Is screening for tuberculosis acceptable to immigrants? A qualitative study

Infections in Asymptomatic Unaccompanied Asylum-seeking Children in London 2016-2022

BACKGROUND

Unaccompanied asylum-seeking children are at increased risk of infections and experience barriers to healthcare access. There is a lack of evidence to underpin existing national and international guidance regarding asymptomatic infection screening in this population. We describe the results from routine infection screening of 1104 unaccompanied asylum-seeking children attending for testing at 3 London centers.

METHODS

We performed a retrospective analysis of routinely collected data from all unaccompanied asylum-seeking children seen in 3 services in London, United Kingdom, between 2016 and 2022.

RESULTS

A total of 1104 unaccompanied asylum-seeking children attended clinic; all accepted screening. The median age was 16 years (range 11-18 years) and 987 (89%) were male. 407 (37%) had at least 1 infection; 116 (11%) had multiple infections. Tuberculosis infection and schistosomiasis were common (found in 18% and 17%, respectively). Hepatitis B infection was identified with a prevalence of 3.9%. Giardia 7.7%, tapeworm 3.3% and Strongyloides 2.8% were also commonly identified.

CONCLUSIONS

We report the largest known dataset to our knowledge of infection screening in asymptomatic unaccompanied asylum-seeking children in Europe to date. This data supports recommendations for routine asymptomatic screening in this high-risk cohort, based on the significant prevalence identified of infections of both personal and public health significance.

Views and experiences of primary care among Black communities in the United Kingdom: a qualitative systematic review

BACKGROUND

In the United Kingdom, people with non-white ethnicities are more likely to report being in worse health conditions and have poorer experiences of healthcare services than white counterparts. The voices of those of Black ethnicities are often merged in literature among other non-white ethnicities. This literature review aims to analyse studies that investigate Black participant experiences of primary care in the UK.

METHODS

We conducted a systematic literature review searching Medline, Web of Science, EMBASE, SCOPUS, Social Policy and Practice, CINAHL plus, Psych INFO and Global Health with specific search terms for appropriate studies. No publish date limit was applied.

RESULTS

40 papers (39 articles and 1 thesis) were deemed eligible for inclusion in the review. A number of major themes emerged. Patient expectations of healthcare and the health seeking behaviour impacted their interactions with health systems in the UK. Both language and finances emerged as barriers through which some Black participants interacted with primary care services. (Mis)trust of clinicians and the health system was a common theme that often negatively impacted views of UK primary care services. The social context of the primary care service and instances of a cultural disconnect also impacted views of primary care services. Some papers detail patients recognising differential treatment based on ethnicity. The review included the voices of primary care professionals where descriptions of Black patients were overwhelmingly negative.

CONCLUSION

Views and experiences of Black groups may be radically different to other ethnic minorities and thus, should be teased out of broader umbrella terms like Black and Asian Minority Ethnic (BAME) and Black Minority Ethnic (BME). To address ethnicity-based health inequalities, culturally sensitive interventions that engage with the impacted community including co-designed interventions should be considered while acknowledging the implications of being racialised as Black in the UK.

Screening for neglected tropical diseases and other infections in refugee and asylum-seeker populations in the United Kingdom

Asylum-seekers and refugees have an increased burden of infections compared with the general population. This has been widely recognised by countries welcoming those fleeing conflict and persecution; however, there are no screening standardised guidelines and regulatory processes. Identification of certain neglected tropical diseases (NTDs) and other infections is important for the health and well-being of the individual in addition to public health and biosecurity. In the United Kingdom, screening for infections at port of entry or after arrival is not mandatory. Those on refugee resettlement programmes will have infection screening as part of their pre-entry health assessment, but no such system exists for those claiming asylum in the United Kingdom. In this article, we have reviewed published, peer-reviewed articles looking at the approaches to screening for NTDs and infectious diseases in the United Kingdom. In addition to this, we have reviewed the literature looking at the acceptability, barriers and facilitators of these screening practices. We found that there is a heterogeneous approach to screening practices in the United Kingdom and a paucity of data to support a single ‘best practice’ approach. Based on our findings, we have made recommendations and consideration for NTD screening strategies and highlighted important areas for future research.

Perspectives of Vietnamese, Sudanese and South Sudanese immigrants on targeting migrant communities for latent tuberculosis screening and treatment in low-incidence settings: A report on two Victorian community panels

Background

Tuberculosis (TB) elimination strategies in Australia require a focus on groups who are at highest risk of TB infection, such as immigrants from high‐burden settings. Understanding attitudes to different strategies for latent TB infection (LTBI) screening and treatment is an important element of justifiable elimination strategies.

Method

Two community panels were conducted in Melbourne with members of the Vietnamese (n = 11), Sudanese and South Sudanese communities (n = 9). Panellists were provided with expert information about LTBI and different screening and health communication strategies, then deliberated on how best to pursue TB elimination in Australia.

Findings

Both panels unanimously preferred LTBI screening to occur pre‐migration rather than in Australia. Participants were concerned that post‐migration screening would reach fewer migrants, noted that conducting LTBI screening in Australia could stigmatize participants and that poor awareness of LTBI would hamper participation. If targeted screening was to occur in Australia, the Vietnamese panel preferred ‘place‐based’ communication strategies, whereas the Sudanese and South Sudanese panel emphasized that community leaders should lead communication strategies to minimize stigma. Both groups emphasized the importance of maintaining community trust in Australian health service providers, and the need to ensure targeting did not undermine this trust.

Conclusion

Pre‐migration screening was preferred. If post‐migration screening is necessary, the potential for stigma should be reduced, benefit and risk profile clearly explained and culturally appropriate communication strategies employed. Cultural attitudes to health providers, personal health management and broader social vulnerabilities of targeted groups need to be considered in the design of screening programs.

Tuberculosis in migrants - screening, surveillance and ethics

Tuberculosis (TB) is the leading infectious cause of human mortality and is responsible for nearly 2 million deaths every year. It is often regarded as a ‘silent killer’ because it predominantly affects the poor and marginalized, and disease outbreaks occur in ‘slow motion’ compared to Ebola or coronavirus 2 (COVID-19). In low incidence countries, TB is predominantly an imported disease and TB control in migrants is pivotal for countries to progress towards TB elimination in accordance with the World Health Organisations (WHO’s) End TB strategy. This review provides a brief overview of the different screening approaches and surveillance processes that are in place in low TB incidence countries. It also includes a detailed discussion of the ethical issues related to TB screening of migrants in these settings and the different interests that need to be balanced. Given recognition that a holistic approach that recognizes and respects basic human rights is required to end TB, the review considers the complexities that require consideration in low-incidence countries that are aiming for TB elimination.

Integrated screening of migrants for multiple infectious diseases: Qualitative study of a city-wide programme

BACKGROUND

Migrants from certain regions are at increased risk of key infectious diseases (including HIV, tuberculosis (TB), hepatitis B and hepatitis C). Although guidelines increasingly recommend integrated screening for multiple infections to reduce morbidity little is known about what migrants and healthcare professionals think about this approach.

METHODS

Prospective qualitative study in Leicester, United Kingdom within a novel city-wide integrated screening programme in three iterative phases to understand views about infections and integrated screening. Phase 1 focus groups (nine) with migrants from diverse communities (n = 74); phase 2 semi-structured interviews with healthcare professionals involved in the screening pathway (n = 32); phase 3 semi-structured interviews (n = 23) with individuals having tested positive for one/more infections through the programme. Analysis was informed by the constant comparative process and iterative across phases 1-3.

FINDINGS

Migrants' awareness of TB, HIV and hepatitis B/C varied, with greater awareness of TB and HIV than hepatitis B/C; perceived susceptibility to the infections was low. The integrated screening programme was well-received by migrants and professionals; concerns were limited to data-sharing. As anticipated, given the target group, language was cited as a challenge but mitigated by various interpretation strategies.

INTERPRETATION

This large qualitative analysis is the first to confirm that integrated screening for key infectious diseases is feasible, positively viewed by, and acceptable to, migrants and healthcare professionals. These findings support recent guideline recommendations and therefore have important implications for policy-makers and clinicians as programmes of this type are more widely implemented in diverse settings.

FUNDING

National Institute for Health Research.

Factors influencing active tuberculosis case-finding policy development and implementation: a scoping review

OBJECTIVE

To explore antecedents, components and influencing factors on active case-finding (ACF) policy development and implementation.

DESIGN

Scoping review, searching MEDLINE, Web of Science, the Cochrane Database of Systematic Reviews and the World Health Organization (WHO) Library from January 1968 to January 2018. We excluded studies focusing on latent tuberculosis (TB) infection, passive case-finding, childhood TB and studies about effectiveness, yield, accuracy and impact without descriptions of how this evidence has/could influence ACF policy or implementation. We included any type of study written in English, and conducted frequency and thematic analyses.

RESULTS

Seventy-three articles fulfilled our eligibility criteria. Most (67%) were published after 2010. The studies were conducted in all WHO regions, but primarily in Africa (22%), Europe (23%) and the Western-Pacific region (12%). Forty-one percent of the studies were classified as quantitative, followed by reviews (22%) and qualitative studies (12%). Most articles focused on ACF for tuberculosis contacts (25%) or migrants (32%). Fourteen percent of the articles described community-based screening of high-risk populations. Fifty-nine percent of studies reported influencing factors for ACF implementation; mostly linked to the health system (eg, resources) and the community/individual (eg, social determinants of health). Only two articles highlighted factors influencing ACF policy development (eg, politics). Six articles described WHO's ACF-related recommendations as important antecedent for ACF. Key components of successful ACF implementation include health system capacity, mechanisms for integration, education and collaboration for ACF.

CONCLUSION

We identified some main themes regarding the antecedents, components and influencing factors for ACF policy development and implementation. While we know much about facilitators and barriers for ACF policy implementation, we know less about how to strengthen those facilitators and how to overcome those barriers. A major knowledge gap remains when it comes to understanding which contextual factors influence ACF policy development. Research is required to understand, inform and improve ACF policy development and implementation.

Evaluating a 24-year tuberculosis screening in first-grade elementary schoolers in a low-burden area

AIM

Early diagnosis of tuberculosis infection can significantly contribute to the control of the disease. The aim of the present study was to describe the tuberculin skin test (TST) trends over a 24-year period (1990-2013) and explore the value of universal tuberculosis screening in a low-burden area.

METHODS

All first graders that underwent TST during the 24-year study period (1990-2013) on the island of Crete, Greece, were retrospectively included in the study.

RESULTS

A total of 82 402 children (92.3% of Greek nationality; 51.0% male) underwent TST, of whom 335 (0.41%, 95% CI 0.37-0.46) were found to have positive TST while 0.27% of the study population had a TST between 5 and 9 mm. The tuberculin index declined significantly between 1990-1994 and 2010-2013 (0.67 vs 0.26; RR 2.73, 95% CI 1.82-4.09; p < 0.0001). Positive TST result was significantly higher in the immigrant than the native group (0.66% vs 0.24%; RR 3.76 95%, CI 2.89-4.84; p < 0.0001). In the last study years, 386 children (488 native; 153 immigrant) should be tested for one to be found TST positive.

CONCLUSION

Our findings question the massive tuberculin testing in low-burden areas and point to selective screening of high-risk groups.

A qualitative study exploring awareness and attitudes towards tuberculosis in migrant populations in a Metropolitan District Council in the North of England

Background

The majority of tuberculosis (TB) cases in the UK occur among people born in high-burden countries (73%), and are concentrated in large urban centres. This study explores migrants' attitudes and beliefs towards TB in an English District where the incidence is higher than the UK average.

Methods

Community engagement workers ran 26 focus groups using a standardized questionnaire. Purposeful sampling was used to obtain a cross-section of migrant communities. The summary reports were analysed using thematic analysis.

Results

Most groups did not see TB as a current issue in their community and associated it either with the past or with their country of birth. It appeared to be rarely discussed in their communities and generally not noted as being associated with stigma.

Conclusions

This study revealed a change in social attitudes to TB in migrant groups to those reported in previous literature. Stigma had considerably less effect than expected. However, the evidence revealed that these high-risk groups made the erroneous assumption that, by moving to a low incidence country, they were no longer at risk of the disease. TB services need to respond by revising the information that they provide to take into account the risk perception of these populations.

Wanting to or having to - a qualitative study of experiences and attitudes towards migrant screening for tuberculosis in Norway

Background

This study assesses how tuberculosis (TB) screening is perceived by immigrants in Norway. Screening is mandatory for people arriving from high incidence countries. To attend screening, immigrants have to contact the health system after receiving an invitation by letter. The proportion of non-attenders is not known, and there are no sanctions for not attending. Generally, only persons who test positive receive test results. The study explores users’ experiences, attitudes and motivations for attending or not attending TB screening, and perceived barriers and enablers.

Methods

We conducted six focus group discussions and three individual interviews with 34 people from 16 countries in Africa, Asia and Europe. Interviews were recorded and transcribed, and data was coded following a general inductive approach: All transcribed text data was closely read through, salient themes were identified and categories were created and labelled. The data was read through several times and the category system was subsequently revised.

Results

Most appreciated the opportunity to be tested for a severe disease and were generally positive towards the healthcare system. At the same time, many were uncomfortable with screening, particularly due to the fear and stigma attached to TB. All experienced practical problems related to language, information, and accessing facilities. Having to ask others for help made them feel dependent and vulnerable. Positive and negative attitudes simultaneously created ambivalence. Many wanted “structuring measures” like sanctions to help attendance. Many said that not receiving results left them feeling anxious.

Conclusions

In order to adapt the system and improve trust and patient uptake, all aspects of the screening should be taken into account. Ambivalence towards screening probably has a negative impact on screening uptake and should be sought reduced. A combination of ambivalence and a wish for “structuring measures” leads the authors to conclude that mandatory screening is a reasonable measure. However, since mandatory screening negatively impacts patient autonomy, and because of fear, stigma and practical problems, the health system should empower users by improving communication and access to services. In addition, it is recommended that negative test results are also communicated to the users.

Electronic supplementary material

The online version of this article (10.1186/s12889-019-7128-z) contains supplementary material, which is available to authorized users.

Community-based testing of migrants for infectious diseases (COMBAT-ID): impact, acceptability and cost-effectiveness of identifying infectious diseases among migrants in primary care: protocol for an interrupted time-series, qualitative and health economic analysis

BACKGROUND

Migration is a major global driver of population change. Certain migrants may be at increased risk of infectious diseases, including tuberculosis (TB), HIV, hepatitis B and hepatitis C, and have poorer outcomes. Early diagnosis and management of these infections can reduce morbidity, mortality and onward transmission and is supported by national guidelines. To date, screening initiatives have been sporadic and focused on individual diseases; systematic routine testing of migrant groups for multiple infections is rarely undertaken and its impact is unknown. We describe the protocol for the evaluation of acceptability, effectiveness and cost-effectiveness of an integrated approach to screening migrants for a range of infectious diseases in primary care.

METHODS AND ANALYSIS

We will conduct a mixed-methods study which includes an observational cohort with interrupted time-series analysis before and after the introduction of routine screening of migrants for infectious diseases (latent TB, HIV, hepatitis B and hepatitis C) when first registering with primary care within Leicester, UK. We will assess trends in the monthly number and rate of testing and diagnosis for latent TB, HIV, hepatitis B and hepatitis C to determine the effect of the policy change using segmented regression analyses at monthly time-points. Concurrently, we will undertake an integrated qualitative sub-study to understand the views of migrants and healthcare professionals to the new testing policy in primary care. Finally, we will evaluate the cost-effectiveness of combined infection testing for migrants in primary care.

ETHICS AND DISSEMINATION

The study has received HRA and NHS approvals for both the interrupted time-series analysis (16/SC/0127) and the qualitative sub-study (16/EM/0159). For the interrupted time-series analysis we will only use fully anonymised data. For the qualitative sub-study, we will gain written, informed, consent. Dissemination of the results will be through local and national meetings/conferences as well as publications in peer-reviewed journals.

Tuberculosis screening for prospective migrants to high-income countries: systematic review of policies

OBJECTIVE

To compare predeparture tuberculosis (TB) screening policies, including screening criteria and screening tests, and visa requirements for prospective migrants to high-income countries that have low to intermediate TB incidence and high immigration.

STUDY DESIGN

Systematic review of policy documents.

METHODS

We systematically identified high-income, high net-migration countries with an estimated TB incidence of <30 per 100,000. After initial selection, this yielded 15 countries which potentially had TB screening policies. We performed a systematic search of governmental and official visa services' websites for these countries to identify visa information and policy documents for prospective migrants. Results were summarized, tabulated, and compared.

RESULTS

Programs to screen for active TB were identified in all 15 countries, but screening criteria and screening tests varied substantially between countries. Prospective migrants' country of origin represented an initial assessment criterion which generally focused on elevated TB incidence based on World Health Organization data but also focused on the countries of origin that sent the most migrants, and this varied between destination countries. Specific categories of migrants represented a second assessment criterion that focused on duration of stay and reasons for migration; the focus of which showed variation between the destination countries. Specific screening tests including medical examination and chest X-rays were used as the final stage of assessment, and there were differences between which tests were used between the destination countries.

CONCLUSIONS

Current approaches to migrant TB screening are inconsistent in their approach and implementation. While this variation might reflect adaptation to local public health situations, it could also indicate uncertainty concerning optimal strategies. Comparative research studies are needed to define the most effective and efficient methods for TB screening of migrants.

'Valuable but incomplete!' A qualitative study about migrants' perspective on health examinations in Stockholm

Background

A voluntary health examination is offered to asylum seekers in Sweden with the purpose of detecting infectious diseases and identifying other health needs. This study aimed to explore the organization, content and perceived value of the health examination from the perspective of asylum seekers.

Methods

Semi-structured interviews were conducted with 18 migrants recruited from different settings in Stockholm. Data were transcribed verbatim and analysed using thematic analysis in relation to the availability, accessibility, acceptability and quality framework.

Results

Participants reported positive aspects of the health examination while raising important concerns, categorized into the following themes: availability-despite being available, the service was considered to be delayed with perceived implication for infection control; accessibility-migrants experienced no physical or economic barrier to access the health examination, especially when it was performed through a mobile clinic, however, they had limited access to information; acceptability and quality-migrants trusted the health staff, however, the examination lacked important aspects related to mental health and dental care needs, among other health needs.

Conclusion

Health examinations are valued by participants but failed to identify and address many perceived health needs. Mobile clinics seem a practical strategy to improve accessibility.

How effective are approaches to migrant screening for infectious diseases in Europe? A systematic review

Rates of migration to Europe, and within Europe, have increased in recent years, with considerable implications for health systems. Migrants in Europe face a disproportionate burden of tuberculosis, HIV, and hepatitis B and C, yet experience a large number of barriers to accessing statutory health care on arrival. A better understanding of how to deliver effective and cost-effective screening, vaccination, and health services to this group is now crucial. We did a systematic review to document and assess the effectiveness and cost-effectiveness of approaches used for infectious diseases screening, and to explore facilitators and barriers experienced by migrants to accessing screening programmes. Following PRISMA guidelines, we searched Embase, PubMed, PsychINFO, the Cochrane Library, and Web of Science (1989 to July 1, 2015, updated on Jan 1, 2018), with no language restrictions, and systematically approached experts across the European Union (EU) for grey literature. Inclusion criteria were primary research studies assessing screening interventions for any infectious disease in the migrant (foreign-born) population residing in EU or European Economic Area (EEA) countries. Primary outcomes were the following effectiveness indicators: uptake of screening, coverage, infections detected, and treatment outcomes. Of 4112 unique records, 47 studies met our inclusion criteria, from ten European countries (Belgium, Denmark, France, Italy, the Netherlands, Norway, Spain, Sweden, Switzerland, and the UK) encompassing 248 402 migrants. We found that most European countries screening migrants focus on single diseases only-predominantly active or latent tuberculosis infection-and specifically target asylum seekers and refugees, with 22 studies reporting on other infections (including HIV and hepatitis B and C). An infection was detected in 3·74% (range 0·00-95·16) of migrants. Latent tuberculosis had the highest prevalence across all infections (median 15·02% [0·35-31·81]). Uptake of screening by migrants was high (median 79·50% [18·62-100·00]), particularly in primary health-care settings (uptake 96·77% [76·00-100·00]). However, in 24·62% (0·12-78·99) of migrants screening was not completed and a final diagnosis was not made. Pooled data highlight high treatment completion in migrants (83·79%, range 0·00-100·00), yet data were highly heterogeneous for this outcome, masking important disparities between studies and infections, with only 54·45% (35·71-72·27) of migrants with latent tuberculosis ultimately completing treatment after screening. Coverage of the migrant population in Europe is low (39·29% [14·53-92·50]). Data on cost-effectiveness were scarce, but suggest moderate to high cost-effectiveness of migrant screening programmes depending on migrant group and disease targeted. European countries have adopted a variety of approaches to screening migrants for infections; however, these are limited in scope to single diseases and a narrow subset of migrants, with low coverage. More emphasis must be placed on developing innovative and sustainable strategies to facilitate screening and treatment completion and improve health outcomes, encompassing multiple key infections with consideration given to a wider group of high-risk migrants. Policy makers and researchers involved with global migration need to ensure a longer-term view on improving health outcomes in migrant populations as they integrate into health systems in host countries.

Acceptability of latent tuberculosis testing of migrants in a college environment in England

OBJECTIVES

The majority of tuberculosis (TB) cases in England occur from reactivation of latent tuberculosis infection (LTBI) in the settled migrant population. The National Institute for Health and Clinical Excellence recommends that new entrants from high-incidence countries are screened to detect LTBI. This article seeks to describe an outreach programme and testing for LTBI in an innovative setting-ESOL (English for Speakers of Other Languages) classes at a community college (CC) with evaluation of acceptability.

STUDY DESIGN

Partnership working with mixed methods used for evaluation of acceptability.

METHODS

A pre-existing network from the local TB partnership designed an outreach intervention and screening for LTBI among students from an ESOL programme at a CC. Screening for LTBI with interferon gamma release assay was the culmination of a programme of health improvement activities across the college. Any student on the ESOL programme younger than the age of 35 years and resident in the UK for less than 5 years was eligible for testing. LTBI testing was carried out on-site, and the experience was evaluated by questionnaires to staff, students and partners. A facilitated debrief among the partners gave further data.

RESULTS

A total of 440 eligible students were tested. One hundred and seventy-two student feedback questionnaires were completed, and 36 partner questionnaires were received with 18 CC staff responding. Students, tutors and healthcare professionals found the setting acceptable with some concerns about insufficient resource for timely follow-up.

CONCLUSIONS

Students, tutors, community organisations and health professionals found the exercise worthwhile and the method and setting acceptable. There were resource issues for the clinical team in follow-up of students with positive results for such a large screening event. Unexpected barriers were found by the CC as this kind of activity was not recognised for external quality review purposes. There were concerns about reputational loss and stigma of being involved in a TB project. As current initiatives aim to divert workload from stretched general practice surgeries, this may be an important addition to primary care screening.

Screening for infectious diseases of asylum seekers upon arrival: the necessity of the moral principle of reciprocity

Background

With a large number of forcibly displaced people seeking safety, the EU is facing a challenge in maintaining solidarity. Europe has seen millions of asylum seekers crossing European borders, the largest number of asylum seekers since the second world war. Endemic diseases and often failing health systems in their countries of origin, and arduous conditions during transit, raise questions around how to meet the health needs of this vulnerable population on arrival in terms of screening, vaccination, and access to timely and appropriate statutory health services. This paper explores the potential role of the principle of reciprocity, defined as the disposition ‘to return good in proportion to the good we receive, and to make reparations for the harm we have done’, as a mid-level principle in infectious disease screening policies.

Main text

More than half of the European countries implemented screening programmes for newly arrived asylum seekers. Screening may serve to avoid potential infectious disease risks in the receiving countries as well as help identify health needs of asylum seekers. But screening may infringe upon basic rights of those screened, thus creating an ethical dilemma.

The use of the principle of reciprocity can contribute to the identification of potential improvements for current screening programmes and emphasizes the importance of certain rights into guidelines for screening. It may create a two way moral obligation, upon asylum seekers to actively participate in the programme, and upon authorities to reciprocate the asylum seekers’ participation and the benefits for the control of public health.

Conclusion

The authors argue that the reciprocity principle leads to a stronger ethical justification of screening programmes and help achieve a balance between justifiable rights claims of the host population and the asylum seekers. The principle deserves a further and more thorough exploration of its potential use in the field of screening, migration and infectious diseases.

Barriers and facilitators to the uptake of tuberculosis diagnostic and treatment services by hard-to-reach populations in countries of low and medium tuberculosis incidence: a systematic review of qualitative literature

Tuberculosis disproportionately affects hard-to-reach populations, such as homeless people, migrants, refugees, prisoners, or drug users. These people often face challenges in accessing quality health care. We did a systematic review of the qualitative literature to identify barriers and facilitators to the uptake of tuberculosis diagnostic and treatment services by people from hard-to-reach populations in all European Union (EU), European Economic Area, EU candidate, and Organisation for Economic Co-operation and Development countries. The 12 studies included in this review mainly focused on migrants. Views on perceived susceptibility to and severity of tuberculosis varied widely and included many misconceptions. Stigma and challenges regarding access to health care were identified as barriers to tuberculosis diagnosis and treatment uptake, whereas support from nurses, family, and friends was a facilitator for treatment adherence. Further studies are required to identify barriers and facilitators to the improved identification and management of tuberculosis in hard-to-reach populations to inform recommendations for more effective tuberculosis control programmes.

Perspectives and experiences of new migrants on health screening in Sweden

BACKGROUND

In Sweden, migrants from countries considered to have a high burden of certain infectious diseases are offered health screening to prevent the spread of these diseases, but also identify their health needs. However, very little is known about their experiences and perceptions about the screening process. This study aimed at exploring these perceptions and experiences in order to inform policy and clinical practice.

METHOD

Using an interpretive description framework, 26 new migrants were interviewed between April and June 2013 in four Swedish counties. Thematic analysis was used to analyze data.

RESULTS

The three themes developed include: new country, new practices; new requirements in the new country; and unmet needs and expectations. Participants described what it meant for them to come to a new country with a foreign language, new ways of communicating with caregivers/authorities and being offered health screening without clarification. Participants perceived health screening as a requirement from the authorities to be fulfilled by all newcomers but conceded that it benefits equally the host society and themselves. However, they also expressed concern over the involvement of the Migration Board staff and feared possible collaboration with health service to their detriment. They further stated that the screening program fell short of their expectations as it mainly focused on identifying infectious diseases and overlooked their actual health needs. Finally, they expressed frustration over delay in screening, poor living conditions in reception centers and the restrictive entitlement to care.

CONCLUSIONS

Migrants are aware of their vulnerability and the need to undergo health screening though they view it as an official requirement. Thus, those who underwent the screening were more concerned about residency rather than the actual benefits of screening. The issues highlighted in this study may limit access to and uptake of the screening service, and compromise its effectiveness. To maximize the uptake: (1) linguistically and culturally adapted information is needed, (2) other screening approaches should be tried, (3) trained medical interpreters should be used, (4) a holistic and human right approach should be applied, (5) the involvement of migration staff should be reconsidered to avoid confusion and worries. Finally, to improve the effectiveness, (6) all migrants from targeted countries should be offered screening and efforts should be taken to improve the health literacy of migrants and the living conditions in reception centers.

Challenges in the provision of healthcare services for migrants: a systematic review through providers' lens

BACKGROUND

In recent years, cross-border migration has gained significant attention in high-level policy dialogues in numerous countries. While there exists some literature describing the health status of migrants, and exploring migrants' perceptions of service utilisation in receiving countries, there is still little evidence that examines the issue of health services for migrants through the lens of providers. This study therefore aims to systematically review the latest literature, which investigated perceptions and attitudes of healthcare providers in managing care for migrants, as well as examining the challenges and barriers faced in their practices.

METHODS

A systematic review was performed by gathering evidence from three main online databases: Medline, Embase and Scopus, plus a purposive search from the World Health Organization's website and grey literature sources. The articles, published in English since 2000, were reviewed according to the following topics: (1) how healthcare providers interacted with individual migrant patients, (2) how workplace factors shaped services for migrants, and (3) how the external environment, specifically laws and professional norms influenced their practices. Key message of the articles were analysed by thematic analysis.

RESULTS

Thirty seven articles were recruited for the final review. Key findings of the selected articles were synthesised and presented in the data extraction form. Quality of retrieved articles varied substantially. Almost all the selected articles had congruent findings regarding language andcultural challenges, and a lack of knowledge of a host country's health system amongst migrant patients. Most respondents expressed concerns over in-house constraints resulting from heavy workloads and the inadequacy of human resources. Professional norms strongly influenced the behaviours and attitudes of healthcare providers despite conflicting with laws that limited right to health services access for illegal migrants.

DISCUSSION

The perceptions, attitudes and practices of practitioners in the provision of healthcare services for migrants were mainly influenced by: (1) diverse cultural beliefs and language differences, (2) limited institutional capacity, in terms of time and/or resource constraints, (3) the contradiction between professional ethics and laws that limited migrants' right to health care. Nevertheless, healthcare providers addressedsuch problems by partially ignoring the immigrants'precarious legal status, and using numerous tactics, including seeking help from civil society groups, to support their clinical practice.

CONCLUSION

It was evident that healthcare providers faced several challenges in managing care for migrants, which included not only language and cultural barriers, but also resource constraints within their workplaces, and disharmony between the law and their professional norms. Further studies, which explore health care management for migrants in countries with different health insurance models, are recommended.

Challenges in the provision of healthcare services for migrants: a systematic review through providers' lens

BACKGROUND

In recent years, cross-border migration has gained significant attention in high-level policy dialogues in numerous countries. While there exists some literature describing the health status of migrants, and exploring migrants' perceptions of service utilisation in receiving countries, there is still little evidence that examines the issue of health services for migrants through the lens of providers. This study therefore aims to systematically review the latest literature, which investigated perceptions and attitudes of healthcare providers in managing care for migrants, as well as examining the challenges and barriers faced in their practices.

METHODS

A systematic review was performed by gathering evidence from three main online databases: Medline, Embase and Scopus, plus a purposive search from the World Health Organization's website and grey literature sources. The articles, published in English since 2000, were reviewed according to the following topics: (1) how healthcare providers interacted with individual migrant patients, (2) how workplace factors shaped services for migrants, and (3) how the external environment, specifically laws and professional norms influenced their practices. Key message of the articles were analysed by thematic analysis.

RESULTS

Thirty seven articles were recruited for the final review. Key findings of the selected articles were synthesised and presented in the data extraction form. Quality of retrieved articles varied substantially. Almost all the selected articles had congruent findings regarding language andcultural challenges, and a lack of knowledge of a host country's health system amongst migrant patients. Most respondents expressed concerns over in-house constraints resulting from heavy workloads and the inadequacy of human resources. Professional norms strongly influenced the behaviours and attitudes of healthcare providers despite conflicting with laws that limited right to health services access for illegal migrants.

DISCUSSION

The perceptions, attitudes and practices of practitioners in the provision of healthcare services for migrants were mainly influenced by: (1) diverse cultural beliefs and language differences, (2) limited institutional capacity, in terms of time and/or resource constraints, (3) the contradiction between professional ethics and laws that limited migrants' right to health care. Nevertheless, healthcare providers addressedsuch problems by partially ignoring the immigrants'precarious legal status, and using numerous tactics, including seeking help from civil society groups, to support their clinical practice.

CONCLUSION

It was evident that healthcare providers faced several challenges in managing care for migrants, which included not only language and cultural barriers, but also resource constraints within their workplaces, and disharmony between the law and their professional norms. Further studies, which explore health care management for migrants in countries with different health insurance models, are recommended.

Informing the design of a national screening and treatment programme for chronic viral hepatitis in primary care: qualitative study of at-risk immigrant communities and healthcare professionals

Background

Effective strategies are needed to provide screening and treatment for hepatitis B and C to immigrant groups in the UK at high risk of chronic infection. This study aimed to build an understanding of the knowledge, beliefs and attitudes towards these conditions and their management in a range of high-risk minority ethnic communities and health professionals, in order to inform the design of a screening and treatment programme in primary care.

Methods

Qualitative data collection consisted of three sequential phases- (i) semi-structured interviews with key informants (n = 17), (ii) focus groups with people from Chinese, Pakistani, Roma, Somali, and French- and English-speaking African communities (n = 95), and (iii) semi-structured interviews with general practitioners (n = 6). Datasets from each phase were analysed using the Framework method.

Results

Key informants and general practitioners perceived that there was limited knowledge and understanding about hepatitis B and C within high-risk immigrant communities, and that chronic viral hepatitis did not typically feature in community discourses about serious illness. Many focus group participants were confused about the differences between types of viral hepatitis, held misconceptions regarding transmission, and were unaware of the asymptomatic nature of chronic infection. Most welcomed the idea of a screening programme, but key informants and focus group participants also identified numerous practical barriers to engagement with primary care-based screening and treatment; including language and communication difficulties, limited time (due to long working hours), and (for some) low levels of trust and confidence in general practice-based care. General practitioners expressed concerns about the workload implications and sustainability of screening and treating immigrant patients for chronic viral hepatitis in primary care.

Conclusions

Strategies to reduce the burden of chronic viral hepatitis in immigrant communities will need to consider how levels of understanding about hepatitis B and C within these communities, and barriers to accessing healthcare, may affect capacity to engage with screening and treatment. Services may need to work with community groups and language support services to provide information and wider encouragement for screening. Primary care services will need ongoing consultation regarding their support needs to deliver hepatitis screening and treatment programmes.

Screening for latent TB, HIV, and hepatitis B/C in new migrants in a high prevalence area of London, UK: a cross-sectional study

Background

Rising rates of infectious diseases in international migrants has reignited the debate around screening. There have been calls to strengthen primary-care-based programmes, focusing on latent TB. We did a cross-sectional study of new migrants to test an innovative one-stop blood test approach to detect multiple infections at one appointment (HIV, latent tuberculosis, and hepatitis B/C) on registration with a General Practitioner (GP) in primary care.

Methods

The study was done across two GP practices attached to hospital Accident and Emergency Departments (A&E) in a high migrant area of London for 6 months. Inclusion criteria were foreign-born individuals from a high TB prevalence country (>40 cases per 100,000) who have lived in the UK ≤ 10 years, and were over 18 years of age. All new migrants who attended a New Patient Health Check were screened for eligibility and offered the blood test. We followed routine care pathways for follow-up.

Results

There were 1235 new registrations in 6 months. 453 attended their New Patient Health Check, of which 47 (10.4%) were identified as new migrants (age 32.11 years [range 18–72]; 22 different nationalities; time in UK 2.28 years [0–10]). 36 (76.6%) participated in the study. The intervention only increased the prevalence of diagnosed latent TB (18.18% [95% CI 6.98-35.46]; 181.8 cases per 1000). Ultimately 0 (0%) of 6 patients with latent TB went on to complete treatment (3 did not attend referral). No cases of HIV or hepatitis B/C were found. Foreign-born patients were under-represented at these practices in relation to 2011 Census data (Chi-square test −0.111 [95% CI −0.125 to −0.097]; p < 0.001).

Conclusion

The one-stop approach was feasible in this context and acceptability was high. However, the number of presenting migrants was surprisingly low, reflecting the barriers to care that this group face on arrival, and none ultimately received treatment. The ongoing UK debate around immigration checks and charging in primary care for new migrants can only have negative implications for the promotion of screening in this group. Until GP registration is more actively promoted in new migrants, a better place to test this one-stop approach could be in A&E departments where migrants may present in larger numbers.

Electronic supplementary material

The online version of this article (doi:10.1186/s12879-014-0657-2) contains supplementary material, which is available to authorized users.

Engaging new migrants in infectious disease screening: a qualitative semi-structured interview study of UK migrant community health-care leads

Migration to Europe - and in particular the UK - has risen dramatically in the past decades, with implications for public health services. Migrants have increased vulnerability to infectious diseases (70% of TB cases and 60% HIV cases are in migrants) and face multiple barriers to healthcare. There is currently considerable debate as to the optimum approach to infectious disease screening in this often hard-to-reach group, and an urgent need for innovative approaches. Little research has focused on the specific experience of new migrants, nor sought their views on ways forward. We undertook a qualitative semi-structured interview study of migrant community health-care leads representing dominant new migrant groups in London, UK, to explore their views around barriers to screening, acceptability of screening, and innovative approaches to screening for four key diseases (HIV, TB, hepatitis B, and hepatitis C). Participants unanimously agreed that current screening models are not perceived to be widely accessible to new migrant communities. Dominant barriers that discourage uptake of screening include disease-related stigma present in their own communities and services being perceived as non-migrant friendly. New migrants are likely to be disproportionately affected by these barriers, with implications for health status. Screening is certainly acceptable to new migrants, however, services need to be developed to become more community-based, proactive, and to work more closely with community organisations; findings that mirror the views of migrants and health-care providers in Europe and internationally. Awareness raising about the benefits of screening within new migrant communities is critical. One innovative approach proposed by participants is a community-based package of health screening combining all key diseases into one general health check-up, to lessen the associated stigma. Further research is needed to develop evidence-based community-focused screening models - drawing on models of best practice from other countries receiving high numbers of migrants.

Tuberculosis control in big cities and urban risk groups in the European Union: a consensus statement

In low-incidence countries in the European Union (EU), tuberculosis (TB) is concentrated in big cities, especially among certain urban high-risk groups including immigrants from TB high-incidence countries, homeless people, and those with a history of drug and alcohol misuse. Elimination of TB in European big cities requires control measures focused on multiple layers of the urban population. The particular complexities of major EU metropolises, for example high population density and social structure, create specific opportunities for transmission, but also enable targeted TB control interventions, not efficient in the general population, to be effective or cost effective. Lessons can be learnt from across the EU and this consensus statement on TB control in big cities and urban risk groups was prepared by a working group representing various EU big cities, brought together on the initiative of the European Centre for Disease Prevention and Control. The consensus statement describes general and specific social, educational, operational, organisational, legal and monitoring TB control interventions in EU big cities, as well as providing recommendations for big city TB control, based upon a conceptual TB transmission and control model.

Tuberculosis in migrant populations. A systematic review of the qualitative literature

BACKGROUND

The re-emergence of tuberculosis (TB) in low-incidence countries and its disproportionate burden on immigrants is a public health concern posing specific social and ethical challenges. This review explores perceptions, knowledge, attitudes and treatment adherence behaviour relating to TB and their social implications as reported in the qualitative literature.

METHODS

Systematic review in four electronic databases. Findings from thirty selected studies extracted, tabulated, compared and synthesized.

FINDINGS

TB was attributed to many non-exclusive causes including air-born transmission of bacteria, genetics, malnutrition, excessive work, irresponsible lifestyles, casual contact with infected persons or objects; and exposure to low temperatures, dirt, stress and witchcraft. Perceived as curable but potentially lethal and highly contagious, there was confusion around a condition surrounded by fears. A range of economic, legislative, cultural, social and health system barriers could delay treatment seeking. Fears of deportation and having contacts traced could prevent individuals from seeking medical assistance. Once on treatment, family support and "the personal touch" of health providers emerged as key factors facilitating adherence. The concept of latent infection was difficult to comprehend and while TB screening was often seen as a socially responsible act, it could be perceived as discriminatory. Immigration and the infectiousness of TB mutually reinforced each another exacerbating stigma. This was further aggravated by indirect costs such as losing a job, being evicted by a landlord or not being able to attend school.

CONCLUSIONS

Understanding immigrants' views of TB and the obstacles that they face when accessing the health system and adhering to a treatment programme-taking into consideration their previous experiences at countries of origin as well as the social, economic and legislative context in which they live at host countries- has an important role and should be considered in the design, evaluation and adaptation of programmes.

Tuberculosis: evidence review for newly arriving immigrants and refugees

BACKGROUND

The foreign-born population bears a disproportionate health burden from tuberculosis, with a rate of active tuberculosis 20 times that of the non-Aboriginal Canadian-born population, and could therefore benefit from tuberculosis screening programs. We reviewed evidence to determine the burden of tuberculosis in immigrant populations, to assess the effectiveness of screening and treatment programs for latent tuberculosis infection, and to identify potential interventions to improve effectiveness.

METHODS

We performed a systematic search for evidence of the burden of tuberculosis in immigrant populations and the benefits and harms, applicability, clinical considerations, and implementation issues of screening and treatment programs for latent tuberculosis infection in the general and immigrant populations. The quality of this evidence was assessed and ranked using the GRADE approach (Grading of Recommendations Assessment, Development and Evaluation).

RESULTS

Chemoprophylaxis with isoniazid is highly efficacious in decreasing the development of active tuberculosis in people with latent tuberculosis infection who adhere to treatment. Monitoring for hepatotoxicity is required at all ages, but close monitoring is required in those 50 years of age and older. Adherence to screening and treatment for latent tuberculosis infection is poor, but it can be increased if care is delivered in a culturally sensitive manner.

INTERPRETATION

Immigrant populations have high rates of active tuberculosis that could be decreased by screening for and treating latent tuberculosis infection. Several patient, provider and infrastructure barriers, poor diagnostic tests, and the long treatment course, however, limit effectiveness of current programs. Novel approaches that educate and engage patients, their communities and primary care practitioners might improve the effectiveness of these programs.

Imported infectious diseases in mobile populations, Spain

Health screening of immigrant populations is needed to ensure early diagnosis and treatment.

Migration has contributed to the emergence of certain infectious diseases. To determine which infectious diseases were most common among 2 mobile immigrant groups (sub-Saharan Africans and Latin Americans) in Spain, we analyzed health and demographic characteristics of 2,198 immigrants referred to the Tropical Medicine Unit of Ramón y Cajal Hospital over a 20-year period. The most frequent diagnoses were for latent tuberculosis (716 patients [32.6%]), filariasis (421 [19.2%]), hepatropic virus chronic infection (262 [19.2%]), intestinal parasites (242 [11.0%]), and malaria (212 [9.6%]). Health screening of immigrant populations is needed to ensure early diagnosis and treatment of potentially transmissible infections.

Using focus groups to inform pharmacy research

BACKGROUND

Focus groups are a powerful research tool for collecting qualitative information across many contexts. The focus group offers pharmacy researchers benefits that support many of the important lines of investigation at the forefront of contemporary pharmacy-based research, particularly within the areas of patient compliance/concordance, customer behavior, patient-provider collaboration, health literacy research, and disease management. This article introduces the focus group as a research method that offers powerful investigative potential to researchers who are attempting to understand human-based phenomena.

OBJECTIVES

To provide sufficient background, examples, and how to information to enable a pharmacy researcher to include focus group methodologies in their initial design decisions, and provide guidance to additional resources necessary for successful implementation of this powerful qualitative approach.

METHODS

The article is organized into sections describing what a focus group is and what it can be used for; the unique benefits and drawbacks of using focus group methodology; organization and planning considerations including participant and recruitment considerations; and sampling strategies, session and question development, practical details of session management, and follow-up activities, including data analysis.

RESULTS/CONCLUSION

Although often considered quick and easy focus groups require thoughtful consideration of need and purpose, considerable planning, and effort to succeed. Because of the unique insight that can be gained, their flexibility, and their ability to mesh with other methods, focus group is gaining currency as an important research tool within health care.

Knowledge of tuberculosis transmission among recently infected patients in Glasgow

OBJECTIVES

To examine perceptions and understanding of disease causation in tuberculosis patients with few epidemiological links detected by contact tracing.

STUDY DESIGN

An exploratory qualitative study using semi-structured interviews was undertaken. Patients' beliefs were explored against a background of medical thinking about tuberculosis transmission and the current approach to contact tracing.

METHODS

Interviews were undertaken with patients (n=23) or suitable next of kin (n=3). Study patients were diagnosed with tuberculosis in Glasgow, an urban area of Scotland, between 1997 and 2004. All had a genetically indistinguishable 15-banded IS6110 restriction fragment length polymorphism pattern of the Beijing family of Mycobacterium tuberculosis, suggestive of recently transmitted infection, yet few had epidemiological links detectable as a result of contact tracing (30.8%).

RESULTS

Interviewees had varying levels of knowledge, but most believed that tuberculosis was caused by a pathogen, spread by person-to-person contact. Modes of transmission were thought to include airborne transmission, sharing utensils with an infected individual, consumption of contaminated foods/liquids, and exchange of bodily fluids. Prolonged contact was not thought to be required for transmission to occur. Impaired immunity, social factors and environmental factors were believed to enhance the potential for transmission.

CONCLUSIONS

Patients have complex beliefs about tuberculosis transmission and causation, which do not always mirror those of health professionals. Adopting and implementing an approach to contact identification that is aligned with lay beliefs may result in improved contact tracing outcomes.

Educational outreach to promote screening for tuberculosis in primary care: a cluster randomised controlled trial

BACKGROUND

Tuberculosis is re-emerging as an important health problem in industrialised countries. Uncertainty surrounds the effect of public-health control options. We therefore aimed to assess a programme to promote screening for tuberculosis in a UK primary health care district.

METHODS

In a cluster randomised controlled trial, we randomised 50 of 52 (96%) eligible general practices in Hackney, London, UK, to receive an outreach programme that promoted screening for tuberculosis in people registering in primary care, or to continue with usual care. Screening was verbal, and proceeded to tuberculin skin testing, if appropriate. The primary outcome was the proportion of new cases of active tuberculosis identified in primary care. Analyses were done on an intention-to-treat basis. This study was registered at clinicaltrials.gov, number NCT00214708.

FINDINGS

Between June 1, 2002, and Oct 1, 2004, 44,986 and 48,984 patients registered with intervention and control practices, respectively. In intervention practices 57% (13,478 of 23,573) of people attending a registration health check were screened for tuberculosis compared with 0.4% (84 of 23 051) in control practices. Intervention practices showed increases in the diagnosis of active tuberculosis cases in primary care compared with control practices (66/141 [47%] vs 54/157 [34%], odds ratio (OR) 1.68, 95% CI 1.05-2.68, p=0.03). Intervention practices also had increases in diagnosis of latent tuberculosis (11/59 [19%] vs 5/68 [9%], OR 3.00, 0.98-9.20, p=0.055) and BCG coverage (mean BCG rate 26.8/1000 vs 3.8/1000, intervention rate ratio 9.52, 4.0-22.7, p<0.001).

INTERPRETATION

Our educational intervention for promotion of screening for tuberculosis in primary care improved identification of active and latent tuberculosis, and increased BCG coverage. Yield from screening was low, but was augmented by improved case-finding. Screening programmes in primary care should be considered as part of tuberculosis control initiatives in industrialised countries.