These people face important challenges in accessing and receiving quality health care services. To identify barriers to, and facilitators for, the uptake of TB diagnosis and treatment services by people from those hard-to-reach populations we performed a systematic reviewed of the qualitative literature following PRISMA guidelines, . Twelve studies were included in this review; most focussed on migrants. Views on perceived susceptibility to and severity of TB varied widely and included misconceptions. Stigma and challenges with accessing health care were identified as barriers for TB diagnosis and treatment uptake whereas nurse, family, and friends' support were facilitators to treatment compliance. Addressing barriers and facilitators may improve identification of potential TB cases and treatment in hard-to-reach populations.
PROSPERO registration number: CRD420150194503
BackgroundManaging polypharmacy is a challenge for healthcare systems globally. It is also a health inequality concern as it can expose some of the most vulnerable in society to unnecessary medications and adverse drug-related events. Care for most patients with multimorbidity and polypharmacy occurs in primary care. Safe deprescribing interventions can reduce exposure to inappropriate polypharmacy. However, these are not fully accepted or routinely implemented.AimTo identify barriers and facilitators to safe deprescribing interventions for adults with multimorbidity and polypharmacy in primary care.Design & settingA systematic review of studies published from 2000, examining safe deprescribing interventions for adults with multimorbidity and polypharmacy.MethodA search of electronic databases: MEDLINE, Embase, Cumulative Index of Nursing and Allied Health Literature (CINHAL), Cochrane, and Health Management Information Consortium (HMIC) from inception to 26 Feb 2019, using an agreed search strategy. This was supplemented by handsearching of relevant journals, and screening of reference lists and citations of included studies.ResultsIn total, 40 studies from 14 countries were identified. Cultural and organisational barriers included: a culture of diagnosing and prescribing; evidence-based guidance focused on single diseases; a lack of evidence-based guidance for the care of older people with multimorbidities; and a lack of shared communication, decision-making systems, tools, and resources. Interpersonal and individual-level barriers included: professional etiquette; fragmented care; prescribers’ and patients’ uncertainties; and gaps in tailored support. Facilitators included: prudent prescribing; greater availability and acceptability of non-pharmacological alternatives; resources; improved communication, collaboration, knowledge, and understanding; patient-centred care; and shared decision-making.ConclusionA whole systems, patient-centred approach to safe deprescribing interventions is required, involving key decision-makers, healthcare professionals, patients, and carers.
Tuberculosis is over-represented in hard-to-reach (underserved) populations in high-income countries of low tuberculosis incidence. The mainstay of tuberculosis care is early detection of active tuberculosis (case finding), contact tracing, and treatment completion. We did a systematic review with a scoping component of relevant studies published between 1990 and 2015 to update and extend previous National Institute for Health and Care Excellence (NICE) reviews on the effectiveness of interventions for identifying and managing tuberculosis in hard-to-reach populations. The analyses showed that tuberculosis screening by (mobile) chest radiography improved screening coverage and tuberculosis identification, reduced diagnostic delay, and was cost-effective among several hard-to-reach populations. Sputum culture for pre-migration screening and active referral to a tuberculosis clinic improved identification. Furthermore, monetary incentives improved tuberculosis identification and management among drug users and homeless people. Enhanced case management, good cooperation between services, and directly observed therapy improved treatment outcome and compliance. Strong conclusions cannot be drawn because of the heterogeneity of evidence with regard to study population, methodology, and quality.
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