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      Impact on and use of health services by international migrants: questionnaire survey of inner city London A&E attenders

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          Abstract

          Background

          Changing immigration trends pose new challenges for the UK's open access health service and there is considerable speculation that migrants from resource-poor countries place a disproportionate burden on services. Data are needed to inform provision of services to migrant groups and to ensure their access to appropriate health care. We compared sociodemographic characteristics and impact of migrant groups and UK-born patients presenting to a hospital A&E/Walk-In Centre and prior use of community-based General Practitioner (GP) services.

          Methods

          We administered an anonymous questionnaire survey of all presenting patients at an A&E/Walk-In Centre at an inner-city London hospital during a 1 month period. Questions related to nationality, immigration status, time in the UK, registration and use of GP services. We compared differences between groups using two-way tables by Chi-Square and Fisher's exact test. We used logistic regression modelling to quantify associations of explanatory variables and outcomes.

          Results

          1611 of 3262 patients completed the survey (response rate 49.4%). 720 (44.7%) were overseas born, representing 87 nationalities, of whom 532 (73.9%) were new migrants to the UK (≤10 years). Overseas born were over-represented in comparison to local estimates (44.7% vs 33.6%; p < 0.001; proportional difference 0.111 [95% CI 0.087–0.136]). Dominant immigration status' were: work permit (24.4%), EU citizens (21.5%), with only 21 (1.3%) political asylum seekers/refugees. 178 (11%) reported nationalities from refugee-generating countries (RGCs), eg, Somalia, who were less likely to speak English. Compared with RGCs, and after adjusting for age and sex, the Australians, New Zealanders, and South Africans (ANS group; OR 0.28 [95% CI 0.11 to 0.71]; p = 0.008) and the Other Migrant (OM) group comprising mainly Europeans (0.13 [0.06 to 0.30]; p = 0.000) were less likely to have GP registration and to have made prior contact with GPs, yet this did not affect mode of access to hospital services across groups nor delay access to care.

          Conclusion

          Recently arrived migrants are a diverse and substantial group, of whom migrants from refugee-generating countries and asylum seekers comprise only a minority group. Service reorganisation to ensure improved access to community-based GPs and delivery of more appropriate care may lessen their impact on acute services.

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          Most cited references 31

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          Access to health care for asylum seekers in the European Union--a comparative study of country policies.

          The aim of our article is to characterise and compare current standards of health care provision for asylum seekers in the 25 European Union (EU) countries in order to identify the needs and potential for improving access to health care for asylum seekers. The study is based on an e-mail survey performed between April and June 2004. The questionnaire was concerned with asylum seekers' access to medical screening upon arrival, and their general access to health care services on April 1, 2004. The questionnaire was sent to ministries and NGOs responsible for asylum seekers' health care in the 25 EU countries. A total of 60% of the ministries and 20% of the NGOs responded. We received answers from 24 out of the 25 countries. Medical screening was provided to asylum seekers upon arrival in all EU countries but Greece. The content of screening programs, however, varied as well as whether they were voluntary or not. We found legal restrictions in access to health care in 10 countries. Asylum seekers were only entitled to emergency care in these countries. A number of practical barriers were also identified. Legal access to health care changed during the asylum procedure in some countries. Access to specialised treatment for traumatised asylum seekers existed in most countries. Health policies towards asylum seekers differ significantly between the EU countries and may result in the fact that the health needs of asylum seekers are not always adequately met.
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            Ethnicity, socio-economic position and gender--do they affect reported health-care seeking behaviour?

            While the pursuit of equity of access to health care is a central objective of many health care systems, there is evidence that patients of ethnic minority descent, in lower socio-economic position (SEP) or of female gender are less likely than Whites, more affluent groups or men, respectively, to access secondary and tertiary medical care. However, it is unclear at which point in the chain of events leading from perception of need through attendance at primary/emergency care, to referral and receipt of secondary care, this inequality occurs. This study examined the influence of ethnicity, socio-economic position and gender on an individual's perception of the need and urgency for seeking health care. A random sample was selected from two large city General Practices in the UK who were sent postal questionnaires which included two clinical vignettes describing characters experiencing chest pain and discovering a lump in the armpit. The main outcome measure was response to the 'chest pain' and 'lump' vignettes in terms of immediate health care utilisation. The questionnaire survey (n=1350, response rate 66%) indicated that Black respondents, respondents from lower socio-economic groups and women were at least as likely to report immediate health care seeking in response to the clinical vignettes than White respondents, those from higher socio-economic groups or men. This finding was consistent across all scenarios after adjustment for interpretation of the vignette, access to health services and attitudes to health and health care. For example, those in the lowest SEP group were almost 60% more likely to report immediate care seeking in response to the lump vignette (OR 1.59, 95% CI 1.08-2.33) compared to those in the highest SEP group; and Black respondents 40% more likely (OR 1.41, 95% CI 0.92-2.17). This study suggests inequalities in access to health care by ethnicity, socio-economic position and gender are not related to patients in these groups failing to self-refer to primary or accident and emergency care, barriers must therefore occur at the level of health care provision.
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              Systematic review of recent innovations in service provision to improve access to primary care.

              In England, there are particularly pressing problems concerning access to adequate primary care services. Consequently, innovative ways of delivering primary care have been introduced to facilitate and broaden access. The aim of this study was to review the evidence of seven recent innovations in service provision to improve access or equity in access to primary care, by performing a systematic review of the literature. Systematic review. Primary care in the United Kingdom (UK). Seven electronic databases were searched and key journals were hand-searched. Unpublished and 'grey' literature were sought via the Internet and through professional contacts. Intervention studies addressing one of seven recent innovations and conducted in the UK during the last 20 years were included. Two researchers independently assessed the quality of papers. Thirty studies (32 papers and two reports) were identified overall. Variation in study design and outcome measures made comparisons difficult. However, there was some evidence to suggest that access is improved by changing the ways in which primary care is delivered. First-wave personal medical services pilots facilitated improvements in access to primary care in previously under-served areas and/or populations. Walk-in centres and NHS Direct have provided additional access to primary care for white middle-class patients; there is some evidence suggesting that these innovations have increased access inequalities. There is some evidence that telephone consultations with GPs or nurses can safely substitute face-to-face consultations, although it is not clear that this reduces the number of face-to-face consultations over time. Nurse practitioners and community pharmacists can manage common conditions without the patient consulting a general practitioner. The evidence is insufficient to make clear recommendations regarding ways to improve access to primary care. In the future, it is important that, as new initiatives are planned, well-designed evaluations are commissioned simultaneously.
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                Author and article information

                Journal
                BMC Health Serv Res
                BMC Health Services Research
                BioMed Central (London )
                1472-6963
                2006
                29 November 2006
                : 6
                : 153
                Affiliations
                [1 ]International Health Unit, Department of Infectious Diseases and Immunity, Faculty of Medicine, Imperial College, Hammersmith Hospital Campus, London, W12 ONN, UK
                [2 ]Department of Primary Care and Social Medicine, Charing Cross Campus, Imperial College, W6 8RP, UK
                [3 ]Charing Cross Hospital, A&E Department, London, W6 8RF, UK
                [4 ]Statistics Advisory Service, Imperial College, London, SW7 2AZ, UK
                [5 ]Dover Health Centre, Dover, Kent CT16 1RH, UK
                Article
                1472-6963-6-153
                10.1186/1472-6963-6-153
                1698917
                17134491
                Copyright © 2006 Hargreaves et al; licensee BioMed Central Ltd.

                This is an Open Access article distributed under the terms of the Creative Commons Attribution License ( http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

                Categories
                Research Article

                Health & Social care

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