Marginalized populations in the West Midlands experience high rates of tuberculosis (TB) and blood-borne viruses like HIV due to structural factors that limit healthcare access. A health needs assessment was conducted using a model incorporating stakeholder input, service comparisons, and local epidemiological data. Findings showed high deprivation, TB, and HIV rates in certain areas. TB nurses recommended a mobile screening unit to test for TB and viruses among hard-to-reach groups. A two-phase mobile screening project will start in March 2015 to improve testing and treatment outcomes for at-risk populations.

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Using a Health Needs Assessment to better target the use of a
mobile TB screening services in marginalised groups in the West
Midlands
J Corrall1, A Te1, E Rehman1, D Kirrage1, N Syed1
INTRODUCTION METHODS
In 2005, funding was made available in London for a mobile x-ray (Find
and Treat); visiting place where high risk groups may be found e.g.
homeless refuges, hostels, drug centres. The unit could also assist TB
specialist teams support those who are at risk of being lost to follow up.
The Find and Treat London initiative, a specialist TB mobile outreach set-
up, has been deemed highly cost-effective and potentially cost-saving by
both NICE and PHE.
EPIDEMIOLOGY
Structured qualitative work seeks to build on existing studies with social
services, local authorities and PHE. Data gathering is sourced from
national disease surveillance data and local TB services. A synthesis of the
findings draws on stakeholder input and data sources. Recommendations
shall inform the key areas of greatest need and the overall capacity to
benefit for a ‘reluctant’ people group.
Targeting and funding resources across a wider
geographical area works well for initiatives such as
a mobile screening unit. Future TB boards will help
to facilitate these projects.
Outreach initiatives should fully utilise the
opportunity to engage with populations for a broad
range of issues as well as infectious disease.
ACKNOWLEDGEMENTS
Thanks to the specialist TB nurses, Wendy
Bladen and Joan Piper for their input to the
initial qualitative data gathering around TB
services in Wolverhampton and Sandwell.
REFERENCES
This Health Needs Assessment (HNA) informs the need for the diagnosis
of TB and Blood-borne Viruses (BBV) i.e. Human Immunodeficiency Virus
(HIV), Hepatitis B Virus (HBV) and Hepatitis C Virus (HCV) in the
marginalised groups of Sandwell and Wolverhampton.
1. Rhodes, Tim, et al. "Structural violence and structural vulnerability within the risk environment:
theoretical and methodological perspectives for a social epidemiology of HIV risk among injection drug
users and sex workers." Rethinking social epidemiology. Springer Netherlands, 2012. 205-230.
2. Stevens A, Raftery J. (1994). Health care needs assessment: the epidemiologically based needs
assessment reviews. Oxford: Radcliffe Medical Press.
3. Tuberculosis in the UK: 2014 report, Public Health England (PHE)
4. BHIVA, BASHH & BIS (2008). UK National Guidelines for HIV Testing 2008
5. PHE and NHS England. Collaborative Tuberculosis Strategy for England, 2015 to 2020
Figure 3. Diagnosed HIV prevalence rate per 1,000 by Local
Authority area (the darkest quintiles show the highest rates
Key data
The West Midlands has some of the most deprived Local Authority areas nationally; corresponding with high TB and blood-borne virus infection rates
Nationally, the West Midlands has the second highest rate of TB nationally at 17.3 per 100,000 in 20133
Four Local Authority areas report a prevalence of diagnosed HIV of at least 2 per 1,000 (aged 15-59 years), a situation NICE recommends for further HIV testing
interventions4.
Key data
The West Midlands has some of the most deprived Local Authority areas nationally; corresponding with high TB and blood-borne virus infection rates
Nationally, the West Midlands has the second highest rate of TB nationally at 17.3 per 100,000 in 20133
Four Local Authority areas report a prevalence of diagnosed HIV of at least 2 per 1,000 (aged 15-59 years), a situation NICE recommends for further HIV testing
interventions4.
Marginalized populations commonly experience a greater burden of
disease with higher relative risk of morbidity and premature mortality.
Research suggests that the inverse-care law and ‘structural violence’
applies to these groups1, who receive less healthcare resource than the
average. These groups are at risk due to their inability or unwillingness to
access the mainstream health services offered within local NHS clinics
and hospitals.
Stevens and Raftery Model
A model which incorporates Corporate, Comparative and Epidemiological
approaches to assess population needs for health care2
Corporate
The structured collection of the knowledge and views of stakeholders on policies, services
and needs.
Comparative
Involves a comparison of levels of service provision between different localities. This could
involve cross-national comparisons of the levels of service provision
Epidemiological
Defining the incidence and/or the prevalence of the health or social problem in question, (ii)
identifying the effectiveness and cost-effectiveness of existing interventions for the problem,
(iii) identifying the current level of service provision.
Stevens and Raftery Model
A model which incorporates Corporate, Comparative and Epidemiological
approaches to assess population needs for health care2
Corporate
The structured collection of the knowledge and views of stakeholders on policies, services
and needs.
Comparative
Involves a comparison of levels of service provision between different localities. This could
involve cross-national comparisons of the levels of service provision
Epidemiological
Defining the incidence and/or the prevalence of the health or social problem in question, (ii)
identifying the effectiveness and cost-effectiveness of existing interventions for the problem,
(iii) identifying the current level of service provision.
FUTURE RECOMMENDATIONS
The Collaborative Tuberculosis Strategy5 for England has
recommended targeted interventions for reducing the incidence
of TB in specific high risk groups; there is evidence that a
number of areas in the West Midlands would benefit from such
interventions.
Immigrants from high-
prevalence countries
Systematic new
entrant latent TB
screening
Out reach service (e.g.
mobile x-ray unit)
Underserved
populations
Substance
misusers
Prisoners
Homeless
Figure 1. TB incidence per 100,000 by Local Authority area, West Midlands
FEEDBACK FROM TB SERVICES
Qualitative information received from TB nurses working in
Wolverhampton and Sandwell re-enforced the need for piloting
the use of a mobile service to screen for TB and ideally other
blood-borne viruses.
Existing workload has highlighted increasing difficulties with the
follow up and outcome of patients with risk factors such as
homelessness. This has increased the work load of TB specialist
nurses as time is spent dealing with social issues. Further data
collected through National Enhanced Tuberculosis Surveillance
highlights that almost 10% of cases had a documented social risk
factor (drug/alcohol use, prison or homelessness), figure
Services suggested geographical areas which could host a mobile
service; most being close to hostels, soup kitchens and a migrant
centre. This information has informed the final itinerary for a two
phase project for mobile screening in the West Midlands starting
in March 2015.
Figure 2. TB incidence per 100,000
by Local Authority area (red areas
indicate rates significantly higher
than the region as a whole).
Data collected from ETS 2010 - 2013
(Sandwell & Wolverhampton)
% of cases reported
% of cases with a social risk factor documented 9.7%
Treatment outcome reported as not completed, died, lost to follow up or unknown. 27%
1 Public Health England, West Midlands Health Protection Team
Figure 4. Data collected through the national ETS system showing social risk factors and corresponding outcomes of this group.
Source: Public Health England Public Health Profiles