Immigration is a key political issue in the United Kingdom. The 2014 Immigration Act includes a number of measures intended to reduce net immigration, including removing the right of non-European Economic Area migrants to access free health care. This change risks widening existing health and social inequalities. This study explored the experiences of undocumented migrants trying to access primary care in the United Kingdom, their perspectives on proposed access restrictions, and suggestions for policymakers. Semi-structured interviews were conducted with 16 undocumented migrants and four volunteer staff at a charity clinic in London. Inductive thematic analysis drew out major themes. Many undocumented migrants already faced challenges accessing primary care. None of the migrants interviewed said that they would be able to afford charges to access primary care and most said they would have to wait until they were much more unwell and access care through Accident & Emergency (A&E) services. The consequences of limiting access to primary care, including threats to individual and public health consequences and the additional burden on the National Health Service, need to be fully considered by policymakers. The authors argue that an evidence-based approach would avoid legislation that targets vulnerable groups and provides no obvious economic or societal benefit.
Background Structured education for people with type 2 diabetes improves outcomes, but uptake is low globally. In the United Kingdom in 2016, only 8.3% of people who were referred to education programs attended the program. We have developed a Web-based structured education program named Healthy Living for People with type 2 Diabetes (HeLP-Diabetes): Starting Out (HDSO), as an alternative to face-to-face courses. A Web-based program gives people more options for accessing structured education and may help improve overall uptake. Objective The aim was to explore the feasibility and acceptability of delivering a Web-based structured education program (named HeLP-Diabetes: Starting Out) in routine primary health care and its potential impact on self-efficacy and diabetes-related distress. Methods HDSO was delivered as part of routine diabetes services in primary health care in the United Kingdom, having been commissioned by local Clinical Commissioning Groups. Quantitative data were collected on uptake, use of the program, demographic characteristics, self-reported self-efficacy, and diabetes-related distress. A subsample of people with type 2 diabetes and health care professionals were interviewed about acceptability of the program. Results It was feasible to deliver the program, but completion rates were low: of 791 people with type 2 diabetes registered, only 74 (9.0%) completed it. Completers improved their self-efficacy (change in median score 2.5, P=.001) and diabetes-related distress (change in median score 6.0, P=.001). Interview data suggested that the course was acceptable, and that uptake and completion may be related to nonprioritization of structured education. Conclusions The study provides evidence of the feasibility and acceptability of a Web-based structured education. However, uptake and completion rates were low, limiting potential population impact. Further research is needed to improve completion rates, and to determine the relative effectiveness of Web-based versus face-to-face education.
Background: Recent British National Health Service (NHS) reforms, in response to austerity and alleged 'health tourism, ' could impose additional barriers to healthcare access for non-European Economic Area (EEA) migrants. This study explores policy reform challenges and implications, using excerpts from the perspectives of non-EEA migrants and health advocates in London. Methods: A qualitative study design was selected. Data were collected through document review and 22 indepth interviews with non-EEA migrants and civil-society organisation representatives. Data were analysed thematically using the NHS principles. Results: The experiences of those 'vulnerable migrants' (ie, defined as adult non-EEA asylum-seekers, refugees, undocumented, low-skilled, and trafficked migrants susceptible to marginalised healthcare access) able to access health services were positive, with healthcare professionals generally demonstrating caring attitudes. However, general confusion existed about entitlements due to recent NHS changes, controversy over 'health tourism, ' and challenges registering for health services or accessing secondary facilities. Factors requiring greater clarity or improvement included accessibility, communication, and clarity on general practitioner (GP) responsibilities and migrant entitlements. Conclusion: Legislation to restrict access to healthcare based on immigration status could further compromise the health of vulnerable individuals in Britain. This study highlights current challenges in health services policy and practice and the role of non-governmental organizations (NGOs) in healthcare advocacy (eg, helping the voices of the most vulnerable reach policy-makers). Thus, it contributes to broadening national discussions and enabling more nuanced interpretation of ongoing global debates on immigration and health.
BackgroundDigital health is increasingly recognized as a cost-effective means to support patient self-care. However, there are concerns about whether the “digital divide,” defined as the gap between those who do and do not make regular use of digital technologies, will lead to increased health inequalities. Access to the internet, computer literacy, motivation to use digital health interventions, and fears about internet security are barriers to use of digital health interventions. Some of these barriers disproportionately affect people of older age, black or minority ethnic background, and low socioeconomic status. HeLP-Diabetes (Healthy Living for People with type 2 Diabetes), a theoretically informed online self-management program for adults with type 2 diabetes, was developed to meet the needs of people from a broad demographic background.ObjectiveThis study aimed to determine whether there was evidence of a digital divide when HeLP-Diabetes was integrated into routine care. This was achieved by (1) comparing the characteristics of people who registered for the program against the target population (people with type 2 diabetes in inner London), (2) comparing the characteristics of people who registered for the program and used it with those who did not use it, and (3) comparing sections of the website visited by different demographic groups.MethodsA retrospective analysis of data on the use of HeLP-Diabetes in routine clinical practice in 4 inner London clinical commissioning groups was undertaken. Data were collected from patients who registered for the program as part of routine health services.. Data on gender, age, ethnicity, and educational attainment were collected at registration, and data on webpage visits (user identification number, date, time, and page visited) were collected automatically by software on the server side of the website.ResultsThe characteristics of people who registered for the program were found to reflect those of the target population. The mean age was 58.4 years (SD=28.0), over 50.0% were from black and minority ethnic backgrounds, and nearly a third (29.8%) had no qualifications beyond school leaving age. There was no association between demographic characteristics and use of the program, apart from weak evidence of less use by the mixed ethnicity group. There was no evidence of the differential use of the program by any demographic group, apart from weak evidence for people with degrees and school leavers being more likely to use the “Living and working with diabetes” (P=.03) and “Treating diabetes” (P=.04) sections of the website.ConclusionsThis study is one of the first to provide evidence that a digital health intervention can be integrated into routine health services without widening health inequalities. The relative success of the intervention may be attributed to integration into routine health care, and careful design with extensive user input and consideration of literacy levels. Developers of digital health interventions need to acknowledge barriers to access and use,...
The COVID-19 pandemic has changed the research landscape with the emergence of platform trials. Platform trials are adaptive clinical trials in which patients with a single disease are randomly allocated to different treatments based on an algorithm to investigate whether various agents have clinical benefit. 1 In The Lancet, the PRINCIPLE Trial Collaborative Group 2 report no benefit of azithromycin compared with usual care (hazard ratio 1•08, 95% Bayesian credibility interval 0•95-1•23) for suspected COVID-19 in older adults in the community. This result is important for guiding clinical practice, not only for preventing unnecessary treatment of patients with COVID-19 but also for antimicrobial stewardship. Furthermore, the findings accord with the RECOVERY trial and the COALITION II trial of azithromycin for hospitalised patients with COVID-19. 3,4 Randomised trials provide robust evidence for clinical management with random treatment allocation that ensures no systemic differences between treatment groups, maximising internal validity and reducing both bias and confounding. This community trial recruited a large sample of 2265 participants aged over 65 years, or over 50 with comorbidity, over 6 months, which is remarkable. There were follow-up data for 2120 (94%) of 2265 participants who were included in the Bayesian primary analysis, with 500 participants in the azithromycin plus usual care group, 823 in the usual care alone group, and 797 in other intervention groups. The mean participant age was 60•7 years (SD 7•8), 787 (57%) participants were women and 599 (43%) were men, and 1233 (88%) of 1388 participants had comorbidities. It is important to remember that during this time national guidance and restrictions were in place in the UK, restricting movement of people, and this is reflected in 1586 (70%) participants being recruited online or by telephone. The PRINCIPLE trial and COVID-19 vac cination roll-out in the UK have highlighted the importance of a good primary care platform to address challenges to health of the population. Therefore, primary care is needed now more than ever in the UK and globally. 5 The PRINCIPLE trial goes some way to reflect groups that are vulnerable to the more serious complications of SARS-CoV-2 infection and is a step in the right direction for external validity. External validity can be a particular limitation in clinical trials, where strict inclusion and For the PRINCIPLE trial news see https://www.principletrial.org/ news Richard Baker/Getty images
Objectives The aim of structured education for type 2 diabetes is to improve knowledge, skills and confidence in self-management. It is recommended in the UK for everyone who is newly diagnosed with type 2 diabetes. We developed an on-line programme called HeLP-Diabetes: Starting Out to address poor uptake of face-to-face structured education. The aim of this paper is to describe the intervention in line with the Template for Intervention Description and Replication guide, which calls for better reporting of interventions. Methods The Template for Intervention Description and Replication guide provided the item headings for the description. These included the theoretical underpinning, materials, procedures, providers, and mode of delivery. Results The programme was developed to meet NICE requirements for structured education and therefore followed a structured curriculum with four sessions covering content such as what diabetes is and how it is treated, possible complications, and how lifestyle changes can improve health. Content was delivered in text, images and video, and behaviour change techniques, self-assessment and feedback were used to help people target key health behaviours. The programme was delivered entirely online, but the team were available for support via telephone. Email feedback and reminders were sent. Conclusions The TIDieR checklist allowed us to provide a clear structure for the description of the intervention. However, it could not capture the full complexity of the programme, and intervention developers considering using it in the future may find that it needs to be adapted to make it more specific to their intervention.
A B ST R AC T Background and objectives: CVD is an important global healthcare issue; it is the leading cause of global mortality, with an increasing incidence identified in both developed and developing countries. It is also an extremely costly disease for healthcare systems unless managed effectively. In this review we aimed to: -Assess the effect of computer-assisted versus oral-and-written history taking on the quality of collected information for the prevention and management of CVD.-Assess the effect of computer-assisted versus oral-and-written history taking on the prevention and management of CVD. Methods: A systematic review of randomised controlled trials that included participants of 16 years or older at the beginning of the study, who were at risk of CVD (prevention) or were either previously diagnosed with CVD (management). We searched all major databases. We assessed risk of bias using the Cochrane Collaboration tool. Results: Two studies met the inclusion criteria. One comparing the two methods of history-taking for the prevention of cardiovascular disease n = 75. The study shows that generally the patients in the experimental group underwent more laboratory procedures, had more biomarker readings recorded and/or were given (or had reviewed), more dietary changes than the control group. The other study compares the two methods of history-taking for the management of cardiovascular disease (n = 479). The study showed that the computerized decision aid appears to increase the proportion of patients who responded to invitations to discuss CVD prevention with their doctor. The ComputerAssisted History Taking Systems (CAHTS) increased the proportion of patients who discussed CHD risk reduction with their doctor from 24% to 40% and increased the proportion who had a specific plan to reduce their risk from 24% to 37%. Discussion: With only one study meeting the inclusion criteria, for prevention of CVD and one study for management of CVD we did not gather sufficient evidence to address all of the objectives of the review. We were unable to report on most of the secondary patient outcomes in our protocol. Conclusions: We tentatively conclude that CAHTS can provide individually-tailored information about CVD prevention. However, further primary studies are needed to confirm these findings. We cannot draw any conclusions in relation to any other clinical outcomes at this stage. There is a need to develop an evidence base to support the effective development and use of CAHTS in this area of practice. In the absence of evidence on effectiveness, the implementation of computer-assisted history taking may only rely on the clinicians' tacit knowledge, published monographs and viewpoint articles.
AimTo determine undergraduate medical students’ teaching preferences and expectations for Culinary Medicine (CM) learning with a view to informing development of a CM course at a UK medical school.SettingA single, urban UK medical school.Participants180 undergraduate medical students.Study designA cross-sectional questionnaire study collecting quantitative and qualitative (free-text) data.Methods and outcome measuresAn online questionnaire consisting of 16 questions of various styles (Likert-type, multiple choice and free-text). Quantitative analysis of multiple choice and Likert-type scale questions was conducted. Qualitative thematic analysis was used to analyse the free-text responses and identify themes.ResultsThree core themes related to students’ understanding of CM were identified: (1) ‘CM Learning’: students’ perceived relevance of CM knowledge, perceived relevance of CM to healthcare and their expectations for teaching; (2) ‘The Relationship between Food and Health’: links between diet, social factors and health; and (3) ‘Evidence-based Medicine’: students’ perceptions about scientific principles underlying CM. Quantitative analysis revealed that, although 83% of students felt that learning CM is important for their future clinical practice, 56% felt unable to take a dietary history. 73% of students were dissatisfied with the quality, and 78% were dissatisfied with the quantity, of existing medical school teaching understood to be relevant to CM. Topics that students would like to be taught on a CM course included weight management and portion control. Students felt that problem-based style learning would be the most appropriate method for delivering CM teaching.ConclusionsThis study revealed that medical students felt their dietary counsulting skills could be improved with further clinically relevant teaching in the undergraduate medical curriculum. Students’ preferences for CM learning have been taken into consideration in the development of a CM course for fifth-year undergraduate students at a UK medical school, which is delivered during their General Practice placement.
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