Week 6 Flashcards

Question

Birmingham is diverse

Answer 1

Both net migration and the diversity of new arrivals is increasing Home to people of more than 187 different nationalities A “majority minority” city In the 2021 census 26.7% population had been born overseas, 39.5% of those born overseas have been in UK for less than 10 years In some wards almost 30% of residents have a main language other than English and around 10-12% cannot speak English well or at all - in some wards 15-20% of households do not have a single household member over 16 who speaks English as a main language

Answer 2

Refers to the movements of refugees and internally displaced people (those displaced by conflicts) as well as people displaced by natural or environmental disasters, chemical or nuclear disasters, famine, or development projects Reasons for forced migration also include: -climate change impact of this is especially severe where other pressures on food security eg conflict -persecution on basis of religious or political beliefs/activity or sexual orientation

Answer 3

Mixed movements (or mixed migration) refers to flows of people travelling together Moving in an irregular manner over the same routes and using the same means of transport The men, women and children travelling in this manner often have either been forced from their homes by armed conflict or persecution or are on the move in search of a better life People travelling as part of mixed movements have varying needs May be asylum seekers, refugees, stateless people, victims of trafficking, unaccompanied or separated children and migrants in an irregular situation Mixed movements are often complex, and can present challenges for all those involved

Answer 4

Mixed migrations occur in a range of political and social contexts that impose their own challenges: -the “opening of the borders” and germanys welcome in 2015 -progressive closure of the Macedonian border in 2016-INDOMENI -the Greek economic crisis was background to this —economy shrank 26% since 2008, public services devastated -60000+ stranded in a society without means to support them -the most expensive (per head) humanitarian crisis in history -70 dollars in every 100 spent wasted

Answer 5

Origin (predeparture and re migration), Health and wellbeing of people and populations Destination (temporary or circular or permanent (resettlement) Short term transit Interception Longer term transit Return

Answer 6

“The recruitment, transportation, transfer, harbouring or receipt of persons by means of threat or use of force or other forms of coercion, of abductions of fraud, of deception, of the abuse of power, or of a position of vulnerability or of the giving or receiving of payments or benefits to achieve the consent of a person, resulting in control over another person, for the purpose of exploitation” Migrants are vulnerable to trafficking before, during or after their journey ‘National referral mechanism” - an official 45 day recovery programme for victims of trafficking after which they may or may not claim asylum or accept repatriation

Answer 7

A person or persons pay another party to transport them illegally from one country to another The person is free once they reach their destination Its always illegal

Answer 8

Modern slavery: -define by the modern slavery act 2015 -“knowlingly holding a person in slavery or servitude or knowingly requiring a person to perform forced or compulsory labour” Includes trafficking and exploitation Over laps with smuggling -the person paying the smuggler may be offered terms- eg “pay later” and given a deadline -this person is then vulnerable to bonded labour and other abuses Resettlement: -official programmes to move recognised refugees from LMIC to high income countries eg Syrian vulnerable persons resettlement scheme

Answer 9

Anticipation: -adverse treatment due to race, ethnicity, sexuality, religion or politics -risk of ethnic violence increases if one group constitutes 40-95% of the population Adversity: -conflict, ethnic cleansing, sexual violence, torture Survival: -risks and challenges of the journey Integration: -challenges and barriers in the host country

Answer 10

>52760 dead inside Europe or Mediterranean since 1993 >18000 children missing Drowning- rivers and oceans: Mediterranean, evros river on land border of Greece and turkey Violence from border officials and police: illegal border push backs and denial of right to claim asylum, refoulment- forcible return to countries they are fleeing, deportation and detention Unsafe modes of transport: refrigerated lorries (suffocation), under trains, road traffic accidents Hypothermia/hostile environments (eg desert) Carbon monoxide poisoning Unsafe and unsanitary conditions inside camps: fire, disease, malnutrition Poor access to healthcare Suicide and addiction

Answer 11

Immigration process -‘culture of disbelief’. Disbelief of accounts of abuse, torture or reason for forced migration. Inexperienced and inadequately trained home office case workers (freedom from torture 2017) -age disputes- incorrect assessments expose minors to risk and increase vulnerability -limited access to legal advice and legal aid to appeal/poor quality advice -immigration detention- can be indefinite with poor access to healthcare -continued uncertainty The “hostile environment” in the UK -proof of ‘right to reside’ needed to access rental accommodation, drivers licenses, employment, some healthcare -family reunification challenging -dispersal (no control over destination and moves disrupt supportive relationships with individuals and organisations) and NRPF status

Answer 12

The 2022 immigration bill Applied to arrivals from June 2022 -those who arrive by any route and apply for asylum without delay and arrive without passing through a “safe” country -same asylum process as previously -5 year permission to stay with the right to indefinite leave after this if protection still needed -governments intention was to remove some people to Rwanda if arrived after 1st jan 2022 this has been challenged

Answer 13

Places a legal duty on the Home Secretary to remove anyone arriving irregularly to the uk, which includes those arriving by small boat and other means of transport either: -to their home country (32 safe countries) -or to a safe third country such as Rwanda. The duty to remove does not apply to unaccompanied children who the Home Secretary will only be required to remove when they turn 18 Anyone arriving after 20 July 2023 will have their asylum claims declared “inadmissible” -the government then intends to “detain and swiftly remove” these people There is no legal duty on the Home Secretary to detain people, it is only a power to do so and people can only be removed to their home country if they are from one of 32 counties, which are the EU 27 member states, Iceland, Liechtenstein, Norway, Switzerland, Albania, anyone else would have to be removed to a safe country

Answer 14

2 circumstances for people claiming asylum in Uk: -pre July 2023 arrival- route to full refugee status: —living conditions often very basic dirty and/or dangerous —basic accommodation and limited financial support (£35 a week) —no automatic right to work (limited rights for some) -post July 2023 arrival the illegal migration bill: —no right to claim asylum (inadmissibility) —threat of removal to Rwanda or other “third country” —for many: basic isolated accommodation in refugee camp like conditions with limited freedom of movement -a small number of people in very limited circumstances will have admissible claims

Answer 15

Initial status- by whatever route is usually “limited leave to remain” 2-5 years of leave to remain Need to accumulate 10 years in UK before “indefinite leave to remain ILR” can be granted and then UK citizenship LLR granted in 30 month chunks, necessitates recurrent applications Total cost of achieving individual ILR and citizenship -well in excess of £20000 -considerable financial burden on low income individuals, driven into debt -cost to families enormous and recurrent -cost have risen 1440%since 2003

Answer 16

Destitution: “Destitution means going without the bare essentials we all need. That’s a home, food, heating, lighting, clothing, shoes and basic toiletries. We define destitution as when people have lacked two or more of these essentials over the past month because they couldn’t afford them; or if their income is extremely low- less than £70 a week for a single adult” Joseph Rowntree foundation

Answer 17

90% of refused asylum seekers remain in UK and brave destitution rather than electing to leave -this leads to destitution -the illegal migration act may lead to a huge increase in destitution- no right to remain, not possible to be removed from UK —hostile environment means access to accommodation, education, healthcare, law enforcement severely restricted —high risk for exploitation and trafficking

Answer 18

Some people are granted a right to stay in the UK but have “no recourse to public funds (NRPF) -eg adult dependent or spouse of someone with settled immigration status -parent of a child who is a UK national -visa overstay -can be nationality specific NRPF status causes a lot of confusion about what people are ands are not entitled to claim/access -its complex but does not reference to healthcare or social services In general NRPF means cannot claim welfare benefits and housing or homelessness support

Answer 19

Public discourse in high income countries presents migrants as burden and exaggerates numbers: stigma, hostility, hate crime. However migration benefits eg NHS by far more than it costs -taxes paid and staffing Rise of the far right in Europe: wave of (largely Islamic) refugees triggered a political back lackeys since 2015, increasing criminalisation of humanitarian and integration efforts, election of politicians/governments on anti-immigration platforms 37% of Drs in UK gained their qualifications abroad 1% increase in migration increases GDP by 2% per person

Answer 20

Integration is challenging: -cultural and language barriers- education and employment -loss of status, profession and standing in society -family separation -difficulties gaining employment and low wage occupations with high risk of hazards (with limited protection) —construction (in US Latino construction workers 1.84x more likely to die than non Latinos) —agriculture —fishing (54% of trafficked workers in Thailand experienced violence vs 10% non-trafficked workers) —domestic work (in UK employers often have influence due to immigration status DW visa) —sex work (higher risk of contracting HIV than non-migrant workers)

Answer 21

The “healthy migrant” Myth or reality- data can be conflicting and context dependent -migrants to high income countries have a mortality advantage compared to their non-migrant counterparts . SMR for migrants lower across all ICD-10 counterparts Migrants are healthier than the UK born population -in 2019 27% said they had a long term condition compared to 42% uk born -those who have lived longer in the uk are more likely to have health problems than those recently arrived (age matched) The opposite is true for those that migrate in circumstances that cause marginalisation eg seeking asylum (Guintella et al 2018)

Answer 22

Migrants who arrive under favourable circumstances report better mental health than UK born (5% vs 10%) Torture and exposure to violence/trauma: PTSD Detention and deportation: UK is one of the few countries who allow indefinite immigration detention, new bill all will be detained Ongoing uncertainty: backlog of asylum cases- huge and growing. Average 75% of initial decisions were negative between 2004-19 (35% of refusals are overturned at appeal) Challenges with integration: once asylum granted 28 days to sort out NI number, job, housing, bank account, benefits. Many refugees are at high risk of homelessness at this point

Answer 23

Torture and exposure to violence/trauma: PTSD, other mental health effects (anxiety, depression) Detention and deportation Ongoing uncertainty: backlog asylum cases, the illegal migration act- perpetual limbo Challenges with integration: once asylum granted 28 days to sort NI number, job, housing, bank account, benefits. High risk homelessness

Answer 24

21% of refugees have been tortured. 30% torture survivors meet diagnostic criteria for PSTD. However torture survivors may have very complex and quite severe symptoms without meeting any threshold for diagnosis of a single disorder A substantial proportion of torture survivors report direct or indirect involvement of clinicians in their abuse Patients experience of torture is often under recognised boy clinicians (this is the norms) Unprompted disclosure is rare and experiences within the immigration process may reduce expectations of being believed Torture is assault on the wellbeing of an individual which impacts on multiple levels: physical, psyche, integrity, spirituality, social stigma and marginalisation. It degrades, dehumanises and debilitates Goal is to break down personality leading to breakdown of cognitive and behavioural function. It’s effects are pervasive can be longstanding (10+ years), relapse and remit and extend to families and communities where torture has occurred

Answer 25

It’s fearful and sad looking back It’s frightening looking forward to the risk of destitution, detention and deportation In the UK post illegal migration act- perpetual limbo and jeopardy It’s not over once your asylum claim is accepted Many people (especially the undocumented and those with refused or inadmissible claims) can be caught in limbo, destitute for many years “The trans national state” deportation to unsafe environments prompts repeated journeys, recurrent deportations Individuals bouncing around between European countries looking for one which will finally accept their claim

Answer 26

Both male and female patients are at risk of sexual violence, exploitation and transactional sex -before during or after migration -not only those trafficked for purposes of sexual exploitation -girls and women at increased risk of early and forced marriage Access to reproductive health and contraception -can be poor- most settings -host nations culture and legal/social structures apply -menstrual hygiene Maternity care and obstetrics -maternal and infant mortality and morbidity very compared to resident population Individuals (esp women) with unstable or irregular immigration status at risk of intimate partner/domestic violence Persecution in home and transit countries on basis of sexuality

Answer 27

Suspicion of migrants as the cause of disease outbreaks is a persistent and damaging myth Migrants come from countries where infectious disease profiles differ from host nations Always ask about immunisation status and offer catch up immunisations -can be disrupted by migration or circumstances that lead to forced migration Screening can benefit individuals and decrease healthcare costs associated with treatment and complications -but in some settings this come at the cost of stigmatisation and negative media and political messages Migrants are highly unlikely to transmit disease to host populations -transmission more likely within households and migrant communities rather than to host communities and individuals -pandemic situations may differ

Answer 28

TB and latent TB infection Collaborative TB strategy for England 2015-2020 Screen all 16-35year olds arriving from countries with TB incidence >150/100000 and all sub Saharan Africa TB in high risk populations- advise about signs and symptoms Be alert to non pulmonary TB- More common then in non migrant population HIV: screen all new registrations in communities where HIV prevalence is more than 2 per 1000 (this includes large part of W midlands). Screen those from countries of origin where prevalence >1% Hep B: screen according to country of origin risk Hep C: screen if from a country of origin higher risk than host nation

Answer 29

What is universal access to healthcare? -all people can use preventative, curative, rehabilitative and palliative health services they need, at sufficient quality to be effective while also ensuring the use of health services does not expose the user to financial hardship. The UCL

Answer 30

There is not such thing as cultural competence when working within Super-diverse populations – one can nev er aspire to grasp all the nuances. The best we can aim for is to approach our patient’s cultural background with a sense of humble curiosity – treat people as competent interpreters of their own lives, admit your ignorance and let them guide you” A word about working with Superdiverse Populations Paraphrased from - Sarah Temple- Smith Project Manager & Children’s Psychotherapist The Refugee Council

Answer 31

Inequitable access to healthcare drives health inequality and thus social inequality Unequal societies- are less economically stable, have higher crime rates, are more violent and are less happy It’s estimated that the annual cost of health inequalities is between £36 billion to £40 billion though lost taxes, welfare payments and costs to NHS Health inequality costs around 1.4% of GDP in European countries (EU parliament) All of the above need to be place into the context of the pandemic We are not safe until we are all safe

Answer 32

Matter of public health: communicable disease, drug and alcohol treatment Financial sense: delayed access to treatment, inappropriate use of services, resource burden of checking and changing patients, health inequalities cost Enshrined in medical ethics and NHS principles: responsibility to protect and promote the health of all patients, NHS founding principle “based on clinical need not the ability to pay”

Answer 33

Chargeability in secondary care depends on immigration status. Undocumented migrants (including. Refused asylum seekers) are charged Charges must be paid before treatment which can be withheld if a patient cant pay “Urgent or immediately necessary” treatment to be provided regardless of ability to pay Some services are exempt: A&E some communicable diseases and family planning Some groups are exempt incl. refugees, asylum seekers, survivors of some types of violence, recognised survivors of trafficking

Answer 34

Payable by anyone applying for a visa over 6 months for study, work or family visit -allows access to the NHS on the same basis as a resident The NHS surcharge doubled from £200 to £400 per person in Jan 2019 It’s estimated this will raise £220 million per year for the NHS and that each person entering on such a visa uses on average £480 of NHS services A “double tax” on migrants- many will be paying income tax ( or will have a relatives who pay) and other forms of taxation eg VAT and/or will be contributing to the economy in other ways eg university fees

Answer 35

Can be argued that it is counterproductive and could be considered to be politically motivated Erodes the primary principle of the NHS that care is free at the point of delivery and available for all Is complex and can be inconsistently applied and can lead to: -erroneous charging -racial profiling -denial of urgent and immediately necessary care -a deterrent effect on individuals seeking care Likely does not save the NHS money- evidence base is evolving - the context of covid pandemic makes this more likely

Answer 36

Consequentialist- the end result is the only thing that matters Deontologists- you have done the right thing by following the rules and guidelines Virtue ethicist- individual and later the practice peer group agrees the hows of practice that serve the patient and societal well being Values vs virtues Phronesis virtue is the how to navigate the other hows to come to a decisions

Answer 37

Concept which advocates a way to make ethical decisions that are grounded in an accumulated wisdom gained through previous practice dilemmas and decisions

Answer 38

Virtue is a ‘mean’ between two extremes (‘vices’ or poles) Poles : ‘too much’ excess and ‘too little’ deficiency Where on the continuum is right for any given situation Practical wisdom or Phronesis is the virtue of discerning the appropriate course of action in any given situation Phronesis: executive virtue or the chair of moral debate to navigate a way through all virtues of relevance

Answer 39

Consequentialist- the end result is only thing that matters Deontologists- you have done the right thing by following rules and guidelines Virtue ethicist- individual and later the practice peer group agrees the hows of practice that’s serve the patient and societal well being

Answer 40

A concept which advocates a way to make ethical decisions that are grounded in an accumulated wisdom gained through previous practice dilemmas and decisions

Answer 41

Measures: unemployment, non-car ownership, non-home ownership, household overcrowding Based on census data can be out of date Measures deprivation not affluence a low Townsend score doesnt mean area is affluent but that there’s few deprived people living there

Answer 42

Low social class, lack car ownership, overcrowding, male unemployment

Answer 43

Initially for determining relative primary care needs populations %elderly living alone, % children under five, %unskilled workers, %overcrowded houses, %changed address in last year, %residents living in household where head born in new commonwealth or Pakistan, %unemployed, % households containing lone parents

Answer 44

Income Employment Education Health Crime Barriers to housing and services Living environments

Answer 45

Death Diseases signs and symptoms Abnormal findings Complaints Cancer AMR Covid 10

Answer 46

Episode of care: period of time that patient spends under care of consultant

Answer 47

Integration of best research evidence with clinical expertise and patient values SACKETT et al 1996 Assessing a situation and asking good questions Accessing/acquiring relevant research evidence Appraising the evidence Act applying the findings to clincial practice or health policy decisions Assessing the consequences of actions undertaken

Answer 48

Doctors need a way of locating the best most reliable evidence on which to base clinical decisions -assimilate large volumes info/evidence on a topic -investigate why some pieces of primary research come to different conclusions to others about a similar clinical question -increase precisions of an estimate of effect size. Metaanalysis- summary estimate of effect increases sample size and statistical power

Answer 49

Not conducted according to explicit methodology The literature chosen to be included narrative review may reflect views of the review author rather than unbiased representation of all literature available

Answer 50

Attempts to collate all evidence that fits pre specified eligibility criteria in order to answer a specific research question. Uses explicit systematic methods that are selected with a view to minimising bias thus providing more reliable findings from which conclusions can be drawn and decisions made. The aim when conducting a systematic review is that another independent researcher replicating the review methods would come up with the same conclusions from literature

Answer 51

Clearly stated set of objectives with pre defined eligibility criteria Explicit reproducible methodology Systematic search that attempts to identify all studies that would meet the eligibility criteria Assessment of the validity of findings of included studies Systematic presentation and synthesis of the characteristics and findings of the included studies Start with a Clear question: Population, Intervention, Comparator, outcome

Answer 52

Can be the best source of evidence Assimilation large amounts of research evidence Provide reliable unbiased estimates of effect Increase precision of estimates of effects Provide information about the generalisability and consistency of effect Identify what information is missing Useful for making decisions Should critically appraise it using CASP

Answer 53

Is the use of statistical methods to summarise the results of more than one independent primary study Individual results need to be expressed in the same way Typically weighted average of results across studies Not appropriate when primary studies in review are considered different to eachother methodologically and clinically -heterogeneity

Answer 54

Exists when the true effects being evaluated differ between studies ands may be detectable if the variation between the results of the studies is above that expected by chance May be caused by: -clinical differences between studies -methodological differences between studies -bias I2 describes the percentage of variability in effect estimates due to heterogeneity rather than chance. The closer to 100% the higher the inconsistency that cannot be explained by chance alone. Heterogeneity

Answer 55

Bias is a systematic error or deviation in results or inferences from the truth Selection bias: systematic differences between the characteristics of the intervention group subjects and the control group subjects Performance bias: systematic differences in care being provided between the intervention and control group apart from the intervention being evaluated Attrition bias: systematic differences between the intervention and control groups in drop outs or exclusions Detection bias: systematic differences between the intervention and control groups in how outcomes are ascertained, diagnosed or verified Publication bias: bias caused by only a subset of all the relevant data being available eg due to nonpublication of studies which show no effect or selective reporting of outcomes in studies Lead time bias: effect overestimation of survival time with screening detected diseases because of detection at earlier point in the natural history of disease but with no real increase in survival time Over-diagnosis bias: length time bias overestimation of screening benefit due to screening preferentially identifying good prognosis diseases

Answer 56

Virtue(mean): negotiates excess:doctor deficiency: patient Virtue: justice/fair Virtue: trust/integrity/confidentiality Virtue: lawful Virtue: collaborative Virtue: culturally competent Virtue: interpersonal/emotional intelligence Virtue: recognising limits to treatment Virtue: approachable/available mentor Virtue: balanced approach Virtue: reflective Virtue: courage to have difficult conversations Virtue: resilience Virtue: phronesis excess:seen all know all can deal with all. Deficiency: applies theory or follow guidelines Virtue: resources awareness

Week 6 Flashcards

(80 cards)