Development of a refugee health assessment toolkit for specific populations to support primary care

Issue/problem

The United Kingdom (UK) hosts c.136,000 refugees and last year received the most asylum applications in two decades. Despite this, expertise in migrant health is not widespread in general practice, with few comprehensive toolkits available to support crucial initial health assessments of new arrivals.

Description of the problem

A large influx of Afghan refugees entered the UK in autumn 2021. In London, primary care practitioners quickly identified a lack of readily accessible, comprehensive guidance to support them in conducting health assessments for arrivals with a complex range of needs. This was compounded by many in primary care having little or no experience of migrant health.

Results

To address this gap in advice on conducting initial health assessments, a bespoke toolkit was created. The toolkit consolidated advice from a range of partners and resources: the UK Afghan migrant health guide, clinicians with humanitarian experience, front-line practitioners, Doctors of the World, and those leading on the health and public health response. The toolkit ensured greater consistency in the nature and content of assessments, considered not only primary needs but also broader wellbeing, and was responsive to both anticipated and known health priorities.

Lessons

The initial health assessment toolkit for Afghan migrants was well received by frontline staff and has implications for international practice in other areas providing similar health support. The toolkit and associated supporting information has formed a template that can be rapidly adapted to suit emerging needs, as has been done for new arrivals from Ukraine. This work has fed into best practice by the UK National Asylum Steering Group and is to be a case study for a WHO project on country-specific health assessments.

Key messages

• The toolkit is a proof of concept for partnership working towards holistic initial health assessments of new migrants in primary care, bringing together best evidence and pragmatic practice.

• This work has implications for other countries experiencing similar trends in migration and providing health support to an increasing number of new refugees.

Patients' Views on how to Run Hospital Outpatient Clinics

To investigate patients' views and expectations when attending outpatient clinics a questionnaire-based study was performed. The questionnaires asked about appointment systems, continuity of care, staff appearance, chaperons and medical students. Patients wanted fixed appointment times, to see the same doctor on successive visits, for the staff to be formally dressed and to have chaperons during examination. The number of medical students should be restricted especially for women patients. Staff should be sensitive to patients' needs.

Comorbidity, healthcare utilisation and process of care measures in patients with congenital heart disease in the UK: cross-sectional, population-based study with case-control analysis

OBJECTIVE

To determine the prevalence of comorbidities, patterns of healthcare utilisation and primary care recording of clinical indicators in patients with congenital heart disease.

PATIENTS AND METHODS

A population-based case-control study using data from general practices across the UK contributing data to the QRESEARCH primary care database. The subjects comprised 9952 patients with congenital heart disease and 29,837 matched controls. Outcome measures were prevalence of selected comorbidities; adjusted odds ratios for risk of comorbidities, healthcare utilisation and clinical indicator recording.

RESULTS

The overall crude prevalence of congenital heart disease was 3.05 per 1000 patients (95% CI 2.99 to 3.11). Prevalence of key comorbidities in patients with congenital heart disease ranged from 2.4% (95% CI 2.1% to 2.7%) for epilepsy to 9.3% (95% CI 8.8% to 9.9%) for hypertension. After adjusting for smoking and deprivation, cases were significantly more likely than controls to have each of the cardiovascular comorbidities and an increased risk of diabetes, epilepsy and renal disease. Patients with congenital heart disease were more frequent users of primary care than controls. Patients with congenital heart disease were also more likely than controls to have lifestyle and risk factor measurements recorded in primary care, although overall levels of recording were low.

CONCLUSIONS

There is a significant burden of comorbidity associated with congenital heart disease, and levels of primary care utilisation and referral to secondary care are high in this patient group. The predicted future expansion in the numbers of adults with congenital heart disease owing to improvements in survival will have implications for primary and secondary care, and not just tertiary centres offering specialist care.

Trends in hospital admissions, in-hospital case fatality and population mortality from congenital heart disease in England, 1994 to 2004

OBJECTIVE

To ascertain time trends in rates of hospital admission, operations, in-hospital case fatality and general mortality for congenital heart disease (CHD) in England and Wales.

DESIGN

Retrospective analysis of Hospital Episodes Statistics for England (April 1995 to March 2004) and mortality statistics for England and Wales (1994-2003).

POPULATION

All NHS patients admitted with a primary diagnosis of CHD to hospitals in England, and all deaths in England and Wales with an underlying cause of CHD.

MAIN OUTCOME MEASURES

Age-standardised hospital admission rates, case fatality rates and death rates from congenital heart disease.

RESULTS

Between 1995/1996 and 2003/2004 the age-standardised hospital admission rate for CHD increased from 30.7 per 100,000 (95% CI 29.9 to 31.4) to 35.5 per 100,000 (95% CI 34.7 to 36.4) in men and boys and from 28.2 per 100,000 (95% CI 27.4 to 28.9) to 32.8 per 100,000 (95% CI 32.0 to 33.6) in women and girls. Between 1997/1998 and 2003/2004 in-hospital case fatality rates fell from 2.10% (95% CI 1.97 to 2.22) to 0.83% (95% CI 0.74 to 0.92). Population mortality fell steadily over the decade from 1994 to 2003 in men and women, with the largest proportionate decrease in the 1-4-year age group.

CONCLUSION

Admission rates for CHD have increased over the past decade, particularly amongst patients in older age groups. There has also been a significant decrease in both in-hospital case fatality rates and in general population mortality rates. These trends are consistent with improvements in the quality of care for these patients, improvements in survival and the predicted expansion in the number of adults living with CHD.

Aids to breast feeding: a look at some of the products

Education about breast feeding is important, as is correct positioning and practical support from midwife, health visitor or counsellor. A number of products can be purchased from pharmacies and other outlets which claim to help breast feeding in various ways. These include nipple creams and sprays, breast pads, nipple shields and shells, pumps, and equipment to store expressed breast milk. Mothers seem to find many of these helpful, often to overcome difficulties at a particular stage of breast feeding. Certain breast creams are currently prescribable on the NHS. A glass or polycarbonate receiver with PVC bulb can also be prescribed on form FP10.

Panic disorder and chest pain in the coronary care unit

Consecutive admissions to a university hospital coronary intensive care unit were prospectively evaluated using a modified version of the Structured Clinical Interview for DSM-III-R by interviewers blind to the patient's cardiac status. Panic disorder was present in almost one-third of the patients. Four (21%) of the 19 patients with panic disorder also had positive cardiac findings, including 2 who had myocardial infarctions. Of the 27 patients with negative cardiac findings, 15 (55.5%) had panic disorder. Whereas panic disorder and coronary heart disease may coexist in patients with acute chest pain, there appears to be a very high prevalence of panic disorder among patients in whom cardiac disease has been excluded.

Use of transesophageal echocardiography to visualize an anomalous right coronary artery arising from the left main coronary artery (single coronary artery)

This case report demonstrates a role for transesophageal echocardiography in defining the course of anomalous coronary arteries. Origin of the right coronary artery (RCA) from the left main (LM) (single coronary artery) is an exceedingly rare congenital anomaly. It is not always benign and may result in myocardial infarction. This may be due to compression between the aorta and the pulmonary artery. Transesophageal echocardiography offers a low-risk, noninvasive means of imaging the proximal coronary arteries. In the majority of patients, the proximal segments of the three major coronaries can be clearly visualized. With the addition of color flow, it is possible to visualize flow in most patients. Proximal obstructive lesions can be seen in some patients although sensitivity thus far seems low.

A method for evaluation of enhancement operations in two-dimensional echocardiographic images

A means of estimating the degree of enhancement of structure and suppression of background noise in filtered two-dimensional echocardiographic images is described. The method is termed the peak-to-background ratio. To test the method, two-dimensional short-axis echocardiographic images were enhanced with Laplacian operations of increasing mask size. There was excellent correlation between the calculated peak-to-background ratio and the subjective opinion of trained echocardiographers. Furthermore, radial length measurements made from images that were thought to be optimally enhanced by the peak-to-background ratio calculation showed the lowest interobserver mean differences. We conclude that the peak-to-background ratio does reflect improvement in characteristics of the image that favor more precise measurement (amplification of peaks and suppression of background) and can be used to help guide a dynamic approach to image processing.