Blog posts

Study Reveals Critical Gaps in Catch-Up Vaccinations Among UK Migrants

In our study published in the journal BMC Medicine, we report significant vulnerabilities to infectious diseases among UK migrants due to under-vaccination for diseases preventable through routine immunisations – such as measles, mumps, rubella, and polio. Our mixed-methods study, conducted between May 2021 and September 2022 across several London-based general practices, sheds light on the urgent need for improved healthcare strategies that ensure migrants receive necessary catch-up vaccinations.

Background

Migrants in the UK and Europe are often at increased risk of vaccine-preventable diseases (VPDs) due to incomplete childhood vaccinations and systemic marginalisation from health services. The COVID-19 pandemic further exacerbated these disparities, highlighting the critical gaps in vaccination coverage among adult and adolescent migrants. The study aimed to quantify these vaccination gaps and explore new strategies to improve vaccination uptake through better integration into primary care systems.

Study Insights

The “Vacc on Track” study involved 57 migrants from 18 countries, revealing a troubling landscape of under-vaccination:

  • 86% of the participants needed catch-up vaccinations for MMR.
  • 88% required catch-up for tetanus, diphtheria, and polio (Td/IPV).
  • Despite high referrals for catch-up vaccinations (93%), completion rates were dismally low, with only 12% completing the Td/IPV series and 64% completing the MMR.

Barriers and Facilitators

We identified numerous barriers to effective vaccination, including:

  • Lack of systematic approaches to catch-up vaccination upon migrants’ arrival.
  • Primary care staff’s limited awareness and implementation of vaccination guidelines.
  • Structural challenges such as limited appointment availability and follow-up.

Conversely, potential facilitators highlighted the importance of staff champions and community-based approaches to improve vaccination uptake. These insights suggest that primary care can play a pivotal role in reducing health inequalities by adopting more culturally competent and accessible vaccination strategies.

Conclusion

The study underscores a pressing public health issue: the need to better integrate catch-up vaccinations within primary care to protect vulnerable populations against VPDs. By strengthening existing pathways and enhancing staff training and resources, healthcare systems can make significant strides toward ensuring that all community members, regardless of their origin, are protected against preventable diseases.

Moving Forward

our findings emphasise the need for further research and larger trials to refine and implement effective strategies that ensure equitable healthcare access. As the UK continues to navigate the challenges posed by migration and health disparities, such studies are essential for informing policy and practice, aiming for a healthier, more inclusive society. This research not only highlights the gaps but also charts a course for future action, aiming to transform insights into impactful health interventions.

Assigning disease clusters to people with multiple long-term conditions

Our new study in the Journal of Multimorbidity and Comorbidity sheds light on the challenges of assigning disease clusters to people with multiple long-term conditions

In the world of healthcare, understanding how to manage and treat multiple long-term conditions (MLTC) is a significant challenge. our explores the effectiveness of different strategies for assigning disease clusters to people with MLTCs, aiming to improve our understanding of health outcomes.

The study, a cohort analysis using primary care electronic health records from England, involved a massive sample of over 6.2 million patients. It evaluated the performance of seven different strategies for grouping diseases into clusters, with the aim of predicting mortality, emergency department attendances, and hospital admissions.

What are Disease Clusters?

Disease clusters are groups of conditions that frequently occur together, which may represent underlying shared causes or risk factors. By identifying these clusters, researchers hope to tailor preventive and therapeutic strategies more effectively.

Findings from the Study

We found that while assigning patients to disease clusters could provide a structured way to understand MLTCs, none of the strategies were particularly effective at predicting health-related outcomes when compared to considering each disease individually. Specifically, the method that counted the number of conditions within each cluster performed the best among the cluster-based strategies, but still fell short compared to a disease-specific approach.

This highlights a critical limitation: diseases within the same cluster may not consistently relate to health outcomes, suggesting that the clusters, while useful for some research applications, might not be reliable for predicting patient outcomes.

Implications for Healthcare

The study underscores the complexity of treating individuals with MLTCs. It suggests that while clustering diseases can help in understanding some aspects of multimorbidity, relying solely on these clusters to predict health outcomes might oversimplify the nuances of individual patient conditions.

For healthcare providers and policymakers, these findings emphasize the need for personalized treatment plans that consider the unique combination of diseases each patient has, rather than applying broad cluster-based approaches.

Future Directions

The researchers recommend further exploration into how disease clusters can be used in conjunction with individual disease information to improve health outcome predictions and treatment strategies. This might include integrating machine learning techniques that can handle large datasets and complex variable interactions more effectively.

Conclusion

This study provides valuable insights into the challenges and limitations of using disease clusters as a tool for managing MLTCs. It calls for a more nuanced approach that balances the simplicity of clustering with the complexity of individual patient profiles, ensuring that treatment strategies are both scientifically sound and tailored to meet individual needs.

For healthcare systems, continuing to invest in research that refines our understanding of MLTCs will be crucial for developing more effective and personalized approaches to treatment and care management in the future.

Bridging the Gap: Enhancing Catch-Up Vaccination Strategies for Migrant Populations in the UK

Among the many public health challenges facing the UK, the issue of equitable access to vaccinations stands out, particularly for adult migrants who might have missed critical immunisations due to disrupted healthcare services in their countries of origin or during the migration process. Our recent in-depth study published in Vaccine provides valuable insights into the experiences and perspectives of adult migrants regarding catch-up vaccinations and outlines strategies to improve their immunization coverage.

The study focused on adult migrants in the UK, including refugees, asylum seekers, undocumented migrants, and those without recourse to public funds. It used in-depth interviews to gather data on migrants’ experiences with and attitudes towards vaccination since arriving in the UK. Despite the UK having guidelines for offering catch-up vaccinations, the study revealed a significant lack of awareness and implementation at the primary care level.

One of the critical findings was that most participants were not routinely offered catch-up vaccinations nor asked about their vaccination history upon arrival. This oversight persists despite existing guidelines that advocate for such measures to prevent the spread of vaccine-preventable diseases (VPDs). Participants expressed a general positivity towards vaccinations when informed about them, although some hesitancy rooted in fears of side effects and distrust in the healthcare system due to past negative experiences.

The barriers to vaccination highlighted by the study include logistical challenges like language barriers, financial constraints, and a fundamental lack of trust in the healthcare system—often exacerbated by migrants’ fears of data sharing with immigration authorities. Moreover, the intense focus on COVID-19 vaccinations has overshadowed the need for routine and catch-up vaccinations, leading to what some describe as vaccination fatigue.

To address these challenges, our study proposes several strategies:

Enhanced Training and Incentives for Healthcare Providers: There’s a pressing need for training healthcare professionals about the importance of checking vaccination histories and actively offering catch-up vaccinations. Financial incentives might also encourage primary care providers to prioritize this activity.

Community Engagement and Tailored Communication: Building trust within migrant communities is crucial. This can be achieved by involving community leaders in health promotion activities and ensuring that vaccination campaigns are sensitive to cultural and individual needs.

Flexible Healthcare Services: Offering vaccinations in community settings and outside of standard clinic hours can make access to immunization more convenient for migrants who might struggle with traditional healthcare settings due to work or family commitments.

Implementing these strategies requires a multi-faceted approach, combining policy enforcement with grassroots initiatives to create an inclusive healthcare environment that recognizes the unique needs and challenges faced by migrants.

This comprehensive approach not only aims to protect vulnerable populations but also contributes to the broader public health goal of eliminating VPDs as a threat, ensuring that no community, especially not the migrant population, is left behind in our collective healthcare efforts. As the UK moves forward, it is crucial to integrate these strategies into routine healthcare practices to improve vaccination uptake and protect public health.

Walk This Way: How Counting Steps Can Lead to Better Health

Too many people in the UK are not physically active enough; leading to an increased risk of health problems. Counting the number of steps you take each day is a good way to monitor and increase your physical activity.

But how many steps should you take? 10,000 steps daily is a reasonable target for an active adult. For older people or those with medical conditions that limit their physical activity, a smaller number of steps may be sufficient.

The common recommendation of 10,000 steps per day is often used as a benchmark for a healthy activity level and it’s a good target for active adults looking to maintain or improve their overall health.

What about specific groups? For older adults, as mobility and energy levels can decrease with age, a lower step count might be a more realistic target and can still be beneficial. Even 6,000 to 8,000 steps per day can significantly benefit older adults. In fact, any amount of physical activity is beneficial.

For those with chronic health conditions, the appropriate number of daily steps can vary widely. It’s important for these individuals to set personalised goals that are challenging but attainable without exacerbating their medical conditions.

Try to find ways to incorporate more walking into your routine. Here are some ideas:

– Take the stairs instead of the elevator.

– Park further away from your destination and walk the extra distance.

– Take walking breaks throughout the workday.

– Walk during your lunch break.

What are the benefits of step counting? 

1. Encourages Physical Activity: Regularly counting steps can motivate individuals to be more physically active. It provides a quantifiable measure of activity, making it easier to set goals and track progress.

2. Health Improvements: Increasing your daily step count has many health benefits, including a reduced risk of cardiovascular disease, improved mental health, weight loss or maintenance, and enhanced muscular strength and endurance.

3. Accessible and Inclusive: Walking is a low-impact, moderate-intensity exercise that most people can perform without needing expensive equipment or facilities, making it an accessible form of physical activity for many.

While 10,000 steps is a good general target, it’s important for each individual to adjust their goals based on their personal health status, fitness level, and medical advice. Some people may find it more practical to start with a lower number of steps and gradually increase the number of steps as their fitness improves.

Using tools like pedometers or smartphone apps can help track your steps. Many of these devices also provide additional features such as estimating the number of calories burned, distance travelled, and active minutes; all of which can help in creating a balanced and customised fitness plan. Many of my patients have found these tools helpful and they are definitely worth exploring.

Ultimately, the key is consistency and integration of physical activity into daily life. Whether it’s aiming for 5,000 steps or 10,000, the goal should be to stay active and improve or maintain your health.

Increasing measles, mumps, and rubella (MMR) vaccine uptake in primary care

Measles cases in the UK have increased recently; putting at risk the health of children who are unvaccinated.[1] What can primary care teams do to boost measles (MMR) vaccine uptake? I discuss some actions that general practices can take in a recent comment in the British Medical Journal.

Implementing an effective vaccination programme within a general practice requires a multifaceted approach; combining clear leadership, comprehensive staff training, patient education, and meticulous record-keeping. The collective effort of the entire practice team is essential for its success. Assigning a dedicated team member to lead the vaccination programme ensures focused oversight. It is crucial that all staff are well-informed about the vaccination programme, including eligibility criteria and the benefits of vaccination for individuals, families, the NHS, and society. This knowledge can be enhanced through free online training.[2]

Developing a set of Frequently Asked Questions based on official sources like NHS England and the UKHSA, and training staff in effective communication strategies, are key steps in addressing patient concerns and misinformation. Accuracy of medical records is essential, especially in urban areas with high population mobility, to avoid unnecessary vaccination reminders. Regular audits and updating vaccine status during patient registration can help maintain record accuracy.[3]

Effective patient communication about the MMR vaccine’s benefits requires using multiple channels, including text messages, emails, and social media, as well as during consultations, to ensure impact. Practices should also consider the cultural and linguistic diversity of their patients, using appropriate materials and partnering with community organisations to enhance outreach.

Accessible clinics are also essential. Vaccination should be offered during routine appointments and through additional channels like mobile clinics or community centres. Monitoring vaccine uptake and actively following up unvaccinated patients through reminders can significantly improve vaccination rates.[4]

For patients vaccinated outside the practice, it is important to verify and record their vaccination status. Motivating staff with incentives to meet vaccination targets and collaborating with community groups can further improve vaccine uptake.

References

1. Bedford H, Elliman D. Measles rates are rising again. BMJ 2024; 384 :q259 doi:10.1136/bmj.q259

2. NHS England Immunisation e-learning programme. https://www.e-lfh.org.uk/programmes/immunisation/

3. Carter J, Mehrotra A, Knights F, Deal A, Crawshaw AF, Farah Y, Goldsmith LP, Wurie F, Ciftci Y, Majeed A, Hargreaves S. “We don’t routinely check vaccination background in adults”: a national qualitative study of barriers and facilitators to vaccine delivery and uptake in adult migrants through UK primary care. BMJ Open. 2022 Oct 10;12(10):e062894. doi: 10.1136/bmjopen-2022-062894.

4. Williams N, Woodward H, Majeed A, Saxena S. Primary care strategies to improve childhood immunisation uptake in developed countries: systematic review. JRSM Short Rep. 2011 Oct;2(10):81. doi: 10.1258/shorts.2011.011112.

Community health and wellbeing workers: a solution for improving health and care in England

In the quest to refine healthcare delivery in England, this innovative approach, inspired by Brazil’s successful community healthcare model, is a promising solution to the challenges faced by the NHS. The strategy focuses on the deployment of Community Health and Wellbeing Workers (CHWWs) to foster more efficient, localised healthcare services. Our recent article in the British Journal of General Practice discusses the potential of this model and how it could revolutionise healthcare in communities across England.

The Inspiration from Brazil

Brazil’s community healthcare model stands as a testament to the power of grassroots health initiatives. Over the past two decades, this approach has led to significant improvements in health outcomes, including reductions in cardiovascular mortality, hospital admissions, and health inequalities. The core of Brazil’s success lies in the integration of CHWWs into the healthcare system. These workers serve as pivotal links between GPs, community services, local authorities, and the communities they serve, especially in marginalized areas.

Pilot Program in Westminster

A pilot program in Westminster tested the feasibility of this model in England. The results were promising, showing increased vaccination and screening rates, along with a 7% drop in unscheduled GP visits in the first year alone. This indicates that CHWWs not only meet the existing demand for healthcare services but also successfully reach those in need of care who might not seek it out.

Addressing the Workforce Crisis

Beyond improving healthcare delivery, training and employing CHWWs offer a strategic solution to the current NHS workforce crisis. By upskilling volunteers and providing them with pathways to employment within the NHS, this initiative could significantly alleviate workforce shortages. Moreover, the role of a CHWW, demanding cultural competence, a non-judgmental attitude, and strong problem-solving skills, represents an attractive career opportunity for individuals passionate about community service.

Potential Impact in England

The adaptation of Brazil’s community health worker model to the English context could yield even greater benefits due to the wider availability of services. Acting as catalysts between healthcare, social care, and public health, CHWWs could play a crucial role in improving population health status and outcomes. The initial successes observed in Westminster suggest that a nationwide deployment of CHWWs could lead to considerable savings within public health, social care, and NHS budgets, alongside notable improvements in public health.

Funding and Support

For the CHWW initiative to be sustainable, securing long-term and reliable funding is essential. Proposals suggest adding to the fixed part of the Public Health Grant as a viable funding source. This approach aligns with the broader goal of creating an English family health strategy, which is both a feasible and cost-effective solution to current healthcare challenges.

Conclusion

The introduction of Community Health and Wellbeing Workers in England represents a forward-thinking solution to improving healthcare accessibility and efficiency. Inspired by Brazil’s model, this approach offers a holistic and integrated strategy to address the pressing challenges of the NHS, including strained budgets, workforce shortages, and the need for improved public health outcomes. With appropriate funding, support, and expansion across the country, CHWWs have the potential to significantly enhance the healthcare landscape in England, making it more responsive to the needs of its diverse populations.

Streamlining Hypertension Care with the BP@Home Programme

The rapid shift towards digital health solutions, propelled by the COVID-19 pandemic, has underscored the critical need for innovative approaches to healthcare delivery in the UK’s NHS. The BP@Home initiative, as explored in our recent study published in the journal PLOS ONE, stands out as a beacon of such innovation, aiming to revolutionise hypertension management in primary care settings across London.

The initiative, a response to the pandemic-induced transition to remote healthcare, supports patients with hypertension in self-monitoring their blood pressure at home. This programme not only aims to maintain continuous care for high-risk patients but also addresses a long-standing challenge of hypertension management — a leading contributor to cardiovascular diseases globally – in trying to improve blood pressure control.

Barriers and Facilitators to BP@Home Implementation

Despite its promise, the BP@Home initiative faces significant hurdles, primarily stemming from resource constraints — including IT, human, and financial resources. Healthcare professionals (HCPs) involved in the program highlighted several barriers, such as the distribution and tracking of blood pressure monitors, a lack of clear guidance on their use, and the substantial workload without commensurate financial incentives.

Conversely, the study also identified facilitators that could smooth the path for BP@Home’s implementation. These include robust communication channels, task-sharing among healthcare teams, and the integration of the programme into daily clinical practice. Moreover, providing blood pressure monitors on prescription and leveraging the role of pharmacists emerged as practical strategies to address logistical challenges.

Towards a More Equitable and Efficient Healthcare Delivery

The insights garnered from the study illuminate the complex dynamics of implementing a remote healthcare initiative within an already stretched healthcare system. The recommendations put forth — centred on project management, logistics, engagement of primary care networks & practices, and patient engagement — offer a roadmap for overcoming the identified barriers.

The BP@Home initiative, by incorporating a person-centred approach and maintaining flexibility in patient engagement (including non-digital options), paves the way for a healthcare model that is not only responsive to the current COVID-19 pandemic but is also resilient in the face of future healthcare challenges.

A Call to Action for Future Healthcare Innovations

The successful implementation of BP@Home and similar initiatives requires a concerted effort from all stakeholders involved — from policy makers and healthcare managers to frontline health care professionals and patients . It highlights the importance of adapting healthcare delivery to meet the evolving needs of the population, leveraging technology to bridge the gap between patients and providers, and ensuring equitable access to healthcare services.

As we move forward, the lessons learned from BP@Home can inform the development of future healthcare innovations, emphasising the need for a healthcare system that is adaptable, patient-centric, and equitable. It is through such initiatives that we can hope to achieve a more sustainable and effective healthcare delivery model, capable of addressing the multifaceted health challenges of the 21st century.

Bridging the Equity Gap in AI Healthcare Diagnostics

In an era where artificial intelligence (AI) is rapidly reshaping the landscape of healthcare diagnostics, our recent BMJ article sheds light on a critical issue: the equity gap in AI healthcare diagnostics. The UK’s substantial investment in AI technologies underscores the nation’s commitment to enhancing healthcare delivery through innovations. However, this evolution brings to the forefront the need for equity: defined as fair access to medical technologies and unbiased treatment outcomes for all.

AI’s potential in diagnosing clinical conditions like cancer, diabetes, and Alzheimer’s Disease is promising. Yet, the challenges of data representation, algorithmic bias, and accessibility of AI-driven technologies loom large, threatening to perpetuate existing healthcare disparities. Our article highlights that the quality and inclusivity of data used to train AI tools are often problematic, leading to less representative data and biases in AI models. These biases can adversely affect diagnostic accuracy and treatment outcomes, particularly for people from ethnic minority groups and women, who are often under-represented in medical research.

To bridge this equity gap, we advocate for a multi-dimensional systems approach rooted in strong ethical foundations, as outlined by the World Health Organization. This includes ensuring diversity in data collection, adopting unbiased algorithms, and continually monitoring and adjusting AI tools post-deployment. We also suggest establishing digital healthcare testbeds for systematic evaluation of AI algorithms and promoting community engagement through participatory design to tailor AI tools to diverse health needs.

A notable innovation would be the creation of a Health Equity Advisory and Algorithmic Stewardship Committee, spearheaded by national health authorities. This committee would set and oversee compliance with ethical and equity guidelines, ensuring AI tools are developed and implemented conscientiously to manage bias and promote transparency.

The advancement of AI in healthcare diagnostics holds immense potential for improving patient outcomes and healthcare delivery. However, realising this potential requires a concerted effort to address and mitigate biases, ensuring that AI tools are equitable and representative of the diverse populations they serve. As we move forward, prioritising rigorous data assessment, active community engagement, and robust regulatory oversight will be key to reducing health inequalities and fostering a more equitable healthcare landscape through the use of AI in healthcare diagnostics.

Understanding the Impact of COVID-19 on Emergency Hospital Admissions in Older Adults with Multimorbidity and Depression

During the COVID-19 pandemic, healthcare systems worldwide grappled with unprecedented challenges, particularly in managing vulnerable populations. Among these, older adults with multimorbidity and depression faced heightened risks, underscoring the need for targeted healthcare interventions to improve their health outcomes. Our recent study published in PLOS ONE offers helpful insights into this issue, focusing on unplanned emergency hospital admissions among patients aged 65 and older with multimorbidity and depression in Northwest London during and after the COVID-19 lockdown.

The study used retrospective cross-sectional data analysis, leveraging the Discover-NOW database for Northwest London. It included a sample of 20,165 registered patients aged 65+ with depression, analysing data across two periods: during the COVID-19 lockdown (23rd March 2020 to 21st June 2021) and an equivalent-length post-lockdown period (22nd June 2021 to 19th September 2022). Using multivariate logistic regression, we examined the impact of sociodemographic and multimorbidity-related characteristics on the likelihood of at least one emergency hospital admission during each period.

Key Findings:

– Men had a higher risk of emergency hospitalisation compared to women in both periods, with a noticeable increase post-lockdown.

– The risk of hospitalisation significantly increased with age, higher levels of deprivation, and a greater number of comorbidities across both periods.

– Asian and Black ethnicities showed a statistically significant protective effect compared to White patients during the post-lockdown period only.

The study’s conclusions highlight the need for proactive case reviews by multidisciplinary teams, especially for men with multimorbidity and depression, patients with a higher number of comorbidities, and those experiencing greater deprivation. The findings underscore the importance of understanding the specific healthcare needs of vulnerable populations during health crises like the COVID-19 pandemic to prevent unplanned admissions, improve health outcomes and reduce pressures on health systems.

This research not only contributes to the body of knowledge on healthcare use during the COVID-19 pandemic but also provides valuable insights for healthcare providers, policymakers, and researchers on the care of older adults with multimorbidity and depression. The findings emphasise the importance of tailored healthcare strategies to address the complex health needs of these patients, thereby ensuring that healthcare systems are better prepared for future public health emergencies.

Exploring the Impact of Diagnostic Timeframes on Multimorbidity Prevalence in England

Our study in published in BMJ Medicine in February 2024 examined the effect of defining timeframes for long-term conditions on the prevalence of multimorbidity in England, and on the role played by sociodemographic factors. Using primary care electronic health records from the Clinical Practice Research Datalink Aurum, the study included over 9.7 million adults registered in England as of 1 January 2020, focusing on 212 long-term conditions.

Key Findings

Varying Prevalence Rates: The prevalence of multimorbidity, defined as the coexistence of two or more long-term conditions, varied widely based on the timeframe used for definition. It ranged from 41% with stricter criteria (requiring three codes within any 12-month period) to a 74% when a single diagnostic code was deemed sufficient. Using conditions marked as active problems resulted in the lowest prevalence rate at 35%.

Sociodemographic Influences: The study revealed that younger individuals, certain minority ethnic groups, and those living in areas of lower socioeconomic deprivation were more likely to be reclassified as not multimorbid under timeframes that required more than one diagnostic code. This suggests that these groups are disproportionately affected by the criteria used to define long-term conditions.

Implications for Healthcare Policy and Research: The substantial variation in multimorbidity prevalence underscores the challenges in directly comparing estimates of multimorbidity between studies. It highlights the need for clear rationales behind the choice of timeframe and suggests a potential bias introduced by definitions requiring multiple codes. We recommended that researchers provide their reasoning for the timeframe choice and consider sensitivity analyses to explore the impact on different patient groups.

Addressing Multimorbidity in Healthcare

The findings emphasize the complexity of measuring multimorbidity and the influence of methodological decisions on prevalence estimates. This has important implications for healthcare policy, practice, and research; stressing the importance of adopting a nuanced approach to understanding and addressing the needs of people with multiple health conditions. It calls for a balance between the granularity of condition definitions and the practicality of healthcare delivery, ensuring that healthcare systems can adequately respond to the nuanced needs of its diverse patient population.

Conclusions

The study serves as a critical reminder of the dynamic nature of health conditions and the need for healthcare systems to adapt their approaches to effectively manage multimorbidity. It opens avenues for further research into optimising care for individuals with multiple long-term conditions, ultimately aiming to enhance clinical outcomes, patient experience quality of life, and healthcare efficiency.