Health literacy strengths and needs among migrant communities from Portuguese-speaking African countries in Portugal: a cross-sectional study

Introduction

Health literacy among migrants is a matter of public health and social justice. Migrants from diverse backgrounds encounter challenges such as linguistic barriers, cultural disparities, restricted access to health services, and heterogeneous migration statuses. Addressing these challenges requires careful consideration of their unique experiences and needs to promote equitable health outcomes. This can hinder their ability to navigate the healthcare system, understand health information, and engage in health-promoting behaviours. However, there is still a significant gap in our understanding of health literacy within migrant communities. This study has a dual aim: to identify health literacy strengths and needs among migrants from Portuguese-speaking African Countries (PALOP) countries in the Lisbon Metropolitan Area and to examine associations between demographic, socioeconomic, migration and health condition characteristics and the health literacy domains.

Methods

A cross-sectional survey was conducted. Data were collected from 506 PALOP migrants using the Health Literacy Questionnaire (HLQ). We also collected demographic, socioeconomic, migration, and health condition data. We employed multiple linear regression to understand the relationship between the HLQ nine domains and these characteristics.

Results

The HLQ scores revealed distinct patterns of health literacy between the groups. Health literacy needs were particularly evident in the domains related to feeling understood and supported by healthcare providers and navigating the healthcare system. Conversely, higher scores and potential strengths were observed in actively managing one's health and understanding enough health information to make informed decisions. However, in these, the average scores suggest that a high proportion of people recognised difficulties. 'The results also indicated that a higher educational level was associated with increased health literacy. In contrast, low self-perceived health status, living alone, shorter duration of residence in Portugal, and being either undocumented or in the process of obtaining legal status were associated with lower health literacy.

Conclusion

Our study highlights the importance of migration-related variables and self-reported health status in understanding health literacy among migrant communities. Factors such as length of stay and low self-perceived health status are associated with potentially disadvantageous levels of health literacy, which could exacerbate health inequalities. Assessing these variables is critical to identify gaps in health literacy and develop tailored interventions to reduce health inequalities.

Implementing a social prescribing program in primary care units in Portugal: A qualitative study exploring enablers, barriers and lessons learned from the perspectives of stakeholders involved in the program implementation

Social prescribing (SP) is a promising intersectoral strategy of integrated and person-centered care that can improve individual health and well-being by going beyond medical treatment, potentially reducing overall disease burden on health system. SP addresses health and social determinants of health by linking patients to community responses, i.e. services and initiatives fostering social interaction, physical activity and creativity, among other health-promoting aspects, provided by local public, private, and non-profit entities. There is limited research on the implementation processes of SP beyond the UK, hindering improvement and scale-up. This study aims to identify enablers and barriers of implementation of an SP program conducted in Portugal. A participatory and qualitative approach was used to assess the implementation of an SP program in health units. Semi-structured interviews were conducted with family doctors, social workers and representatives of community partners who participated in SP implementation. The Consolidated Framework for Implementation Research was used to conduct thematic analysis. The main enablers of SP implementation included its recognition as an evolution towards a holistic model of health, the personal characteristics of professionals as being proactive, motivated, and concerned with social determinants of health, and the communication strategy used to engage the stakeholders. Perceived challenges included raising users' awareness of SP and ensuring intervention adherence. Lack of preparedness for intersectoral working processes, including insufficient communication channels, limited community responses and the need for a more systematic collection of data on activities adherence and progress were also highlighted as barriers to SP implementation. SP implementation seems simple, but the results show that in practice, we are facing a complex intervention with multiple stakeholders, diverse community responses and factors influencing project success. A deeper understanding of SP specificities, local context, enablers, and barriers is vital to develop strategies for improvement and successful implementation, ensuring scalability and sustainability.

High-Risk Areas for Congenital Zika Syndrome in Rio de Janeiro: Spatial Cluster Detection

Brazil reported 18,282 suspected congenital Zika syndrome (CZS) cases up to 2018 and accounts for 61.4% of the total reported Zika cases in the Americas in the period. To detect high-risk areas for children with CZS in the city of Rio de Janeiro, we used cluster detection and thematic maps. We analyzed data using a Poisson model in Satscan 10.1.3 software. We also analyzed the records of children with CZS from 2015 to 2016 to describe the clinical and epidemiological maternal and child profile, as well as live births in 2016 and the social development index (SDI) by neighborhood. In 2015 and 2016, the incidence rates of CZS were 8.84 and 46.96 per 100,000 live births in the city, respectively. Severe congenital findings such as microcephaly and brain damage, osteoarticular impairment, ocular abnormalities, and hearing loss were observed in 47 children. The spatial distribution of CZS was concentrated in the north and west zones in heterogeneous neighborhoods. The neighborhoods with the highest occurrence of CZS cases were found to have the worst SDIs. Stascan detected three spatial clusters in the north zone, where the SDI is lower. The clusters presented high relative risks for CZS (7.86, 1.46, and 2.08), although they were not statistically significant. Our findings highlight a higher occurrence of CZS in areas with less favorable socioeconomic conditions.

Efficacy of health literacy interventions aimed to improve health gains of higher education students-a systematic review

BACKGROUND

Health literacy (HL) among higher education students is low, making them vulnerable about their health. To reverse this trend, higher education institutions promote HL interventions with various topics and methods. A comprehensive understanding of HL interventions is essential to determine whether these interventions meet the health information needs to improve health outcomes (health gains). The aim of this review was to identify and synthesise evidence on the efficacy of HL interventions implemented in academic settings to improve health outcomes.

METHODS

A systematic review was performed followed the PRISMA guidelines, protocol was registered in PROSPERO (CRD42022369869). A search strategy was performed in the EBSCO Host Web platform, the time limit placed was: 01/01/2017 to 30/09/2022. Eligible studies were those published in peer-reviewed journals and involved higher education students over the age of 18 as the subject of the intervention. Eligible interventions included any interventions evaluated in a study with comparison group that included a pre-post measure of health outcomes, were conducted in an academic setting. To methodology quality of included studies, it was used the Joanna Briggs Institute critical appraisal tool. To synthesise results narrative and thematic synthesis was conducted.

RESULTS

A total of 9 articles were included in this review, identified health literacy interventions with an impact on health outcomes. The total studies involved 2902 higher education students. All 9 studies were randomised controlled trials. The synthesised evidence supports the efficacy of interventions that contributed to positive changes in mental health, attitudes, norms, and self-efficacy of condom use, emotional, social, and psychological well being, subjective sleep quality, sleep latency, and habitual sleep efficiency, physical activity, and self-reported servings fried foods. HL interventions were educational or motivational and related to health promotion, disease prevention or healthcare.

CONCLUSIONS

HL interventions in higher education students can significantly improve health outcomes protecting them from the negative effects of threats for their health. The interventions designed with different strategies are more effective. HL interventions are associated with health benefits on health promotion, disease prevention and healthcare. For the attendance of higher education to be a successful experience, continuity of HL interventions developed in academic settings is necessary.

Problemas ligados ao álcool em centros de emergência (PLACE)-People experiencing homelessness with alcohol-related problems in Lisbon's emergency shelters during the COVID-19 pandemic: a description and analysis of a harm reduction intervention

Introduction

Alcohol-related problems disproportionally affect people experiencing homelessness. As the first wave of the COVID-2019 pandemic spread in 2020, a number of emergency shelters were opened in Lisbon. Increased difficulties in obtaining alcohol could have led to an increased incidence of alcohol withdrawal. Therefore, a low-threshold harm reduction intervention was introduced to these emergency shelters. This consisted of a fixed medication treatment, made available immediately for those with specific conditions, without the need for a medical evaluation or abstinence from alcohol, together with an offer of subsequent access to specialized addiction centers. The Problemas Ligados ao Álcool em Centros de Emergência (PLACE) study (alcohol-related problems in emergency shelters) is a retrospective mixed-methods observational study. It describes the demographic, health, and social characteristics of shelter users participating in the program and aims to evaluate the intervention as well as the experience of the patients, professionals, and decision-makers involved.

Results

A total of 69 people using shelters self-reported alcohol-related problems. Among them, 36.2% of the people accepted a pharmacological intervention, and 23.2% selected an addiction appointment. The take-up of the intervention was associated with better housing outcomes. A description of an individual's trajectory after leaving the shelter is provided.

Discussion

This study suggests that non-abstinence-focused interventions can be useful and well-tolerated in treating addiction in this population.

Can everyone hear me? Reflections on the use of global online workshops for promoting inclusive knowledge generation

Online research methods have risen in popularity over recent decades, particularly in the wake of COVID-19. We conducted five online workshops capturing the experiences of participatory health researchers in relation to power, as part of a collaborative project to develop global knowledge systems on power in participatory health research. These workshops included predominantly academic researchers working in 24 countries across Africa, Asia, Europe, and the Americas. Here, we reflect on the opportunities, limitations, and key considerations of using online workshops for knowledge generation and shared learning. The online workshop approach offers the potential for cross-continental knowledge exchange and for the amplification of global South voices. However, this study highlights the need for deeper exploration of power dynamics exposed by online platform use, particularly the 'digital divide' between academic partners and community co-researchers. Further research is needed to better understand the role of online platforms in generating more inclusive knowledge systems.

What is the role of attitudinal barriers on cervical cancer screening non-attendance? Findings from a cross-sectional study with migrant women in Portugal

BACKGROUND

Cervical cancer is a common disease which can be effectively and timely detected by cervical cancer screening. However, access to cervical cancer screening is unequal, and it is known that migrant women have a lower attendance to cervical cancer screening. These inequalities are associated with several factors, including attitudes and beliefs of the women regarding screening practices, which prevents them from participating. This study aims to explore the attitudinal barriers to cervical cancer screening among migrant women in Portugal.

METHODS

A web-based cross-sectional survey was conducted with 1100 migrant women residing in Portugal. Women were recruited through social media platforms. The survey included items on socioeconomic characteristics, cervical cancer screening history and an 11-item attitudinal questionnaire to assess attitudinal barriers. Logistic regression models were used for statistical analysis.

RESULTS

The attitudinal barriers to CCS most often reported by participants were fear of the test result (25.3%), worry about seeing a male health professional (23.8%), perceiving the test as painful (23.1%), embarrassment (18.5%), difficulties scheduling the test (14.3%), and having a negative experience in screening (12.4%). Low perceived need in absence of symptoms and lack of motivation to be screened were reported by less than 5% of the women. However, the results suggest that most of the attitudinal barriers with higher agreement percentage have no association with cervical cancer screening attendance. Among all the attitudinal barriers, low perceived need of screening and lack of motivation were associated with CCS non-attendance.

CONCLUSIONS

Based on the findings, out of all the factors analyzed, low perceived need of screening and lack of motivation are the most relevant factors associated with non-attendance among migrants in Portugal. Promoting health literacy and empowering women with knowledge about benefits of screening may help overcoming these barriers. Therefore, this study provides a foundation for stakeholders on which areas should be prioritized when developing strategies aiming to reduced cervical cancer screening non-attendance among migrant women.

LOCUS (LOng Covid-Understanding Symptoms, events and use of services in Portugal): A three-component study protocol

Approximately 10% of patients experience symptoms of Post COVID-19 Condition (PCC) after a SARS-CoV-2 infection. Akin acute COVID-19, PCC may impact a multitude of organs and systems, such as the cardiovascular, respiratory, musculoskeletal, and neurological systems. The frequency and associated risk factors of PCC are still unclear among both community and hospital settings in individuals with a history of COVID-19. The LOCUS study was designed to clarify the PCC's burden and associated risk factors. LOCUS is a multi-component study that encompasses three complementary building blocks. The "Cardiovascular and respiratory events following COVID-19" component is set to estimate the incidence of cardiovascular and respiratory events after COVID-19 in eight Portuguese hospitals via electronic health records consultation. The "Physical and mental symptoms following COVID-19" component aims to address the community prevalence of self-reported PCC symptoms through a questionnaire-based approach. Finally, the "Treating and living with Post COVID-19 Condition" component will employ semi-structured interviews and focus groups to characterise reported experiences of using or working in healthcare and community services for the treatment of PCC symptoms. This multi-component study represents an innovative approach to exploring the health consequences of PCC. Its results are expected to provide a key contribution to the optimisation of healthcare services design.

Improving equity in access to early diagnosis of cancer in different healthcare systems of Latin America: protocol for the EquityCancer-LA implementation-effectiveness hybrid study

INTRODUCTION

Healthcare fragmentation, a main cause for delay in cancer diagnosis and treatment, contributes to high mortality in Latin America (LA), particularly among disadvantaged populations. This research focuses on integrated care interventions, which have been limitedly implemented in the region. The objective is to evaluate the contextual effectiveness of scaling-up an integrated care intervention to improve early diagnosis of frequent cancers in healthcare networks of Chile, Colombia and Ecuador.

METHODS AND ANALYSIS

This research is two pronged: (A) quasi-experimental design (controlled before and after) with an intervention and a control healthcare network in each LA country, using an implementation-effectiveness hybrid approach to assess the intervention process, effectiveness and costs; and (B) case study design to analyse access to diagnosis of most frequent cancers. Focusing on the most vulnerable socioeconomic population, it develops in four phases: (1) analysis of delays and barriers to early diagnosis (baseline); (2) intervention adaptation and implementation (primary care training, fast-track referral pathway and patient information); (3) intracountry evaluation of intervention and (4) cross-country analysis. Baseline and evaluation studies adopt mixed-methods qualitative (semistructured individual interviews) and quantitative (patient questionnaire survey) methods. For the latter, a sample size of 174 patients with cancer diagnosis per healthcare network and year was calculated to detect a proportions difference of 15%, before and after intervention (α=0.05; β=0.2) in a two-sided test. A participatory approach will be used to tailor the intervention to each context, led by a local steering committee (professionals, managers, policy makers, patients and researchers).

ETHICS AND DISSEMINATION

This study complies with international and national legal stipulations on ethics. It was approved by each country's ethical committee and informed consent will be obtained from participants. Besides the coproduction of knowledge with key stakeholders, it will be disseminated through strategies such as policy briefs, workshops, e-tools and scientific papers.

Health literacy development is central to the prevention and control of non-communicable diseases

The WHO's report Health literacy development for the prevention and control of non-communicable diseases (NCDs) delivers practical what-to-do how-to-do guidance for health literacy development to build, at scale, contextually-relevant public health actions to reduce inequity and the burden of NCDs on individuals, health systems and economies. The key premise for health literacy development is that people's health awareness and behaviours are linked to lifelong experiences and social practices, which may be multilayered, hidden and beyond their control. Meaningful community engagement, local ownership and locally driven actions are needed to identify health literacy strengths, challenges and preferences to build locally fit-for-purpose and implementable actions. Health literacy development needs to underpin local and national policy, laws and regulations to create enabling environments that reduce community exposures to NCD risk factors. Deficit approaches and siloed health system and policy responses need to be avoided, focusing instead on integrating community-based solutions through co-design, cognisant of people's daily experiences and social practices.

Oral health-related quality of life in portuguese pre-school children: a cross-sectional study

PURPOSE

To study Oral Health related Quality of Life (OHRQoL) of pre-school children and its associated factors.

METHODS

Cross-sectional study with sample data collected through an on-line questionnaire to a non-probabilistic sample. The questionnaire included the Portuguese version of the Early Childhood Oral Health Impact Scale (ECOHIS) and questions about sociodemographic characteristics, oral health behaviours, and reported oral health of the child. Data analyses included descriptive statistics, Mann-Whitney and Kruskal-Wallis tests and Linear regression (α = 0.05).

RESULTS

The sample consisted of 1475 parents of pre-school children (3-5 years-old), residing in Portugal. The mean ECOHIS total score was 1.5 (sd = 3.4). In the bivariate analysis the child's age, starting toothbrushing after one year of age, frequent intake of sugary food and drinks, previous appointment with an oral health professional, all reported of oral health problems, and a negative perception of oral health were negatively associated with OHRQoL (p < 0,05). In the regression model the factors that most contributed to a worse quality of life were dental caries and abscess, contributing to an ECOHIS average increase of 2.56 and 3.34, respectively.

CONCLUSIONS

The studied population presented a good OHRQoL, with the item related to pain being the most relevant for the ECOHIS score. Worst OHRQoL was found in older children, whose parents negatively rated the children's oral health and with reported dental caries, trauma, and abscess.

Barriers and facilitators to cervical cancer screening among under-screened women in Cuenca, Ecuador: the perspectives of women and health professionals

Background

Cervical cancer screening is a cost-effective method responsible for reducing cervical cancer-related mortality by 70% in countries that have achieved high coverage through nationwide screening strategies. However, there are disparities in access to screening. In Ecuador, although cervical cancer is the second most common cancer in women, only 58.4% of women of reproductive age have ever been screened for cervical cancer.

Methodology

A qualitative study was performed to understand the current barriers to screening and to identify strategies that could increase uptake in Azuay province, Ecuador. Seven focus group discussions (FGDs) were conducted with under-screened women and health professionals (HPs). The FGDs were recorded and transcribed. Content analysis was done using the socio-ecological framework to categorize and analyse the data.

Results

Overall, 28 women and 27 HPs participated in the study. The two groups perceived different barriers to cervical cancer screening. The HPs considered barriers to be mainly at the policy level (lack of a structured screening plan; lack of health promotion) and the individual level (lack of risk perception; personal beliefs). The women identified barriers mainly at organizational level, such as long waiting times, lack of access to health centres, and inadequate patient–physician communication. Both groups mentioned facilitators at policy level, such as national campaigns promoting cervical cancer screening, and at community and individual level, including health literacy and women’s empowerment.

Conclusions

The women considered access to health services the main barrier to screening, while the HPs identified a lack of investment in screening programmes and cultural patterns at the community level as major obstacles. To take an integrated approach to cervical cancer prevention, the perspectives of both groups should be taken into account. Additionally, new strategies and technologies, such as self-administered human papillomavirus (HPV) testing and community participation, should be implemented to increase access to cervical cancer screening.

Integration of School Health Program actions among health and education professionals: a case study in Belo Horizonte, Minas Gerais

ABSTRACT The School Health Program aims to build healthy schools. This qualitative case study aimed to identify and understand how professionals involved in the School Health Program behave in the integration based on their inclusion in the recommended activities. The consensus was reached with experts to develop a matrix of indicators after building the Program’s logical model, resulting in a semi-structured roadmap. Twenty-five interviews were held in the Basic Health Units, Elementary Schools, and the Regional Health and Education Administrations. The practices were multisectoral, with no combined efforts and effective co-participation, planned by a single sector or professional, the existing gaps are recognized as much as the importance of the program, and the practices are implemented with a low bond between teams. The fragmented perception of students’ problems hinders this integration.

Integração das ações do Programa Saúde na Escola entre profissionais da saúde e da educação: um estudo de caso em Belo Horizonte, Minas Gerais

RESUMO O Programa Saúde na Escola tem como meta a construção de escolas saudáveis. Estudo de caso, de abordagem qualitativa com intenção de identificar e compreender como se comportam, no esforço de integração, profissionais envolvidos no Programa Saúde na Escola, a partir de sua inserção nas atividades preconizadas. Após construção do modelo lógico do programa, foi realizado consenso com experts para elaboração de matriz de indicadores, originando roteiro semiestruturado. Foram realizadas 25 entrevistas, nas Unidades Básicas de Saúde e Escolas de Ensino Fundamental, além das Gerências Regionais da Saúde e da Educação. As práticas foram consideradas multissetoriais, sem soma de esforços e coparticipação efetiva, sendo planejadas por um único setor ou profissional; os gaps existentes são reconhecidos tanto quanto a importância do programa; as práticas acontecem com baixo vínculo entre equipes. A forma fragmentada de perceber os problemas dos escolares dificulta essa integração.

Addressing health literacy to reduce inequalities among migrants: which profiles need our attention?

 

Health literacy, the ability to access, understand, appraise, remember and use health information and services, has great potential to reduce inequalities in access to and outcomes of care. People may have different patterns of health literacy needs and strengths. Yet, the design of interventions is frequently not responsive to the specificities of different segments of the population, including migrant groups. We aimed to identify profiles of migrants to inform the co-design of interventions targeting people at risk of poor outcomes. A cross-sectional survey was conducted with 1126 adult migrants living in Portugal. Data were collected using the 9-dimension HLQ (Health Literacy Questionnaire), and a sociodemographic questionnaire. A cluster analysis of data was performed. Semi-structured interviews were conducted with 15 migrants, stratified by the clusters. The optimal cluster solution yielded 16 profiles revealing diversity in combinations of strengths and needs across the HLQ domains. While 29.8% of migrants scored moderate to high on all 9 domains (profiles 2, 6, 8, 16), 63.4% of participants struggled with 1 or several aspects of health literacy, namely ‘Feeling understood and supported by healthcare providers'. Notably, 36.8% (6 profiles) exhibited difficulty across most of health literacy domains. The interviews provided a tangible description of the health literacy needs and resources with five main themes (access, understand, appraise, retrieve and use). Regarding ‘access', migrants expressed different preferred learning styles and needed to access different sorts of information at distinct times. The ‘use’ of information was rarely a one-time decision but a decision that people needed to make repeatedly. Health literacy is a highly diverse concept where subgroups exhibited diverse patterns. The cluster analysis can be used to inform the co-design, prioritisation and implementation of locally designed, fit-for-purpose solutions to improve health literacy.

Key messages

• Health literacy profiles can inform interventions to mitigate health inequalities among vulnerable migrant groups.

• The identification of distinct profiles can contribute to minimise the disconnect between what people/communities need and what is developed to improve health and equity.

Which effects had the pandemic in migrants’ health and well-being? A mixed-methods approach

Background

The COVID-19 pandemic affected populations’ health, with a disproportionate impact on those most socially vulnerable such as migrants. The way these populations experienced the pandemic lockdowns and its effects on daily life are yet to be known. This study aimed to understand the effects of the pandemic on health and well-being of migrants in Portugal.

Methods

In a mixed-methods approach, a survey was conducted with a community-based sample of 1126 migrants in the Lisbon Metropolitan Area, assessing sociodemographics, migration-related characteristics and the perceived impact of the pandemic on health. In addition, n = 12 migrants purposively recruited were invited to participate in a photovoice study, sharing photographs about their daily life during the lockdowns. Following semi-structured interviews were conducted. Quantitative data were analysed using multivariable analysis and qualitative data were analysed through content analysis.

Results

A fifth of the participants perceived having worse health condition since the pandemic, which was more likely among women (OR = 1.58, CI95% 1.13-2.20), those &gt;45 years old (OR = 1.78, CI95% 1.02-3.16), with lower education (Basic education: OR = 1.57, CI95% 1.01-2.47) and with lower monthly income (&lt;EUR 650: OR = 1.69, CI95% 1.18-2.44). Two themes emerged from the photovoice: effects of the pandemic lockdowns on daily life (routines, social relations, work) and on health and well-being (eating habits, physical exercise, leisure). Strategies to cope with the adverse effects included social activation and changes in lifestyles.

Conclusions

The pandemic had disproportionate effects on some migrant groups, intensifying social and health inequalities, with consequences for their well-being. Participatory methods can contribute to further understand migrants’ experiences while involving and empowering them for health promotion.

Key messages

• The pandemic had adverse effects on migrants’ health and well-being, disproportionately affecting most socially vulnerable migrant groups.

• Participatory research methods as photovoice are valuable to gain access to individual experiences and perspectives, while involving and empowering participants.

Mental health of migrants during the COVID-19 pandemic: additional stressors, increased inequalities

 

The COVID-19 pandemic has resulted in an unprecedent range of negative mental health outcomes across populations worldwide. Such effects are increasingly being documented, however an evidence gap persists on the consequences on most vulnerable groups, as certain subgroups of migrants. These populations already suffer from increased psychological burden, and the pandemic effects may potentially exacerbate adverse experiences and outcomes. This study aims to uncover the perceived impact of the COVID-19 pandemic on the mental health of migrants in Portugal and the associated sociodemographic aspects. A survey was conducted with a community-based sample of 1126 adult migrants in Portugal, assessing sociodemographics, migration-related characteristics and the perceived impact of the pandemic on mental health. Association between sociodemographics and mental health indicators was measured through bivariable analysis. In total, 1126 adult migrants were surveyed: 53.4% female, mean age of 35.8 years (range 18-77), 48.9% from African countries, 29.5% from Middle East/Asian countries, 21.6% from Brazil. Most participants (80%) reported feelings of agitation, anxiety or sadness during the pandemic period with 26.4% experiencing these feelings most days. The pandemic had a disproportionate impact on women (86.9% reported negative impact compared to 72.5% of men, p < 0.05), those undocumented (83.3% vs 75.4%, p < 0.05), those whose financial situation got worse since the pandemic (82.8% vs. 77.3%, p < 0.05) and those who had increased food shortages (84.4% vs 79%, p < 0.05). Migrants perceived an elevated deterioration of their mental health during the COVID-19 pandemic. In addition, particular groups such as women and those with a more insecure income or residence status are particularly susceptible to experiencing negative mental health outcomes.

Key messages

• There is a need to recognize the detrimental mental health impact of the COVID-19 pandemic on particular migrant groups and to develop interventions that target their unique needs.

• Investigating sociodemographic and migration aspects could help identifying migrants at a higher risk of experiencing mental health distress.

'I Didn't Know Where to Go': A Mixed-Methods Approach to Explore Migrants' Perspectives of Access and Use of Health Services during the COVID-19 Pandemic

The COVID-19 pandemic put pressure on health systems, affecting populations' use of health services, especially those experiencing increased difficulties in healthcare access, as some migrant groups. This study aimed to investigate access and use of health services during the COVID-19 pandemic among migrants in Portugal. A mixed-methods approach was used. A community-based cross-sectional survey was conducted involving migrant communities residing in the Lisbon Metropolitan Area. Analyses of a subsample of participants (n = 929) examined factors associated with perceived worsening of access to health services during the pandemic. Semi-structured interviews with 14 migrants were conducted and thematically analyzed to further understand experiences and difficulties in health services' use. Around 44% of surveyed participants reported worsening of access to health services since the pandemic, more frequently women, those with lower income, and those who perceived being at moderate or high risk for COVID-19 infection. Digital change in services and lack of formal and informal support during lockdowns were highlighted by interviewers as main barriers in access to healthcare for migrants. The pandemic renewed concerns about inequalities in healthcare access among migrants. It is key that in following years health systems are able to address the potential accumulated burden of disease.

Health literacy measurement: embracing diversity in a strengths-based approach to promote health and equity, and avoid epistemic injustice

Definitions of health literacy have evolved from notions of health-related literacy to a multidimensional concept that incorporates the importance of social and cultural knowledge, practices and contexts. This evolution is evident in the development of instruments that seek to measure health literacy in different ways. Health literacy measurement is important for global health because diverse stakeholders, including the WHO, use these data to inform health practice and policy, and to understand sources of inequity. In this Practice paper, we explore the potential for negative consequences, bias and epistemic injustice to occur when health literacy instruments are used across settings without due regard for the lived experiences of people in various contexts from whom data are collected. A health literacy measurement approach that is emic-sensitive, strengths based and solution oriented is needed to minimise biased data interpretation and use and to avoid epistemic injustice.

Quality and performance indicators in Portuguese anatomical pathology laboratories: a panel validation by qualitative Delphi technique

Background

In laboratory medicine, quality and performance indicators (QPIs) are essential tools to ensure the quality of healthcare services and patient safety. QPIs allow comparison of outcomes, favouring accountability and transparency. Internationally, there are some QPI evaluation models, but the fact that they are paid limits their dissemination in smaller/poorer laboratories. In Portugal, each laboratory defines its own QPIs, with no uniformity between institutions. The development of a free QPI panel suitable for anatomical pathology laboratories (APLs) would allow for quality assessment and improvement.

Objective

To develop a consensual and validated QPI panel suitable for Portuguese APLs.

Methods

The study was developed in two stages. First, a bibliographic review was carried out, selecting the adequate QPIs. Afterwards, these QPIs were evaluated by experts through the Delphi method, where they could also suggest other pertinent QPIs.

Results

By the end of the Delphi method, there was a consensus on 64 QPIs (31 for ‘structure’, 30 for ‘process’ and 3 for ‘result’). The consensual QPIs covered all phases of the total test cycle. The lack of specific anatomical pathology QPIs in the bibliography was noticeable. There was greater consensus on ‘process’ and ‘result’ QPIs than on ‘structure’. This was supported by the bibliography, where the first ones were more valued. Nevertheless, it is important to monitor all the main laboratory processes, prioritising the evaluation of QPIs with greater impact on healthcare quality and patient safety. These results should allow APLs to identify the causes behind poor performance and improve their services.

Conclusions

This panel is a valuable tool for APLs, contributing to quality awareness. It can be the first step towards the development of a free benchmarking quality programme in Portugal, encouraging competitiveness and cost-efficiency.

Association between perception of COVID-19 risk, confidence in health services and avoidance of emergency department visits: results from a community-based survey in Portugal

OBJECTIVES

To examine the association between the perception of COVID-19 risk, confidence in health services and avoidance of emergency department (ED) visits in Portugal during the COVID-19 pandemic.

DESIGN

Community-based, cross-sectional survey.

SETTING

Volunteer sample that completed the online survey between April 2020 and May 2021.

PARTICIPANTS

987 participants who perceived needing ED care. Of those, 242 reported avoiding ED visits.

OUTCOME MEASURES

Logistic regression models for ED avoidance were conducted to estimate the effect of risk perception and confidence in health services, adjusted for sociodemographics, health status and time.

RESULTS

The adjusted odds for ED avoidance were higher for participants lacking confidence in health service response to non-COVID-19 conditions (adjusted OR: 6.39; 95% CI 3.19 to 12.82) and COVID-19 (1.81; 1.19 to 2.77) and lower for those perceiving a low risk of being infected at a health provider (0.16; 0.07 to 0.38).

CONCLUSION

In our sample, confidence in health services and risk perception of infection at a health provider were associated with the decision to avoid the ED. These results suggest that policymakers and care providers need to mitigate the negative consequences of delayed healthcare; be aware of the implications of distrust and fear from those in need of healthcare and provide equally distributed safe alternatives to ED care.

Non-adherence to COVID-19 lockdown: who are they? A cross-sectional study in Portugal

Objectives

The SARS-CoV-2 virus has spread worldwide, leading governments to implement mitigation measures. Understanding the reluctance to adhere to non-pharmacological interventions might help promote adherence to these measures. This study aimed to identify factors associated with non-adherence to the first lockdown in Portugal.

Study design

Cross-sectional study.

Methods

This study used data from a Portuguese community-based survey entitled ‘COVID-19 Barometer: Social Opinion’. Data were collected on risk perception, health status and social experiences using a snowball sampling technique. The event of interest corresponded to participants who reported not staying home during the lockdown period, serving as a proxy for non-adherence to lockdown. Logistic regression was used to identify factors associated with non-adherence to the first lockdown.

Results

Responses from 133,601 individual questionnaires that were completed during the first week of the first lockdown in 2020 were analysed. A minority of participants (5.6%) reported non-adherence to lockdown (i.e. leaving home for reasons other than essential situations). Working in the workplace was the factor with the strongest association of non-adherence to the lockdown. Several other factors were also associated with non-adherence to the first lockdown; namely, being a man, being a student, having a low level of education, having a low income, living alone or with a high-infection-risk professional (e.g. doctor, nurse, pharmaceutical, health technician, firefighter, police officer, military, essential services worker), perceiving the risk of getting COVID-19 to be high, not having social support in case of infection, feeling agitated, sad or anxious every day, and considering the preventive measures to be unimportant or inadequate.

Conclusions

Non-adherence to lockdown was associated with socio-economic, trust and perception factors. Future research should investigate the mechanisms underlying these associations to help identify the population groups who are most at risk of non-adherence.