Dissertation

Cribado de patología infecciosa y otras condiciones de salud en población migrante en Atención Primaria

Sequeira Aymar, Ethel

2024

Overview

Title: Screening for infectious pathology and other health conditions in migrant population in primary care.Introduction: Migration is an omnipresent phenomenon that affects all communities. The migrant population has specific health needs related to their country of origin and the migratory route, different from those of the native population, and which can sometimes go unnoticed in our health system.Primary Care (PC) is the gateway to the Spanish health system. If professionals are sensitive to the health needs of this group, a great impact can be generated on their health.Hypothesis: If PC health professionals are provided with tools and knowledge to identify andaddress certain health conditions early, the health of the migrant population will improve. The evidence of screening in the migrant population is low and most of the time, it is not contextualized at PC care level. There are recommendations on screening in the immigrant population, most of them based on expert opinions, but in many cases the implementation depends on health professionals.Goals:The main objective of our work is to improve the health of the migrant population through the early detection of certain infectious diseases and other health conditions such as mental health (MH) and female genital mutilation (FGM).Specific aims:1. To identify and evaluate good health practices in migrant care and to develop recommendations adapted to the PC context regarding infectious diseases including imported diseases, MH and FGM2. To raise awareness and to train PC professionals in the health needs of the migrant population.3. To evaluate through a pilot study the feasibility and effectiveness of the implementation of a screening program using a computer tool incorporated into the PC clinical history that would help the health professional in the decision-making process.4. To analyze the prevalence of pathologies included in the screening program.Methods:1. A literature review of national and international guidelines on health care and screening in immigrant population was carried out to develop recommendations adapted to the territory and PC which could be integrated into the digital tool.2. A pragmatic pilot cluster-randomized-controlled trial was deployed from March to December 2018. Eight primary care centers in Catalonia, Spain, were randomly allocated 1:1 to use of the digital tool for screening, or to routine care. The alert generates for each migrant patient who comes to the PCC for any reason, recommendations for screening conditions according to sex, age, and country of origin, variables collected in all PC users. In all centers, training was carried out on the health needs of the migrant population and referral circuits to specialized care were designed if necessary. The primary outcome was the monthly diagnostic yield of all aggregated infections. Intervention and control sites were compared before and after implementation with respect to their monthly diagnostic yield using a differences-in-differences analysis. This study is registered on international standard randomised controlled trial (ISRCTN14795012). Health data were extracted in an anonymized manner from the SIDIAP database (2012-2018).3. Prevalence of all condition included in the screening programme and regression models.4. Focus groups were subsequently held to find out the professionals' opinions on the usefulness of the alert, the training received and other perceptions regarding care for migrants.Main results:After a review of the existing literature and a consensus of experts, screening recommendations were based on coming from an endemic country for strongyloidiasis, schistosomiasis, and Chagas diseases; on a threshold level of prevalence for HIV (>1%), HBV (>2%), and HCV (>2%), and on incidence (>50 cases/100,000-inhabitants) for active tuberculosis in immigrants with <5 years in Europe. Exploring the risk of FGM is recommended in women from countries where this practice is prevalent. Evaluation of MH status is recommended for people from areas of conflict and violence.A total of 15,780 migrants registered at least one visit during the intervention period. 92.51% met the criteria to be screened for at least one infection. There were 210 (2.57%) individuals from the intervention group with new diagnoses compared with 113 (1.49%) from the control group [OR: 2.08, 95%CI 1.63-2.64, p<0.001]. The intervention centers raised their overall monthly diagnosis rate to 5.80 (1.23-10.38, p=0.013) extra diagnoses compared with the control centers.2,410 individuals were tested for at least one infection. Of the 508 (21.1%) migrants diagnosed with at least one condition, a higher proportion originated from Sub-Saharan Africa (207, 40.8%), followed by South-East Europe (117, 23.0%), (p-value<0.001). The proportion of migrants diagnosed with Chagas disease was 5/122(4.1%,0.5-7.7), for strongyloidiasis 56/409(13.7%, 10.3-17.0) and 2/101(2.0%, 0.0-4.7) for schistosomiasis, 67/1,176(5.7%, 4.4-7.0) for HIV; 377/1,478 (25.5%, 23.3-27.7) for HBV, and 31/1,433(2.2%, 1.4-2.9) for HCV.There were 3.7% of migrants diagnosed with at least one MS problem, the majority being women (65.8%). Of the 547 MH diagnoses diagnosed in 520 patients, 0.5% were mood disorders, 2.5% were anxiety disorders and 0.9% were sleep disorders. Overall, mental disorders were more frequent in migrants from Latin America and migrants who had arrived more recently in Spain.A total of 29 PC physicians participated in 4 focus groups. The main themes identified were:GPs found the ISMiHealth tool to be very useful for identifying specific health problems in migrants, although there are several additional barriers to screening.The importance of considering cultural perspectives when caring for migrants, and of the impact of migration on mental healthThe important role of PC in healthcare provision for migrantsKey proposals to improve screening of migrant populations. GPs also highlighted the urgent need to shift to a more holistic and adequately resourced approach to healthcare in PC.Conclusions:The ISMiHealth tool has improved the implementation of the screening program in migrant population in PC. Screening of migrants and detection of pathologies has increased in the period studied. PC professionals have been sensitized to the health needs of the migrant group. It is necessary to promote research to state and international levels to be able to serve more efficiently the migrant population in PC.

• Publisher: ProQuest Dissertations & Theses
• Subject: Health care management
• ISBN: 9798314837221