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Dawood M. Restoring hope. Emerg Med J 2024:emermed-2024-214259. [PMID: 38937073 DOI: 10.1136/emermed-2024-214259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2024] [Accepted: 06/20/2024] [Indexed: 06/29/2024]
Affiliation(s)
- Mary Dawood
- Emergency Department, Imperial College NHS Trust, London, UK
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Khanom A, Evans BA, Alanazy W, Couzens L, Fagan L, Fogarty R, John A, Khan T, Kingston MR, Moyo S, Porter A, Richardson G, Rungua G, Williams V, Snooks H. Navigating challenges and workarounds: A qualitative study of healthcare and support workers' perceptions on providing care to people seeking sanctuary. Health Expect 2024; 27:e14061. [PMID: 38678592 PMCID: PMC11056205 DOI: 10.1111/hex.14061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2023] [Revised: 03/12/2024] [Accepted: 04/17/2024] [Indexed: 05/01/2024] Open
Abstract
BACKGROUND Healthcare and support workers play a pivotal role in delivering quality services and support to people seeking sanctuary who have experienced poor physical and mental health linked to previous trauma, relocation and loss of freedoms. However, they often encounter various challenges in their daily work, ranging from communication barriers to resource constraints. This qualitative study seeks to delve into the perspectives of healthcare and support workers' experience of workarounds, employed to overcome barriers to providing care. AIM This study aims to describe healthcare providers', practitioners' and health and third sector support workers' views on barriers and workarounds to providing care for people seeking sanctuary, to inform policy and practice. DESIGN A qualitative study was carried out using semi-structured telephone interviews. SETTING This study focused on primary, secondary, community and specialist National Health Service (NHS) support services for people seeking sanctuary in Wales, United Kingdom (2018). METHOD We interviewed 32 healthcare providers, practitioners and support workers employed by primary care and third sector organisations. Our approach involved obtaining verbal informed consent before digitally recording and transcribing all interviews. To analyse the data, we used the Four Levels of Change for Improving Quality model as a guiding framework for interpretation. RESULTS Our study findings reveal that certain respondents expressed challenges in meeting the needs of people seeking sanctuary; notably, their experience of delivering care differed by care settings. Specifically, those involved in providing specialist NHS care believed that there was room for improvement. Mainstream primary, secondary and community health practitioners faced limitations due to resource constraints and lacked tailored information to address the unique circumstances and needs of sanctuary seekers. To address these gaps, workarounds emerged at both individual and local levels (team/departmental and organisational level). These included establishing informal communication channels between providers, fostering cross service collaboration to fill gaps and adapting existing services to enhance accessibility. CONCLUSION Understanding healthcare providers', practitioners' and support workers' perspectives offers invaluable insights into ways to enhance healthcare delivery to sanctuary seekers. Acknowledging challenges and harnessing innovative workarounds can foster a more effective and compassionate service for this vulnerable population. PATIENT OR PUBLIC CONTRIBUTION The HEAR study actively involved public contributors in the design, delivery and dissemination of the research. Two public contributors (S. M. and G. R.) who had personal experience of seeking asylum served as study co-applicants. They played pivotal roles in shaping the research by participating in its development and securing funding. Alongside other co-applicants, S. M. and G. R. formed the Research Management Group, overseeing study delivery. Their contributions extended to strategic decision-making and specific feedback at critical junctures, including participant recruitment, data collection, analysis and reporting. Additionally, S. M. and G. R. were instrumental in recruiting and supporting a team of peer researchers, enhancing respondent participation among people seeking sanctuary. To facilitate effective public involvement, we provided named contacts for support (A. K. and R. F.), research training, honoraria, reimbursement of expenses and accessible information in line with best practice.
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Affiliation(s)
| | - Bridie A. Evans
- Swansea University Medical School, ILS 2Swansea UniversitySwanseaUK
| | | | | | | | | | - Ann John
- Swansea University Medical School, ILS 2Swansea UniversitySwanseaUK
| | | | - Mark R. Kingston
- Swansea University Medical School, ILS 2Swansea UniversitySwanseaUK
| | | | - Alison Porter
- Swansea University Medical School, ILS 2Swansea UniversitySwanseaUK
| | | | | | | | - Helen Snooks
- Swansea University Medical School, ILS 2Swansea UniversitySwanseaUK
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Hudson BF, Dzeng E, Burnett A, Yeung M, Shulman C. Palliative care, homelessness, and restricted or uncertain immigration status. Palliat Care Soc Pract 2023; 17:26323524231216993. [PMID: 38144973 PMCID: PMC10748891 DOI: 10.1177/26323524231216993] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Accepted: 11/07/2023] [Indexed: 12/26/2023] Open
Abstract
Background People experiencing homelessness have limited access to palliative care support despite high levels of ill health and premature mortality. Most research exploring these challenges in the United Kingdom has focused on people living in hostels or temporary accommodation. People with uncertain or restricted immigration status are often unable to access this accommodation due to lack of entitlement to benefits. There is little research about the experiences of those in the United Kingdom who cannot access hostels or temporary accommodation due to restricted or uncertain immigration status with regards to palliative and end-of-life care access. Aim To explore the barriers to palliative and end-of-life care access for people with uncertain or restricted immigration status, who are experiencing homelessness and have advanced ill health, and the experiences of UK hospices of supporting people in this situation. Design A multi-method cross-sectional study. Setting/participants An online survey for hospice staff followed by online focus groups with staff from inclusion health, homelessness and palliative care services, charities and interviews with people experiencing homelessness. Results Fifty hospice staff responded to the online survey and 17 people participated in focus groups and interviews (focus groups: n = 10; interviews: n = 7). The survey demonstrated how hospices are not currently supporting many people with restricted or uncertain immigration status who are homeless and that hospice staff have received limited training around eligibility for entitlements or National Health Service (NHS) care. Interview and focus group data demonstrated high levels of unmet need. Reasons for this included a lack of consistency around eligibility for support from local authorities, issues relating to NHS charging, and mistrust and limited knowledge of the UK health and social care system. These barriers leave many people unable to access care toward the end of their lives. Conclusion To advocate for and provide compassionate palliative and end-of-life care for people with uncertain immigration status, there is need for more legal literacy, with training around people's entitlement to care and support, as well as easier access to specialist legal advice.
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Affiliation(s)
- Briony F. Hudson
- Marie Curie, One Embassy Gardens, 8 Viaduct Gardens, London SW11 7BW, UK
- Division of Psychiatry, Marie Curie Palliative Care Research Department, University College London, 6th Floor, Maple House, 149 Tottenham Court Road, London W1T 7NF, UK Pathway, London, UK
| | - Elizabeth Dzeng
- Department of Global Health and Social Medicine, King’s College London, London, UK
- Division of Hospital Medicine, Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | | | - Michelle Yeung
- Department of Primary Care Health Sciences, Radcliffe Observatory Quarter, University of Oxford, Oxford, UK
| | - Caroline Shulman
- Division of Psychiatry, Marie Curie Palliative Care Research Department, University College London, London, UK
- Pathway, London, UK
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Namata C, Hatzidimitriadou E. Strategies for improving access to primary care services for homeless immigrants in England: a Delphi study. Prim Health Care Res Dev 2023; 24:e70. [PMID: 38093561 PMCID: PMC10790723 DOI: 10.1017/s1463423623000646] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Revised: 09/22/2023] [Accepted: 11/05/2023] [Indexed: 12/18/2023] Open
Abstract
AIM The aim of the study was to identify the most prioritized strategies in improving access to primary care services (PCS) for homeless immigrants. BACKGROUND The issue of improving access to PCS for homeless immigrants is a complex and multifaceted one, and yet there is limited research on the strategies aimed at improving these services. Hence, the need for more studies that directly engage homeless immigrants and service providers in understanding their barriers to accessing PCS and their preferences for improving access to these services. METHODS The study used a two round Delphi method to elicit the views of stakeholders. The Delphi process utilized a web-based questionnaire. The stakeholders included healthcare providers and voluntary sector providers. The first round had a total of 58 items belonging to 14 categories. The second round comprised a total of 25 items belonging to 12 categories which were preselected based on participants' ranking of their importance in the first round. Participants were required to rank the relative importance of all the items on a 5-point Likert scale. Data were analysed using the STATA-15 software package. FINDINGS A total of 12 stakeholders participated in both rounds of the Delphi survey. The top three strategies encompassed fighting against discrimination and prejudice, improving and promoting mental health services, and empowering homeless immigrants. These evidence-based strategies hold the potential to support the implementation of healthcare interventions aimed at improving access to PCS and healthcare outcomes for homeless immigrants. However, it is crucial to conduct further research that includes homeless immigrants in the Delphi study to gain insights into the strategies that are most important to them in enhancing access to PCS, as they are the primary target users. Such research will contribute to the development of comprehensive and effective interventions tailored to the specific needs of homeless.
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Affiliation(s)
- Carol Namata
- Faculty of Medicine, Health and Social Care, Canterbury Christ Church University, Canterbury, Kent, England
| | - Eleni Hatzidimitriadou
- Faculty of Medicine, Health and Social Care, Canterbury Christ Church University, Canterbury, Kent, England
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Tomkow L, Prager G, Drinkwater J, Morris RL, Farrington R. 'That's how we got around it': a qualitative exploration of healthcare professionals' experiences of care provision for asylum applicants' with limited English proficiency in UK contingency accommodation. BMJ Open 2023; 13:e074824. [PMID: 37996230 PMCID: PMC10668227 DOI: 10.1136/bmjopen-2023-074824] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Accepted: 10/11/2023] [Indexed: 11/25/2023] Open
Abstract
OBJECTIVES The inadequate provision of language interpretation for people with limited English proficiency (LEP) is a determinant of poor health, yet interpreters are underused. This research explores the experiences of National Health Service (NHS) staff providing primary care for people seeking asylum, housed in contingency accommodation during COVID-19. This group often have LEP and face multiple additional barriers to healthcare access. Language discrimination is used as a theoretical framework. The potential utility of this concept is explored as a way of understanding and addressing inequities in care. DESIGN Qualitative research using semistructured interviews and inductive thematic analysis. SETTING An NHS primary care service for people seeking asylum based in contingency accommodation during COVID-19 housing superdiverse residents speaking a wide spectrum of languages. PARTICIPANTS Ten staff including doctors, nurses, mental health practitioners, healthcare assistants and students participated in semistructured online interviews. Some staff were redeployed to this work due to the pandemic. RESULTS All interviewees described patients' LEP as significant. Inadequate provision of interpretation services impacted the staff's ability to provide care and compromised patient safety. Discrimination, such as that based on migration status, was recognised and challenged by staff. However, inequity based on language was not articulated as discrimination. Instead, insufficient and substandard interpretation was accepted as the status quo and workarounds used, such as gesticulating or translation phone apps. The theoretical lens of language discrimination shows how this propagates existing social hierarchies and further disadvantages those with LEP. CONCLUSIONS This research provides empirical evidence of how the inadequate provision of interpreters forces the hand of healthcare staff to use shortcuts. Although this innovative 'tinkering' allows staff to get the job done, it risks normalising structural gaps in care provision for people with LEP. Policy-makers must rethink their approach to interpretation provision which prioritises costs over quality. We assert that the concept of language discrimination is a valuable framework for clinicians to better identify and articulate unfair treatment on the grounds of LEP.
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Affiliation(s)
| | | | - Jessica Drinkwater
- Centre for Primary Care and Health Services Research, The University of Manchester, Manchester, UK
| | - Rebecca L Morris
- Centre for Primary Care, The University of Manchester, Manchester, UK
| | - Rebecca Farrington
- Division of Medical Education, University of Manchester Faculty of Biology, Medicine and Health, Manchester, UK
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Peng B, Ling L. Health service behaviors of migrants: A conceptual framework. Front Public Health 2023; 11:1043135. [PMID: 37124818 PMCID: PMC10140430 DOI: 10.3389/fpubh.2023.1043135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Accepted: 03/14/2023] [Indexed: 05/02/2023] Open
Abstract
Universal health coverage is vital to the World Health Organization's (WHO's) efforts to ensure access to health as a human right. However, it has been reported that migrants, including both international immigrants and internal migrants, underuse health services. Establishing a conceptual framework to facilitate research on the health service behaviors (HSB) of migrants is particularly important. Many theoretical frameworks explaining the general population's HSB have been published; however, most theoretical frameworks on migrants' HSB only focus on international immigrants without the inclusion of internal migrants. Of note, internal migrants are much more abundant than immigrants, and this group faces similar barriers to HSB as immigrants do. Based on theoretical frameworks of immigrants' HSB and Anderson's behavior model, the author proposes a new conceptual framework of migrants' HSB that includes both immigrants and internal migrants. The new conceptual framework divides the determinants into macro-structural or contextual factors, health delivery system characteristics, and characteristics of the population at risk and describes subgroup-specific factors. The author added some variables and reclassified variables in some dimensions, including characteristics of health delivery systems and access to healthcare. The characteristics of health delivery systems comprise the volume, organization, quality, and cost of the health delivery system, while the characteristics of access to healthcare include time accessibility, geographic accessibility, and information accessibility. The outcomes of HSB have been expanded, and relationships between them have been reported. The mediating effects of some variables have also been described. This conceptual framework can facilitate a deep and comprehensive understanding of the HSB determination process for migrants, including internal migrants.
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Affiliation(s)
- Boli Peng
- Department of Actuarial Science, School of Insurance, Guangdong University of Finance, Guangzhou, China
| | - Li Ling
- Department of Medical Statistics, School of Public Health, Sun Yat-sen University, Guangzhou, China
- Center for Migrant Health Policy, Sun Yat-sen University, Guangzhou, China
- *Correspondence: Li Ling,
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Elisabeth M, Maneesh PS, Katarina SF, Slobodan Z, Michael S. Antimicrobial Resistance & Migrants in Sweden: Poor Living Conditions Enforced by Migration Control Policies as a Risk Factor for Optimal Public Health Management. Front Public Health 2021; 9:642983. [PMID: 34277534 PMCID: PMC8281056 DOI: 10.3389/fpubh.2021.642983] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Accepted: 06/11/2021] [Indexed: 11/13/2022] Open
Abstract
Infectious diseases exacerbated by Antimicrobial Resistance (AMR) are of increasing concern in Sweden, with multi-drug resistant strains associated with new resistance mechanisms that are emerging and spreading worldwide. Existing research has identified that sub-optimal living conditions and poor access to healthcare are significant factors in the spread and incubation of AMR strains. The article considers this linkage and the effort to control the spread of AMR in relation to migrants, highlighting deficiencies in public policy where such individuals are often increasingly exposed to those conditions that exacerbate AMR. In many of the richest countries, those conditions are not accidental, but often direct goals of policies designed with the goal of deterring migrants from staying within host countries. Without engaging with the politics around migration control, the article points to urgent need for more holistic assessment of all public policies that may, however unintentionally, undermine AMR control through worsening living conditions for vulnerable groups. The consequences of prioritizing policies meant to deliberately worsen the living conditions of migrants over avoiding those conditions that accelerate AMR spread, are today made ever apparent where new AMR strains have the potential to dwarf the societal effects of the current Covid-19 pandemic.
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Affiliation(s)
- Mangrio Elisabeth
- Department of Care Science, Faculty of Health and Society, Malmö University, Malmö, Sweden.,Malmö Institute for Studies of Migration, Diversity and Welfare (MIM), Malmö University, Malmö, Sweden
| | | | - Sjögren Forss Katarina
- Department of Care Science, Faculty of Health and Society, Malmö University, Malmö, Sweden
| | - Zdravkovic Slobodan
- Department of Care Science, Faculty of Health and Society, Malmö University, Malmö, Sweden.,Malmö Institute for Studies of Migration, Diversity and Welfare (MIM), Malmö University, Malmö, Sweden
| | - Strange Michael
- Malmö Institute for Studies of Migration, Diversity and Welfare (MIM), Malmö University, Malmö, Sweden.,Global Political Studies, Malmö University, Malmö, Sweden
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Jafar AJN. Advocating for those who need it most: our responsibility for delivering appropriate care to refugee and asylum seeking patients. Emerg Med J 2020; 38:3-4. [PMID: 33214198 DOI: 10.1136/emermed-2020-210800] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Accepted: 10/21/2020] [Indexed: 11/03/2022]
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9
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Health and hostile hospitality: Understanding asylum applicants' narratives of life and health in the UK. Soc Sci Med 2020; 265:113509. [PMID: 33190925 DOI: 10.1016/j.socscimed.2020.113509] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Revised: 10/27/2020] [Accepted: 11/05/2020] [Indexed: 11/24/2022]
Abstract
This paper explores how middle aged and older asylum applicants in the UK speak about health in relation to migratory experiences. It proposes biocredibility as a novel theoretical concept, through which the narratives of those migrating to the UK to seek asylum can be analysed. The UK government's hostile environments policies, which aim to make life uncomfortable for irregular migrants in the UK in order to drive down migration, have been criticised on legal, material and moral grounds. This paper adds to this critique. Narrative analysis of semi-structured interviews shows that the majority of the asylum applicants interviewed felt their health was poor and told of the difficulties of life in the UK. Stories of homelessness, poverty and exclusion dominated, underpinned by the erosion of their perceived trustworthiness and credibility through encounters with the Home Office. Particular personal experiences of social, political and economic strife in exile were narrated closely against stories of illness. The concept of biocredibility refers to, and provides a way of understanding, participants' propensity for creating narrative enclaves for pathographies as a discursive mechanism to add credibility to narratives of lived experience. In this way, visceral descriptions of biological suffering can function as a narrative resource. It does this firstly by providing material and social context for adverse health, thus allowing participants to attribute a socio-political cause for their illness. Secondly it interjects experiences of illness into life narratives, thus effectively communicating the significance of such experiences. Finally, it provides narrative evidence of individuals' autobiographical testimony. For discredited and marginalised asylum applicants, biocredibility can be understood to represent a strategy used to re-negotiate credibility and urges a critical consideration of the hostile and austere socio-political context in which it is observed.
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Baroudi M, San Sebastian M, Hurtig AK, Goicolea I. The perception of youth health centres' friendliness: does it differ between immigrant and Swedish-Scandinavian youths? Eur J Public Health 2020; 30:780-785. [PMID: 32417877 PMCID: PMC7445032 DOI: 10.1093/eurpub/ckaa077] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Ensuring a good quality service and equal access according to need for all young people is a key objective of the Swedish health system. The aim of this study was to explore youths' perception of youth health centres' (YHCs') friendliness and to assess the differences in perception between immigrant and Swedish-Scandinavian youths. METHODS All YHCs in the four northern counties in Sweden were invited (22 centres), and 20 agreed to participate. Overall, 1089 youths aged 16-25 years answered the youth-friendly health services-Sweden questionnaire between September 2016 and February 2017. Thirteen sub-domains of friendliness were identified and their scores were calculated. Multilevel analysis was used to examine the differences in perception between immigrant and Swedish-Scandinavian youths. RESULTS Our sample consisted of 971 Swedish-Scandinavian youths (89.2%) and 118 immigrants (10.8%). Generally, both groups perceived the services to be very friendly. All 13 sub-domains were rated more than three in a four-point scale except for fear of exposure and parental support of psychosocial services. However, immigrant youths perceived YHCs less friendly than their counterparts, particularly regarding the domains of equity, respect, quality and parental support. CONCLUSIONS Our study suggests that even though youths perceived YHCs as highly friendly, there is a space for improvement regarding access to health care. Our findings highlight the importance of an open and culturally sensitive attitude of the staff and the need to engage parents and community as a key to improve immigrant youths' accessibility to health care.
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Affiliation(s)
- Mazen Baroudi
- Department of Epidemiology and Global Health, Umeå University, Umeå, Sweden
| | | | - Anna-Karin Hurtig
- Department of Epidemiology and Global Health, Umeå University, Umeå, Sweden
| | - Isabel Goicolea
- Department of Epidemiology and Global Health, Umeå University, Umeå, Sweden
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Bailey C. Basic safety first: trauma-informed care in a hostile environment. BJPsych Bull 2020; 44:41-43. [PMID: 32223785 PMCID: PMC7283123 DOI: 10.1192/bjb.2019.91] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Accepted: 12/18/2019] [Indexed: 11/23/2022] Open
Abstract
SUMMARY This editorial introduces and reflects on a Praxis article in the trainees' section of this issue. The article, 'Assessing asylum seekers, refugees and undocumented migrants' by Waterman et al, begins with a clinical scenario describing an emergency presentation at a 'place of safety'. The authors are to be congratulated for navigating a compassionate path through the complexities of law, health and new diagnostic categories. The resources found in the article, drawing on the principles of trauma-informed care and the work of Judith Herman, can help trainees to be more confident in promoting the basic rights of survivors of trauma, which might form a first step in the re-establishment of trust and empowerment.
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Affiliation(s)
- Cate Bailey
- East London NHS Foundation Trust, UK
- Barts and the London School of Medicine, UK
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12
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Abstract
People seeking asylum experience health inequalities, and it is challenging to meet their needs in primary care. Consultations can feel overwhelming; however, there are excellent opportunities for Transformational Learning, transferable to other vulnerable people. A critical approach to evidence-based medicine, emphasising values, can be used to mitigate the consternation generated by these encounters and expand learners' perceptions about their roles and responsibilities. Global health, diversity, discrimination, intersectionality and power differentials can be explored. Realisation of the part practitioners play in leadership and advocacy is key. Helping the most marginalised is crucial to understanding patient-safety and quality improvement. Community-orientated approaches are performed well by Voluntary and Community Organisations. There is much to learn about co-production and their 'No Wrong Door' philosophy. Recognition of health literacy and promoting cultural sensibility for a growing population with Limited English Proficiency, also requires learning advanced communication skills. Developing therapeutic trust with forced migrants subjected to ill-treatment brings skills and behaviour relevant to other challenging encounters in primary care. Vicarious traumatisation is well-recognised when dealing with the sequelae of violence and, aided by their educators, primary care learners must understand ways to protect themselves and reflect on vicarious resilience, through recognising meaning in their work.
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Affiliation(s)
- Rebecca Farrington
- Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom of Great Britain and Northern Ireland.,GPwSI Specialist Asylum Seeker Service, Greater Manchester Mental Health Foundation Trust, Manchester, United Kingdom of Great Britain and Northern Ireland
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