Doctor, Patient, Society

"The conscientious, judicious and explicit use of current best evidence when making decisions about the care of individual patients"

• Collecting the best external evidence

• Applying the best individual expertise

• Acknowledging patient values and expectations

• Dictates whether a procedure is used in healthcare or not.

• only evaluated and useful procedures are used in healthcare

• However unevaluated procedures may be used due to public enthusiasm, political convictions or commercial pressure. This is a problem as it means procedures with a lack of evidence may be used, this can cause harm

Thalidomide

• Marketed as sleeping pill in 1950s, Claimed to be safe in pregnancy

• In the late 50s and early 60s it was also used to combat morning sickness

• In 1961 a connection was made between thalidomide and an epidemic of congenital defects. Early mortality rate was 40% in affected babies. In the UK 5070 babies were affected

This framework is used to scrutinise new knowledge being presented. A doctor should keep up to date.

• Assess - what type of healthcare question, what type of study?

• Access - finding the best evidence in terms of validity and relevance

• Appraise - evaluating the quality of evidence and interpreting the results

• Act - is the evidence relevant to clinical practice. Should it be used to change my practice

These are observational studies - used to answer questions about frequency and patterns of disease e.g how much, time, place, person and distribution.

Data is collected at population level (ecological) or at individual level (cross sec, case report , case series)

• Ecological studies = info is collected from whole population to compare disease frequency. Can be different population and the same time or same population at different times.

• Cross sectional studies = Info is collected in a planned way from individuals in a defined population at one point in time/time period. e.g population / community surveys, health survey for england and census.

• case report = detailed report of unusual condition occurrence in a single patient

• Case series = detailed report of an unusual condition in several patients

Explicit comparison of 2 or more groups of individuals - aims to establish if an exposure causes outcome (cause and effect).

The exposure can be harmful or benefit. Two types: Observational (cohort or case control) and intervention (clincial trials)

• Observational = researcher is an observer of exposure and outcomes. Exposure is not under the control of the researcher due to ethical reasons.

  • Case control - study starts with identification of an outcome e.g. disease. Compares exposure (multiple) in those with the disease (cases) to those without (control). If the level of exposure is higher in cases, the exposure may be a risk factor e.g What causes lung cancer (smoking, asbestose, pollution) (retrospective)

  • Cohort - study starts with identification of one exposure e.g risk factor. Compares those exposed to those not exposed to a factor. Both groups followed over time and the disease development (multiple outcomes) measured and compared. If the incidence is higher in case group, the exposure might be a risk factor. e.g does smoking cause lung cancer (prospective)

• Interventional / experimental = researcher allocates exposure and observes outcome.

  • RCT - Researchers decide whether participants receive the new intervention being tested or receive a control treatment (Rx vs placebo). The trial ? effectiveness of the intevention. Have design feature that can increase validity and reduce bias. E.g does HRT in post menopausal women reduce their risk of IHD / stroke.

Qualitative research - Healthcare questions about patient, carers and professional experiences. e.g

• Why do patients continue to smoke despite evidence of harm and RCT evidence that nicotine replacement therapy is effective

• Why  don't parents immunise children even though the evidence for benefit far outweighs any harms

Qualitative research answer these questions by collecting non-numerical data about people’s subjective understandings of their lives and experiences. These are indepth studies of small no of individual in a specific setting, rather than aiming for generalisability.

Multiple methods are available - direct observation / individual interviews and group interviews.

AAAA

• Assess: what type of healthcare question or study is most appropriate

• Access: finding the 'best' evidence (validity and relevance)

• Appraise: evaluate quality and interpret results

• Act: is the evidence relevant to clinical practice, should it change my practice?

E.g If a patient comes with lower back pain, Dr want to refer him for physio but patient asks for chiropractor. Dr want to know the effectiveness of the chiropractor compared to physio.

• Assess —> define a clinical question, what study desing?

• The clinical Q: is there a beneficial treatment

• Best study design for effectiveness: RCT

• PICO framework can be used to formulate questions

PICO framework - important for efficient searching for evidence in electronic bibiliographic database e.g. pubmed, and for assessing the applicability of the research to the patient

• Population: those who are eligible for treatment with the intervention

• Intervention: new treatment

• Comparator: existing treatment / usual care (no Rx)

• Outcome: mortality, morbidity, physiological measures e.g. blood pressure, blood glucose, pain relief

A 45 year old man consults GP) for treatment for his chronic low back pain. Dr would normally refer him physiotherapy but the patient has requested a referral to a chiropractor. Dr want to know how effective chiropractic treatment is, compared to physiotherapy, for the treatment of low back pain before deciding where to refer him.

• P = Adult with chronic back pain

• I = Chiropractic treatment

• C = Phyiso

• O = outcome Dr want to measure

• The Cochrane Library

• Bibliographic databases such as Medline, PubMed, Embase

• MEDLINE and EMBASE have study design filters (including an RCT filter)

• PUBMED has a clinical query facility

E.g. to know the effectiveness of chiropractor in treating lower back pain in adult:

• Use the component of the clinical question (elements of PICO) - to narrow search results

• Start with the intervention / population of interest. E.g. Chiropractic Rx, adults

• Use alternative terms e.g. manipulation

• Use MESH terms (Medical subject heading)

• Use ‘and / or’

Appraisal questions:

• Does the study address a Q relevant to my clinical problem? e.g. is there a match between PICO and study question / population interested

• Does the study design likley to give valid ans to the Q? e.g for effectiveness did the study use RCT

• Was it done well / trustworthy? e.g steps taken to reduce bias

• If it was done well, what were the results? e.g. direction, size, precision, statistical significance

Bias = Systematic deviation from the normal value (in same direction), can affect validity, usually an over estimate of the effect.

Imprecise = wide variability, less certain (hit or miss), can affect precision

• Random allocation of participants to either New intervention or comparator treatment (or no Rx)

• Having control group helps to compare if pt would get better with existing or no Rx, increases sample size.

• Allocation concealment - hides allocation of participants and those recruiting until they actually start the Rx = reduce selection bias (not same as blinding)

• Blinding - minimise measurement and performance bias

  • If the study population or HCP know which arm of the study pt in, they may have preconceived ideas about the Rx (placebo effect) - it may lead to disappointment and not engage e.g. if in placebo group

• Intention to treat - helps minimise attribution bias

• If we allow manufacturer of a drug to allocate - they may deliberately choose patient who has milder form of the disease who will get better with or without treatment > which may over estimate the effectiveness of the new drug and not true respresentation of the true population

• If we allow participant or clinician to choose - they are likely to choose people who has chronic issue, resisitant to previous treatment.

• So random allocation minimise selection bias

4 groups of people involved in RCT are: Participants, clinicians delivering the Rx, researcher measuring outcomes and staticians analysing. The more blinding possible, the better

• Single blind - only one group is blinded

• Double blind - 2 groups are blinded

• Triple blind - 3 groups are blinded

• Patients may be lost to follow-up at different points in a trial

• They may be available for outcome measurement but not adhere to trial protocol (not taking the new / allocated Rx)

• Patients drop out for a reason from either arm e.g side effect from new Rx or ineffectiveness of new Rx.

  • also patient from control group is likely to drop out as they are not receiving Rx

• Intention to treat analysis helps to minimise it - analysis includes all the original participants regardless of adherance to protocol.

e.g In a RCT of new analgesia (intervention) compared to ibuprofen (comparator) for back pain. Some participants allowcated for new Rx did not take it, instead buys OT ibuprofen. What can be done to these pt to ensure validity?

• They should still be analysed with the group who took the new drug. This is due to intention to treat analysis.

• Analysis includes all participants in groups they were originally assigned regardless of: compliance, withdrawal or protocol deviation

• This helps to preserve randomisation - mimics real world scenarios (if a pt is poor compliant in a trial, they are likley to be in real world) and avoids over estimating the treatment effect.

RR is the risk in exposed group / risk in unexposed group - measures the strength of association.

• RR = 1: no difference between the treatment group and the comparator group (null value)

• RR > 1: more outcomes in the treatment group than comparator. e.g Chiro (Rx) vs physio (control)

  • RR 1.35 = pt in chiro group is 35% more likely to be pain free than physio)

• RR < 1: less outcomes in treatment group than comparator

RD = risk in exposed group - risk in unexposed. Measures absolute effect. E.g comparing physio vs chiro

• RD = 0: no difference between treatment and comparator groups. Both physio + chiro same effect (null value)

• RD > 0: (+ve) more risk of outcome in treatment group than comparator group. Chiro is more effective than physio

  • If RD is +0.22 = 22% = 22/100 more pt in the chiro group felt better compared to physio

• RD < 0: (-ve)less risk of outcome in treatment group than comparator group. Chiro is less effective than physio

This is the no of patients who needed to be treated with the treatment compared to control group to achieve one more patient with an outcome = 1/RD

• e.g physio/chiro study with NNT +4.5 —> extra 5 patient (always round up the number) would need to be treated to achieve one more patient with no pain in the chiro group.

• So higher the no of patient needed to treat = lower the effectiveness of the drug

• Chance and precision —> outcome of a study shoud be cheked to see if the results are statistically significant or due to chance alone.

• This is done through hypothesis (statistical) testing using P values.

• P value of 0.05 = there is a 5% probability that the observed result is due to chance

• Smaller the P value, the higher the chance that the results are true and not by chance.

• Sometimes the evidence found may be valid but not relevant to the patient population.

• If no evidence found that the intervention is better than the original Rx, then the patient should continue the existing Rx

• Check to see if the study considered all outcomes (including harms), is the trial setting mimics the Dr’s setting, cost of the new intervention, what other Rx available and their cost, finally if the workforce is skilled enough to offer the Rx.

CI – range of values likely containing the true effective size.

95%CI – if study repeated 100x, 95/100 intervals contain true value. So a wide CI means estimate or more uncertainty, a narrow CI means more precise

e.g if RR of a study is 2.1, the CI can range between 1.29 to 3.41.

Review of all literature on one particular question using scientific methods

• Chance

• differences in people, intervention / comparator

• Differences in care, way Rx effects measured, follow-up

• Reporting of available evidence and selection from available evidence

Occurs when the publication of research results depends on their nature and direction. Either be:

• +ve result bias = authors are more likely to submit or editors accept positive than negative or inconclusive results

• outcome reporting bias = Several outcomes within a trial is measured but are reported selectively depending on the strength and direction of those results

Research method used to synthesis multiple pieces of research evidence on effectiveness of a treatment.

• Review of all literature on one specific topic using scientific methods to answer a specific question

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1. Define a Qustion - Use PICO

   E.g The effect of aerobic exercise (intervention) compared to lifestyle modification (comparator) to reduce cardiovascular risk (outcome) in obese men (population)

2. Write a protocol - Description of methods

3. Search for studies - using biniliographic databases like Medline, EMBASE.

4. Select relevant studies - Unbiased manner by using more than one reviewer to independently select relevent studies using pre-defined selection criteria based on PICO

5. Appraise studies - unbiases assessment of quality of each study by 2 or more independent reviewers using CASP checklist to draw strength / weakness of selected studies

6. Analyse & summarise data - statistical techniques to combine quantitative results from several studies (meta analysis)

7. Interpret results - unbiased interpretation

8. Discussion and conclusion - provide summary of the findings, considers the implication of the findings in the context of current practice and knowledge and outlines future research.

It is a statistical technique used to combine the quantitative results of various studies.

• combines data from RCT for the same intervention, compared to the same comparator in the same population for the same outcomes. 

• It combines this data to produce a summary effect for intervention vs control/comparator for that outcome. 

• This gives a stronger and more precise measure of effect of intervention vs comparator.

Meta analysis column components:

• 1st Name of the studies used

• 2nd / 3rd is data from intervention / comparator

• Forest plot

• last column - relative risk and confidence intervals

• Vertical line = line of no difference between intervention and comparator. (this equals to RD of 1 or mean value of 0)

• If the diamonf lies entirely to one side of the line of no difference, the results are statistically significant (+ve or -ve)

• Best source of evidence on effects and effectiveness of interventions

• Assimilation of large amount of research evidence which is better than single study

• Provide reliable, unbiased estimates of effect

• increase precision of effects

• Provide information on generalisability and consistency

• Identifies missing information for future studies

• Useful for making decision

Critical appraisal is the systematic identification of strengths and weakness of pieces of information and application of that info within identified limits.

·     Internal validity: Degree to which the effect observed is attributable to the evidence, rather than any other cause (such as bias and other methodological problems of the review).

·     External Validity: Degree to which the review's conclusion applies to other persons in other places at other times (Only considered if internal validity is strong).

CASP checklist is a tool designed to evaluate the quality and validity of research studies across various methods. Focus in 3 main sections:

1. Validity of the study

   • is the review trustworthy (internal validity)

   • Did it ask clear focus question (PICO)

   • Did it include right type of study?

2. Results of the study

   • Did they identify all relevant studies

   • was it reasonable to do meta-analysis

   • Heterogeneity - ?disimilarity in combined studies

   • Presentation of the results - RD, mean, differences, precision (CI)

3. Applicability / relevance (external validity)

   • Can the results be applied to local population?

   • risk vs benefit vs cost of changing the practice as a result of the finding in the study

The WHO defines self-care as ”the ability of individuals, families and communities to promote own health, prevent disease, maintain health, and cope with illness and disability with or without support from a health worker”.

• recognise individual as active agents in managing their own health.

Self-care interventions are evidence-based tools such as

• Quality drugs

• devices

• diagnostics or digital products

  that support individuals in managing their own health, with or without professional support.

The users are individuals and caregiver who might choose these interventions for positive reasons, or those who dont have acccess to healthcare.

Examples of quality / cost effective interventions include:

• pregnancy tests

• HPV + STI self-test, HIV self-tests

• self-monitoring of blood pressure / blood glucose

• over-the-counter contraceptives.

Positive reasons:

• Convenience, cost-effectiveness, empowerment, and better fit with lifestyle or personal values.

To avoid the healthcare system

• lack of quality healthcare or lack access

Keeping fit and healthy while understanding when and how to seek help from a pharmacist, GP or other professional, and managing long-term conditions effectively.

• Its about understanding the condition and how to live with it

• Restorative: to alleviate illness.

  • E.g. going to GP with symptoms and being told what they must do

• Reactive: to alleviate symptoms.

  • E.g. taking medication from a pharmacy

• Preventative: to prevent disease.

  • E.g. Recognising you are at risk of a particular condition (FH or risk of lung cancer if you smoke)

• Regulatory: to regulate body processes.

  • E.g. Looking after your health

Preventative self-care aims to prevent disease, while reactive self-care aims to relieve symptoms after they occur.

• Self-care maintenance

  • Behaviours performed to improve well-being, preserve health, or to maintain physical and emotional stability

• Self-care monitoring

  • A process of routine, vigilant body monitoring, surveillance or “body listening”

• Self-care management

  • Evaluation to determine if action is needed, treatment implementation and treatment evaluation

• Symptom management

• Definitions of health and illness changing

• Healthism/consumerism

• Body maintenance

• Changing beliefs about medical power and expertise

• Internet use

• Technology (e.g. self-testing kits)

• Over-the-counter medication/on-line pharmacy

• Increase in number of people with chronic disease

• Expert patients

• Patient choice/empowerment

• Need to reduce NHS costs

The presence of two or more long-term health conditions in one person. Include physical, mental and infectious diseases

Because conditions may be treated separately rather than holistically, leading to poorly coordinated and inefficient care > poor patient experience.

• this can occur when an individual’s conditions are non-synergistic (not related in a way they can be treated together e.g. arthritis and HTN)

Conditions that are related and can be treated together, such as hypertension and heart failure.

A dominant social identity that overrides other social roles and defines a person in most situations.

• It is the primary identifying characteristic of an individul.

• Whether ascribed or achieved, it overshadows all other social positions.

• E.g. Upon qualifying, being a “doctor” would be master status (non medically) or medically - “patient with HTN”

  • In healthcare, master status (HTN) determines the priority assigned to particular condition e.g BP management is most important to avoid stroke

Acute illness is usually short-term and curable, whereas chronic illness is long-term and often incurable; professional knowledge dominates in acute illness, while patients often develop greater illness knowledge in chronic conditions.

To equip patients with chronic illnesses with the knowledge, confidence and skills to manage their own condition and work in partnership with health professionals (diet, exercise, setting goals, dealing with difficulties). Focuses on people with chronic illness (e.g. COPD, DM, MS, HIV) due to:

• Ageing population & new concept of ageing

• Co-morbidity

• health service demand

Recognising & responding to symptoms,

medication management

maintaining nutrition / diet

engaging in exercise

Not smoking

managing stress

communicating with healthcare providers

Seeking info and using community resources

Through the development of self-testing kits, digital health tools - smart watch, internet access to information, and online pharmacies.

It provides shared experience, emotional support and practical advice to help individuals manage mental and physical health conditions.

Psychology is the scientific study of the mind and how it influences behaviour, health, emotions, thoughts, and illness outcomes.

Psychological factors can affect disease progression, treatment outcomes, and health behaviours such as smoking or medication adherence.

• strong link between the both - an ill patient suffers both mentally and physically.

Sociology examines how health, illness, and behaviours are shaped by social and cultural contexts.

It argues that traditional medicine focuses too heavily on biological and individual factors while ignoring wider social forces such as poverty and inequality.

• Social determinants of health show disadvantage start before birth and accumulates throughout life.

• Sociology helps to shift the perspective to wider social norm rather than individualism e.g complex social, economical and environmental factors.

The social determinants of health are the conditions in which people are born, grow, live, work, and age that influence health outcomes and are responsible for health inequities > unfair & avoidable differences in healt status between countries.

• These circumstances are shaped by distribution of money, power, global/national/local resources

Economic stability, education, neighbourhood/environment, healthcare access, and community context.

The biomedical model defines health as the absence of disease and focuses on biological causes of illness.

It focuses on specific biological causes (germs, radiation, toxins, genetics), excludes psychological and social factors, relies on technology, and treats the body mechanistically.

• Mind-body dualism (mind and body treated as separate entities).

• Mechanistic (body is regarded as a machine that can be fixed)

• Reductionist (Driven by germ theory, focusing on biological changes that cause disease only)

• Ignoring social, cultural, biographical, and environmental explanations.

• Over reliance on technology

The approach of explaining disease purely in terms of biological processes, ignoring social and psychological influences.

It refers to individuals reporting good health and quality of life even while living with chronic illness.

Health as absence of disease, health as functional ability, health as psycho-social wellbeing, health as physical fitness, health as energy and vitality.

Migration can increase stress, social isolation, and exposure to discrimination, which are linked to higher rates of mental illness such as psychosis.

Cultural stigma may create shame or fear around mental illness, discouraging individuals from seeking professional help.

An explanatory model is a patient’s personal understanding of their illness, including its cause, symtoms, and expected outcome.

• E.g patient with back pain, when HCP asks what they think is causing the pain, they say likely lifting heavy object at work or being stressed lately.

Because beliefs about illness are influenced by culture, religion, social background, and personal experience.

A person may simultaneously hold medical and religious explanations for illness, both shaping their understanding.

• e.g pt says DM caused by genetics and witch

Humanism is a philosophy that prioritises human value, dignity, wellbeing, and evidence-based approaches to reducing suffering.

All individuals have equal worth and should be respected

Human happiness should be optimised while suffering is reduced.

• in humanism, worth is not related to social status, a wealthy person is same as poor, as everyone has same inherent value

• Human rights are derived from humanism - it not only addresses basic human rights but also their needs

The NHS is based on principles of universal care, equal worth, and healthcare as a human right.

Derived from humanist ideology:

An ethical approach focused on meeting individuals’ needs through caring, respectful relationships.

Communicating ill experience is how humans cope with disease allowing then to receive acknowledgement and validation of illmess.

• Listening improves diagnostic accuracy, strengthens therapeutic relationships, validates patient experiences, and improves outcomes.

Not being heard activates stress pathways such as the sympatho-adreno-medullary axis and the hypothalamic-pituitary-adrenal axis.

Listening helps patients feel validated and in control, increasing their ability to make informed decisions about their health.

It refers to ensuring all patients are equally listened to and respected, regardless of gender, ethnicity, or social class.

• e.g. women with pain are perceived as emotional or somatic. Ethnic minorties generally feel more dissatisfied with communication from GP esp older age. Style of dressing, tattoo, being in lower socio-economic status can all impact equality.

Hierarchy can reduce patient autonomy and participation, limiting their sense of control in consultations.

• pt at bottom of social hierarchy have less autonomy / control over their lives / social participation.

Agency is the ability to act independently and make informed decisions about one’s health.

• Dr seen as higher in the hierarchy in Dr-pt relationship > reduce agency in pt as they are powerless

  
  

Intersectionality refers to overlapping social disadvantages (e.g., gender and ethnicity) that compound inequalities in how patients are heard and treated.

Health is considered a fundamental human right that should be enjoyed without discrimination based on race, religion, political belief, or social condition.

A refugee is a person forced to leave their country of citizenship to escape war, persecution (race, religion, politics), or natural disaster.

An asylum seeker is a person who left their country of origin and applied for asylum in another country but whose claim has not yet been decided.

• legally not allowed to work, benefit entitlement of £49.18/week.

An undocumented migrant is someone living in a country without valid immigration documentation, including overstayers or trafficked individuals.

A refused asylum seeker is someone whose asylum claim has been rejected and who has no ongoing protection claim.

All humans have equal worth, and everyone has a right to the highest attainable standard of health regardless of status.

Humanism supports universal healthcare by asserting equal moral worth and the reduction of suffering for all individuals.

Concerns about terrorism, increased demand on services, and crime.

• Gov primary responsibility is to their own citizens.

Migration from war-torn countries are associated with increased attacks, but overall influence is limited and varies by context.

PTSD (31%), depression (31%), anxiety disorders (11%), psychosis (1.5%), as well as grief and distress.

• These can increase the demands on already stretched existing services. Meeting complex needs > significant investment and planning.

Limited opportunities, unmet social needs, and lack of social or familial support can increase vulnerability to criminal activity.

The process of trying to determine whether something is right or wrong. A helpful skill for ethical decision making.

Stage 1: Authority/punishment

• Act is done to avoid punishment e.g. if i don’t let immigrant in, UN will punish me

Stage 2: Egoistic exchange

• getting a favour in return e.g refugees give back more than they get (contribute to economy)

Stage 3: Interpersonal conformity

• Being good - right thing to do

Stage 4: Societal maintenance

• to keep global system running (trade and development)

Stage 5: Greatest good (utilitarianism)

• What brings good to most people. e.g. accepting refuge > reduce suffering at tiny cost to accepting nation.

Stage 6: Commitment to ethical principles (justice).

• Right thing to do because it satisfies demands of justice

Justice and the development of increasingly abstract principles of moral reasoning.

An ethical framework focused on meeting human needs through caring relationships and contextual understanding.

Justice ethics focuses on rights and abstract principles, whereas care ethics focuses on relationships and meeting human needs in context.

A reductionist response simplifies complex ethical situations by applying abstract principles without considering context.

It argues that the wife’s right to life outweighs the pharmacist’s right to property.

The care response considers long-term relationships and ongoing needs rather than simply applying abstract rights.

• so if he steals the drug he might save the wife’s life but he need to go jail for stealing > if his wife get sick again, he is not there to take care.

Reductionist response is same as justice response - it ignores the complexity of the situation. It is concerned with whats right and not the consequences. It assumes that one individual must win.

The NHS prioritises treatment based on clinical need, reflecting a care-based ethical approach.

• Justice is around human RIGHT but care is around human NEED. (both are humanist)

It would prioritise meeting the needs of refugees rather than focusing solely on legal rights or restrictions.

1. Undocumented migrant

2. Antenatal care, MH care and STI check

3. No, everyone in the UK is entitled to free primary care, regardless of immigration status.

She may need interpreter to see GP, need to be flaged as vulnerable and homeless, may not be able to receive referral letters, may not attend appt. Give guidance on 111, how to access NHS services, medication info

Her wider needs ( food, housing, social isolation)

Refugees and asylum seekers are entitled to free NHS care, including prescriptions, dental care, and eye tests (with exemptions).

• They may have barriers to access healthcare - Proof if ID / adress (there is no regulatory requirement to check and appt should not be withheld because of lack of proof).

Service that are excempt - Immediately necessary and urgent treatment (A&E), including lifesaving and antenatal care, communicable disease.

Some groups (victims of trafficking / slavery / domestic abuse / sexual violence / FGM, or childer under care of local authority and Rx under MH act)

• for 2ndary care services in UK, it is residence-based = must be living in UK lawfully on settled basis to be entitled to free healthcare. > charge applies to undocumented migrants / refused asylum seekers (except those above).

Fear of unaffordable bills and data sharing with the Home Office can deter people from seeking care.

• Bills > £500 and 2 months outstanding > reported to home office > detention / affects future asylum claim.

• NHS somtimes wrongly charges those who should be exempt

It enables clinicians to weigh justice, needs, and societal responsibilities when treating displaced individuals.

Rights-based approaches focus on legal entitlements, while needs-based approaches focus on addressing human suffering and wellbeing.

Because migration history, trauma, language barriers, and social exclusion significantly affect health needs and access to care.