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Inclusion health and COVID-19

e.schaessens13 May 2020

Authors: Chantal Edge, Al Story, Andrew Hayward

As the UK continues to wage war against COVID-19 the news is awash with stories speculating when vaccines and diagnostics will become available, and when life can return to ‘normal’ for the general population. Yet amongst these reports we hear very little about society’s most marginalised groups. What has the UK been doing to protect and support the most vulnerable – homeless, prisoners, drug users, and what problems do they foresee for these groups in the near future? We asked the UCL Collaborative Centre for Inclusion Health (CCIH) what they’ve been up to in support of pandemic response.

What is the UCL Collaborative Centre for Inclusion Health?

The UCL Collaborative Centre for Inclusion Health (CCIH) was set up by a multidisciplinary team of researchers, experts with lived experience and frontline professionals who are dedicated to reducing health inequity amongst socially excluded groups. Inclusion Health is a service, research, and policy agenda that aims to prevent and redress health and social inequities among the most vulnerable and excluded populations such as homeless, prisoners and drug users. The Centre is co-directed by UCL’s Professor Andrew Hayward and Dr Alistair Story, Clinical lead of the London Find&Treat Service.

COVID-19 and socially excluded groups

Homeless accommodation

At CCIH we were very aware early on in the outbreak that excluded groups would be highly vulnerable. There was a well-timed conference – 2020: A Decade for Inclusion – on homeless and inclusion health justbefore the UK went into lockdown, which we used to raise awareness across the homeless sector about what needed to be done to prevent outbreaks, particularly within overcrowded hostels, night shelters and day centres. We were able to secure a lot of support from different agencies, for example, the Ministry of Housing, Communities and Local Government set up an initiative to place those living on the streets in hotels and to close down the large hostels in which people share dormitory-style accommodation. This was achieved incredibly rapidly, over the course of about a week. We’ve also done a lot of work to raise awareness in settings which remain vulnerable to outbreaks, including improving social distancing by encouraging closure of communal areas, and strict rules about social distancing measures. We’ve been able to bring in drug treatment services and addiction services for people with very challenging addiction issues. A pan-London methadone-prescribing service has been established so that homeless people can get access to substitution treatment for addictions much more easily than they would have done on the streets. This video tells the story about one such homeless hotel in Shrewsbury.

We’ve also established what we’re calling a COVID-CARE hotel in East London for homeless people who are diagnosed as having the disease. They are referred from the streets, hotels, hostels, Secondary Care and A&E departments across the capital to be clinically monitored in a safe infection control environment. The accommodation is provided by GLA, while the medical staff are provided by the UCLH Find&Treat team working with Médicins Sans Frontières (MSF) – this is the first time MSF have deployed in the UK, a video about this work can be found here.

Another aspect of our work has been to establish a surveillance system with UCLH Find & Treat and led by Miriam Bullock, through which we survey hostels for COVID-19 control and social distancing measures, suspected COVID-19 cases and related hospitalisations or deaths. This surveillance system triggers telephone triage and advice from the Find&Treat team who are outreaching same day testing to homeless people across the city with three outreach teams.

Prisons

Public Health England and the prison service have published guidance on their management strategies for COVID-19 in prisons and have as yet managed to avoid the ‘explosive outbreaks’ predicted at the start of the pandemic. Yet healthcare delivery in prisons remains challenging now that inmates are confined to their cells for up to 23 hours a day and many staff are off sick or isolating with COVID-19 symptoms.

One of the CCIH PhD fellows, Chantal Edge, has paused her work on local prison telemedicine implementation in Surrey, to go to the central NHS England Health and Justice team to lead on the rapid deployment of prison telemedicine nationally. Telemedicine will be scaled up across 135 secure sites in England including prisons, immigration removal centres and secure children’s homes. Approvals have also been secured from the prison service to deploy NHS 4G enabled tablets in prisons to support the telemedicine work, a ground-breaking change seeing as mobile devices are traditionally strictly prohibited in prison settings.  Telemedicine will remain in prisons after the pandemic and support improved access and quality of healthcare services for prisoners, so in this way the pandemic has driven forward innovation.

Migrant health

Ines Campos Matos, who has a joint appointment between PHE and CCIH has led PHE’s investigation of the high levels of COVID in BAME groups showing how poverty is compounding this inequality.

Advocacy in the media

We have also been working closely with the press to advocate for inclusion health groups including articles on prisons, and homeless hotels and GP surgeries.

Looking to the future

As COVID-19 decreases in the general population following lockdown, we’re moving to a stage of continued vigilance. This is going to be really important because there are likely to be more transmissions when the lockdown is eased. So far, we have avoided large outbreaks of COVID-19 in the homeless community and in prisons. In other countries such as the USA up to half of people in big, night-shelter-type hostels are being infected, our screening finds only about 3 or 4% of homeless people have been infected. Prisons in countries such as Italy and the USA have also seen huge outbreaks, whereas cases in England remain controlled.

There is a concern that people will begin to think the outbreak is over and will start to relax both the social distancing across society but also in the homeless hostels. As the numbers decrease, there will be pressure to close down the COVID-CARE facility and the hotels. Prisons will likely need to keep measures in place to isolate the vulnerable and enforce social distancing for many months, the mental health consequences of this enforced isolation remain as yet unknown.

We’re planning to launch a major health needs assessment (HNA) led by Dr Binta Sultan, to systematically identify the health needs of people within the hotels. We’ll have 38 clinicians doing telephone interviews, and have established referral pathways into mental health, sexual health and drug and alcohol services. We’ll be screening everybody for hepatitis C, then starting people on treatment with the aim of completion while they’re at the hotel. This could have a major impact on the transmission of hepatitis C in the homeless population. We’re hoping to do the same thing for latent TB infection. The HNA will also identify people who need shielding, therefore requiring their own self-contained accommodation. This will move people up the priority list for permanent housing and will help with advocating for their needs.

During this pandemic, many of us are having to change what we do and prioritise everything towards this response. It’s too serious and awful to feel any excitement about the research: it feels more like a war. We’re trying to use every resource and opportunity that we have – and every waking hour – to work out what we can do to help in the fight against COVID-19. It is rewarding to feel that you’re able to make a difference, but it’s heart-breaking to see how terrible it has become.

Chantal Edge is an NIHR Clinical Doctoral Research Fellow and Specialty Registrar in Public Health, researching the use of telemedicine for hospital appointments in prison. Dr Al Story leads the Find&Treat Outreach Service based at UCLH and is Co-Director of the UCL Collaborative Centre for Inclusion Health. Professor Andrew Hayward is the Director of the UCL Institute of Epidemiology and Health Care and Co-Director of the UCL Collaborative Centre for Inclusion Health.

Do you not feel clever enough? Some advice to existing and new PhD students about Impostor Syndrome.

guest blogger4 October 2018

This blog post is written by Alexis Karamanos, who is a very active and engaged PhD student within UCL’s Institute of Epidemiology and Health Care (Research Department of Epidemiology and Public Health). A big thank you to Alex for providing this piece which I’m sure many staff and students will find useful.

Doing a PhD is rewarding, but at times challenging. During my PhD, there are times when I feel I should not be there. While I was indeed struggling to get some results, other very clever students in the IEHC were doing an amazing job; they were publishing to international journals, they were writing and talking to the media about their work, and they were also attending great conferences in the UK and abroad. It was then that I started feeling an outsider in academia; that I maybe sneaked my way in and I was/am about to be found out anytime soon. This is impostor syndrome and (believe it or not) it is very common among PhD students. Paradoxically, impostor syndrome is that intrusive idea that your success is due to mere luck and not your talent or qualifications. Evidence shows that about 70% of people experience it, according to the Journal of Behavioral Science https://www.tci-thaijo.org/index.php/IJBS/article/view/521 . So far, there is no single explanation as to why impostor syndrome occurs. Some experts believe that it has to do with personality traits like anxiety or neuroticism, while others focus on family and behavioural determinants.

Working day-in day-out towards an ultimate goal; a completion of a PhD in this case was never meant to be an easy task. Many people describe PhD time as an emotional ‘’roller coaster‘’ (https://core.ac.uk/download/pdf/11233054.pdf) with many ups and downs along the way, but for some people like me, it looks to be more than that. During one of the first panel meetings with my PhD supervisors, one of them explained to me that ‘’doing a PhD would render me an expert in my topic’’.  While that is true to a certain extent, living up to such an expectation (if taken literally and really did take it literally) can be very difficult. However, the good news is that impostor feelings can be managed to enable you to work to the best of your ability.

One of the first steps to start dealing with impostor feelings is to acknowledge that you have impostor thoughts and put them into perspective. Remind yourself than an impostor thought is just a thought, and not the reality.

Consider your PhD as just a beginners qualification. A PhD is the time during which you develop basic research skills, which you can further develop along the course of your professional career (academic or not). Never say never! Probably in the future you can become a prominent expert in your field, but this certainly takes much more effort and time than a three or four year long PhD.

Something that my PhD topic and experience has taught me so far is that my/your ability is not fixed, but something that can be developed and improved over time with effort and most importantly, patience. What I am always trying to remind myself of is the Socratic paradox; according to which the Greek philosopher Socrates responded to an oracle posed by Pythia, the oracle of Delphi ‘’Socrates is the wisest’’ that ‘’The only thing I know is that I know nothing’’. Truly liberating!

One thing that you can also try is to reframe your thoughts. One way to do so is to learn how to respond to challenges by learning how to value constructive criticism; that it is not a sign of academic incompetence to ask ‘’stupid’’ questions, to ask for help even for something that is considered ‘’easy’’ by others, or remembering that the more you practice a skill, the better you will get at it.

Last but not least, it can be helpful to share your feelings with trusted friends, your partner, mentors or your supervisors. When in doubt, our thoughts may be tricking us to believe in something which may not be true. Therefore, being open about your impostor thoughts may allow other people to critically assess your thoughts together and possibly de-dramatise them. People who have more experience can reassure you that what you’re feeling is normal, and knowing others have been in your position can make it seem less frightening. Nevertheless, if you think that by doing so will not make any difference, it will be wise to seek professional help. UCL’s Students Psychological and Counselling Services  are doing a great job in helping students with challenging feelings such as those related to impostor syndrome, either by providing a number of one to one sessions with a therapist or by providing specialized courses on how to overcome PhD perfectionist thoughts (I have been to one of those great courses and they really do help a lot).

To conclude, if you have impostor thoughts, it is important to remember that most people experience moments of doubt, and that is completely normal and not something to feel bad about it. The main goal should not be for you to not have impostor related moments, but not an impostor life. No matter how much effort and time it takes, the impostor syndrome can effectively be managed and overcome.

Internship insights: how to find and get one as a PhD student.

guest blogger6 September 2018

Internships are increasingly being seen as a valuable addition to PhD training. In fact a report commissioned by the Government recommended that, “All full‐time PhD students should have an opportunity to experience at least one 8 to 12 week internship during their period of study” (Wilson Review, 2012, p.8). But how do you go about getting one? And how do you convince your supervisors if they’re not so keen? Fran Harkness, PhD student at the MRC Unit of Lifelong Health and Ageing lets us in on her insights.  

I did an internship in the MRC External Affairs team March-June this year. I enjoyed it so much that I’ve since been asked if I’m being paid to persuade other students to go on one by demonic internship overlords? Anyway, as I had to do the hard work of understanding how to get one, I hope that I’ve managed to clarify the process a bit for you. Good luck!

Research it. Think about what you want to get out of this time. I was interested in science policy so it made sense to apply to the Academy of Medical Sciences policy internship scheme. Research councils have links with many organisations. You could intern with the Royal Institution to plan their Christmas lecture. The UKRI scheme sponsors students to get insight into areas as diverse as the civil service, Age UK, and Public Health England. Alternatively you could apply for funding to work in a research unit abroad to pick up new skills and ideas in your own field.

Take time over your application. You need to collate your CV, a statement of interest, and often a fresh piece of work, plus signature from your supervisor. I’d broach the latter first. Don’t do what I did once and stall asking your primary supervisor for so long that it’s now the day of admission and she surprisingly isn’t looking at her emails in Chamonix. That was after I’d spent, I mean wasted, five days writing a government POST note far out of my subject area for the application. On my second application I’d mortifyingly left in a note to myself in blank space after my essay. Proofreading doesn’t take that long.

Convince your supervisors part 1. My stalling behaviour was partly fuelled by anxiety that mine would say no. Your supervisors want to support you to finish on time and may believe that an internship will derail this ambition. Many schemes include a funded extension but their worry is that any absence breaks your flow and delays finish time. Reassuringly, researchers from the University of California found that interns don’t take any longer to graduate, despite halting their programme entirely during the three months. My experience has been that my internship returned me to a mental state helpful for finishing: professional, confident and newly reminded of the point of my research.

Convince your supervisors part 2. Like being asked by my parents to plan how I was going to take the bus into town by myself for the first time, my panel had kindly reservations for me to consider. They requested that I talk to previous interns about the benefits and challenges and how I would overcome the latter. They also asked that I continue to work on my thesis during my internship and that I take it up towards the end of my PhD so that there wasn’t too much write-up hanging over my head. Those last two things didn’t end up happening, but by this time I’m already on the bus into town and nobody minds.

Apply! With your head stuck in a stats problem or down a microscope you may forget that you have time for an internship. Look up and remember that your PhD is a training opportunity for the real world. You can gain new skills, meet contacts, and learn of roles you didn’t realise existed. It can help you get a job afterwards. At the Academy of Medical Sciences every single policy advisor I spoke to had done an internship there during their PhD. I know someone whose internship was so successful she’s now working part time for that organisation whilst finishing her PhD. On top of all this they’re great fun. Go on!