Date of Award

9-2014

Document type

Thesis

Degree Name

PhD (Doctor of Philosophy)

First Supervisor

Professor Samuel McConkey

Second Supervisor

Professor Ruairí Brugha

Third Supervisor

Professor Richard Coker

Funder/Sponsor

Health Research Board (HRB) in Ireland

Keywords

Refugees, Communicable Disease Control, Mass Screening, Ireland

Abstract

Introduction

Numerous countries employ migrant communicable disease screening programmes and initial health assessments (IHAs). Although the evidence base under-pinning screening policies has been criticised, relatively little is known about the extent to which screening policies, guidelines and programmes are implemented and practice is evidence-informed.

Methods

A case study design was employed to examine the development of communicable disease screening guidelines for asylum seekers and refugees in Ireland and the enacting of the guidelines and programme in practice. A national mapping study of screening service provision was undertaken, alongside a document review. Three sets of in-depth interviews were conducted with key informants involved in the guideline development, the related broader policy context, either current or past screening service provision or the provision of services relating to HIV/AIDS, TB or depression, for example referral services.

Results

Screening service coverage was decentralised and fragmented nationally, and concerns were raised regarding access and continuity of care. Where screening services existed the national guidelines were broadly implemented, but there was variation in implementation and barriers were particularly identified to Mantoux testing and polio screening.

Adaptation of the screening service and guidelines was evident, with some screening health care providers (sHCPs) adopting a more holistic perspective. The findings demonstrated the importance of the adaptable elements of the intervention in understanding the enacting of the guidelines, programme and services, for example, the provision of screening through a dedicated screening service or mainstream General Practitioners (GPs).

Conceptual and theoretical insights were gained from the critical use of a conceptual framework, based on an adapted version of the Consolidated Framework for Implementation Research (CFIR) and the Normalisation Process Theory (NPT). The use of the adapted CFIR highlighted the multiple interacting barriers to implementation and normalisation. These included the characteristics of the intervention, the multiple stakeholders involved and the process, including the development of the guidelines. Contextual factors were also influential, for example, the lack of national level responsibility for the screening programme and the historic decentralised establishment of the screening service. The use of the NPT in the conceptual framework particularly highlighted the dynamic and social nature of implementation, including the individual and collective responses to implementation.

Conclusions

The findings illustrate the value of a more bottom-up perspective in order to understand the enacting of the screening guidelines and programme, and provide support for an alternative view to a simple top-down conceptualisation of an implementation gap. Through the use of the conceptual framework these findings could have broader applicability to understanding and getting knowledge into action in other contexts.

Screening service provision needs to be evidence-informed, rather than determined by the implementation barriers identified in this thesis. Ensuring evidence informs guideline and programme development, and is subsequently enacted in practice, is necessary in order to provide equitable, high quality and sustainable health services, including screening, which contribute towards public health. This is also essential if the services are to meet the needs of vulnerable populations, including asylum seekers and refugees.

Creative Commons License

Creative Commons License
This work is licensed under a Creative Commons Attribution-Noncommercial-Share Alike 4.0 License.

File Size

10.3 MB

Comments

A thesis submitted for the degree of Doctor of Philosophy from the Royal College of Surgeons in Ireland in 2014.

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