Cancer prevention in people experiencing homelessness: ethical considerations and experiences from the CANCERLESS project.

The incidence of cancer in Europe has been increasing in recent years. Despite this, cancer prevention has remained a low priority in health policies. Cancer is one of the main causes of mortality among people experiencing homelessness, who continue to have difficulties accessing prevention programs. A strategy that has been tested to favor cancer prevention is the health navigator figure. The objective of CANCERLESS project is to implement this model among populations experiencing homelessness in four European countries to foster the prevention and early detection of cancer. In this perspective, a presentation of CANCERLESS project is made, and its ethical aspects are discussed according to the ethics of public health, the ethics of care, solidarity, relational autonomy, and the social recognition of the virtue of just generosity. The ethical foundations of CANCERLESS project are rooted in social justice and in equity in access to health systems in general and cancer screening programs in particular. The ethics of public health guided by utilitarianism are insufficient in serving the interests of the most disadvantaged groups of the population. Hence, it is necessary to resort to relational bioethics that includes the ethics of care and solidarity and that recognizes the moral identity of socially excluded persons, reaffirming their position of equality in society. Relational autonomy therefore provides a broader conception by including the influence of living conditions in decisions. For this reason, the CANCERLESS project opts for a dialogue with those affected to incorporate their preferences and values into decisions about cancer prevention.

Cancer risk factors and access to cancer prevention services for people experiencing homelessness.

Cancer is one of the most pressing global health issues, and populations with complex needs, such as people experiencing homelessness, have higher cancer incidence and mortality rates compared with the housed population. We mapped the evidence on cancer risk factors as well as barriers and facilitators to cancer prevention services among people experiencing homelessness, which is key to localising research gaps and identifying strategies for tailored interventions adapted to people experiencing homelessness. The results of 40 studies contribute to an understanding of the dynamic, interactive factors at different levels that determine access to cancer prevention services: socioeconomic, psychological, and physical factors (individual level); practical support and relational loops between health-care providers and people experiencing homelessness (interpersonal level); housing and regular medical care (system level); and interventions to facilitate access to cancer prevention (policy level). Furthermore, studies reported higher prevalence of various cancer-associated risk factors among people experiencing homelessness with the most common being tobacco use, ranging from 26% to 73%. The results show the importance of interventions to facilitate cancer prevention services through social support and low-threshold interventions (eg, navigation programmes), and training health-care staff in creating supportive and trusting environments that increase the likelihood of the continuity of care among people experiencing homelessness.

Barriers and facilitators to health care access for people experiencing homelessness in four European countries: an exploratory qualitative study.

BACKGROUND: People experiencing homelessness (PEH) are known to be at higher risk of adverse health outcomes and premature mortality when compared to the housed population and often face significant barriers when attempting to access health services. This study aimed to better understand the specific health care needs of PEH and the barriers and facilitators associated with their timely and equitable access to health services in the European context. METHODS: We conducted an exploratory cross-national qualitative study involving people with lived experience of homelessness and health and social care professionals in Austria, Greece, Spain, and the UK. A total of 69 semi-structured interviews comprising 15 social care professionals, 19 health care professionals, and 35 PEH were completed, transcribed, and analysed thematically. RESULTS: Findings were organised into three overarching themes relating to the research question: (a) Health care needs of PEH, (b) Barriers to health care access, and (c) Facilitators to health care access. Overall, the general health of PEH was depicted as extremely poor, and mainstream health services were portrayed as ill-equipped to respond to the needs of this population. Adopting tailored approaches to care, especially involving trusted professionals in the delivery of care, was identified as a key strategy for overcoming existing barriers. CONCLUSIONS: The results of this study indicate there to be a high degree of consistency in the health care needs of PEH and the barriers and facilitators associated with their access to health care across the various European settings. Homelessness in itself is recognized to represent an essential social determinant of health, with PEH at risk of unequal access to health services. Changes are thus required to facilitate PEH's access to mainstream primary care. This can also be further complemented by investment in 'in-reach' services and other tailored and person-centred forms of health care. TRIAL REGISTRATION: This study was registered retrospectively on June 6, 2022, in the registry of ClinicalTrials.gov under the number NCT05406687.

Access to cancer preventive care and program considerations for people experiencing homelessness across four European countries: an exploratory qualitative study.

Background: People experiencing homelessness (PEH) have a higher prevalence of adverse health outcomes and premature mortality compared to the non-homeless population. These include a higher burden of cancer and cancer-specific morbidity and mortality-outcomes that may be a consequence of significant barriers to accessing primary and secondary prevention and community health services. This study aimed to better comprehend the health needs and barriers to accessing preventive cancer care for PEH across four European countries as well as necessary considerations for developing interventions around cancer prevention for this population. Methods: In this exploratory qualitative study, 69 semi-structured interviews were conducted across Austria, Greece, Spain, and the UK, with a sample comprising 15 professionals working in homelessness support services, 19 health professionals, and 35 PEH. Interviews took place between August 1 and October 31, 2021, and data were analysed inductively and iteratively following a thematic approach. Findings: Findings were organised into two overarching themes: (1) Experiences and understanding of cancer prevention and treatment and (2) Considerations for program interventions. While cancer was a significant worry among PEH across all settings, they generally had minimal knowledge and understanding of cancer symptoms and prevention. Specific programs for cancer prevention for PEH were described as almost non-existent. Health professionals in some settings indicated that cancer in PEH was often missed in the early stages and instead diagnosed when the severity of symptoms intensified. Interpretation: Overall, our findings indicate many commonalities in the health needs of PEH and the barriers they face when they seek access to cancer-specific healthcare services in the European context. Funding: This study received funding from the European Union's Horizon 2020 Research and Innovation Programme under GA 965351.

Cancer risk factors and access to cancer prevention services for people experiencing homelessness: a scoping review protocol.

INTRODUCTION: Homelessness is a complex social issue that significantly impairs the health of those affected. People experiencing homelessness (PEH) have a higher prevalence of adverse health outcomes, including premature mortality, compared with the general population, with cancer being the second-leading cause of death. The objective of this scoping review is to map the evidence to assess the exposure of PEH to known cancer risk factors and identify barriers and facilitators PEH experience in accessing cancer prevention services. METHODS AND ANALYSIS: This scoping review will be conducted in line with the Joanna Briggs Institute guidelines for scoping reviews. For a time window from the date of database establishment until 20 February 2023, the research team will create a detailed search strategy and apply it to the following databases: CINAHL, Embase, Global Index Medicus, PubMed, Scopus and Web of Science. In addition, we will search OpenGrey and Google for grey literature and contact non-governmental organisations to request relevant reports. In the first stage, eligibility criteria will be assessed through a blinded title/abstract assessment, and following this assessment, a full-text screening will be performed. Subsequently, the research team will perform the data extraction and synthesise all relevant information in relation to the scoping review question. ETHICS AND DISSEMINATION: As this protocol does not involve gathering primary data, ethical approval is not necessary. The results of this review will be published in a peer-reviewed journal and on institutional websites.

Characteristics and Effectiveness of Co-Designed Mental Health Interventions in Primary Care for People Experiencing Homelessness: A Systematic Review.

People experiencing homelessness (PEH) face a disproportionately high prevalence of adverse mental health outcomes compared with the non-homeless population and are known to utilize primary healthcare services less frequently while seeking help in emergency care facilities. Given that primary health services are more efficient and cost-saving, services with a focus on mental health that are co-designed with the participation of users can tackle this problem. Hence, we aimed to synthesize the current evidence of such interventions to assess and summarize the characteristics and effectiveness of co-designed primary mental healthcare services geared towards adult PEH. Out of a total of 10,428 identified records, four articles were found to be eligible to be included in this review. Our findings show that co-designed interventions positively impacted PEH's mental health and housing situation or reduced hospital and emergency department admissions and increased primary care utilization. Therefore, co-designed mental health interventions appear a promising way of providing PEH with continued access to primary mental healthcare. However, as co-designed mental health interventions for PEH can improve overall mental health, quality of life, housing, and acute service utilization, more research is needed.

Associations between workplace characteristics and 'outness' in LGBTI workers in Austria.

OBJECTIVES: Lesbian, gay, bisexual, transgender and intersex (LGBTI) individuals are often subjected to negative attitudes in the workplace, which may lead to non-disclosure of their sexual orientation and/or gender identities. We aimed to determine the prevalence of workplace disclosure of sexual or gender identity (ie, 'outness'; being 'out') and to examine its associations with workplace characteristics in LGBTI workers in Austria. METHODS: This cross-sectional study analysed sociodemographic, work-related and well-being-related data from self-identifying gender and/or sexual minority participants elicited by an online questionnaire between February and June 2017. From the initial 1268 respondents, 1177 (93%) provided complete data and were included in the subsequent analyses. RESULTS: The largest proportion of the sample were 26-35 years old (39.1%), cisgender gay men (40.0%) in full-time employment (63.9%). Overall, 51.7% of the sample were 'out' at the workplace. Being bisexual (OR=0.46, 95% CI 0.27 to 0.81), the provision of antidiscrimination guidelines in the workplace (OR=0.53, 95% CI 0.32 to 0.90), living alone (OR=0.50, 95% CI 0.32 to 0.79) and in shared households (OR=0.49, 95% CI 0.25 to 0.96) were associated with a decreased likelihood of being 'out' at work.Factors associated with being 'out' at work were being middle aged (36-45 years old; OR=1.74, 95% CI 1.07 to 2.85), having been in employment for >10 years (OR=2.03, 95% CI 1.08 to 3.81), an LGBTI-friendly work environment (OR 1.61, 95% CI 1.36 to 1.91), labour-management antidiscrimination contract (OR=2.02, 95% CI 1.23 to 3.32) and work council protections (OR=1.56, 95% CI 1.04 to 2.36). CONCLUSIONS: Instating antidiscrimination protections might facilitate 'outness' of LGBTI workers and lead to a better promotion of diversity in the workplace.

Associations between Physical Activity, Sitting Time, and Time Spent Outdoors with Mental Health during the First COVID-19 Lock Down in Austria.

Measures implemented to reduce the spread of SARS-CoV-2 have resulted in a decrease in physical activity (PA) while sedentary behaviour increased. The aim of the present study was to explore associations between PA and mental health in Austria during COVID-19 social restrictions. In this web-based cross-sectional study (April-May 2020) moderate-to-vigorous physical activity (MVPA), sitting time, and time spent outdoors were self-reported before and during self-isolation. Mental well-being was assessed with the Warwick-Edinburgh Mental Well-being Scale, and the Beck depression and anxiety inventories. The majority of the participants (n = 652) were female (72.4%), with a mean age of 36.0 years and a standard deviation (SD) of 14.4. Moreover, 76.5% took part in ≥30 min/day of MVPA, 53.5% sat ≥10 h/day, and 66.1% spent ≥60 min/day outdoors during self-isolation. Thirty-eight point five percent reported high mental well-being, 40.5% reported depressive symptoms, and 33.9% anxiety symptoms. Participating in higher levels of MVPA was associated with higher mental well-being (odds ratio = OR: 3.92; 95% confidence interval = 95%CI: 1.51-10.15), less depressive symptoms (OR: 0.44; 95%CI: 0.29-0.66) and anxiety symptoms (OR = 0.62; 95%CI: 0.41-0.94), and less loneliness (OR: 0.46; 95%CI: 0.31-0.69). Participants sitting <10 h/day had higher odds of mental well-being (OR: 3.58; 95%CI: 1.13-11.35). Comparable results were found for spending ≥60 min/day outdoors. Maintaining one's MVPA levels was associated with higher mental well-being (OR = 8.61, 95%CI: 2.68-27.62). In conclusion, results show a positive association between PA, time spent outdoors and mental well-being during COVID-19 social restrictions. Interventions aiming to increase PA might mitigate negative effects of such restrictions.

Access to Healthcare for Migrant Patients in Europe: Healthcare Discrimination and Translation Services.

BACKGROUND: Discrimination based on ethnicity and the lack of translation services in healthcare have been identified as main barriers to healthcare access. However, the actual experiences of migrant patients in Europe are rarely present in the literature. OBJECTIVES: The aim of this study was to assess healthcare discrimination as perceived by migrants themselves and the availability of translation services in the healthcare systems of Europe. METHODS: A total of 1407 migrants in 10 European Union countries (consortium members of the Mig-HealthCare project) were surveyed concerning healthcare discrimination, access to healthcare services, and need of translation services using an interviewer-administered questionnaire. Migrants in three countries were excluded from the analysis, due to small sample size, and the new sample consisted of N = 1294 migrants. Descriptive statistics and multivariable regression analyses were conducted to investigate the risk factors on perceived healthcare discrimination for migrants and refugees in the EU. RESULTS: Mean age was 32 (±11) years and 816 (63.26%) participants were males. The majority came from Syria, Afghanistan, Iraq, Nigeria, and Iran. Older migrants reported better treatment experience. Migrants in Italy (0.191; 95% CI [0.029, 0.352]) and Austria (0.167; 95% CI [0.012, 0.323]) scored higher in the Discrimination Scale to Medical Settings (DMS) compared with Spain. Additionally, migrants with better mental health scored lower in the DMS scale (0.994; 95% CI [0.993, 0.996]), while those with no legal permission in Greece tended to perceive more healthcare discrimination compared with migrants with some kind of permission (1.384; 95% CI [1.189, 1.611]), as opposed to Austria (0.763; 95% CI [0.632, 0.922]). Female migrants had higher odds of needing healthcare assistance but not being able to access them compared with males (1.613; 95% CI [1.183, 2.199]). Finally, migrants with chronic problems had the highest odds of needing and not having access to healthcare services compared with migrants who had other health problems (3.292; 95% CI [1.585, 6.837]). CONCLUSIONS: Development of culturally sensitive and linguistically diverse healthcare services should be one of the main aims of relevant health policies and strategies at the European level in order to respond to the unmet needs of the migrant population.

Changes in Sitting Time, Screen Exposure and Physical Activity during COVID-19 Lockdown in South American Adults: A Cross-Sectional Study.

The worldwide prevalence of insufficient physical activity (PA) and prolonged sedentary behavior (SB) were high before the coronavirus (COVID-19) pandemic. Measures that were taken by governments (such as home confinement) to control the spread of COVID-19 may have affected levels of PA and SB. This cross-sectional study among South American adults during the first months of COVID-19 aims to (i) compare sitting time (ST), screen exposure, moderate PA (MPA), vigorous PA (VPA), and moderate-to-vigorous PA (MVPA) before and during lockdown to sociodemographic correlates and (ii) to assess the impact of lockdown on combinations of groups reporting meeting/not-meeting PA recommendations and engaging/not-engaging excessive ST (≥7 h/day). Bivariate associations, effect sizes, and multivariable linear regressions were used. Adults from Argentina (n = 575) and Chile (n = 730) completed an online survey with questions regarding demographics, lifestyle factors, and chronic diseases. Mean reductions of 42.7 and 22.0 min./day were shown in MPA and VPA, respectively; while increases of 212.4 and 164.3 min./day were observed in screen and ST, respectively. Those who met PA recommendations and spent <7 h/day of ST experienced greatest changes, reporting greater than 3 h/day higher ST and more than 1.5 h/day lower MVPA. Findings from the present study suggest that efforts to promote PA to South American adults during and after COVID-19 restrictions are needed.

COVID-19 Confinement and Sexual Activity in Spain: A Cross-Sectional Study.

Restrictions of free movement have been proven effective in tackling the spread of COVID-19 disease. However, sensitive populations submitted to longer periods of restrictions may experience detrimental effects in significant areas of their lifestyle, such as sexual activity. This study examines sexual activity during the COVID-19 confinement in Spain. A survey distributed through an institutional social media profile served to collect data, whereas chi-squared tests, t-tests, analyses of variance, and multiple logistic regression analysis were used to assess differences among sample subgroups. A total of 71.3% adults (N = 536) (72.8% female) reported engaging in sexual activity with a weekly average of 2.39 times (SD = 1.80), with significant differences favoring males, middle age, married/in a domestic relationship (p < 0.001), employed (p < 0.005), medium-high annual household income, living outside the Iberian Peninsula, and smoking and alcohol consumption. Analyses adjusted for the complete set of control variables showed significant odds for a lower prevalence of weekly sexual activity in women (OR = 0.44, 95% CI 0.27-0.72). Interventions to promote sexual activity in confined Spanish adults may focus on groups with lower sexual activity.

Differences in health status, health behaviour and healthcare utilisation between Immigrant and native homeless people in Spain: An exploratory study.

Few studies have examined the differences between immigrant and native-born homeless populations. Our aim was to conduct an exploratory study to examine the differences in health status, health behaviour and healthcare utilisation in a sample of Spanish immigrant and native homeless people. Study was conducted in eight different temporary accommodations in the Valencia region in August 2018. Overall, 86 participants were included in the analysis who answered questionnaires concerning socio-demographic characteristics, immigration status, health status and behaviour, healthcare utilisation and experienced discrimination in healthcare and health literacy. In total, 76.7% were men with a mean age of 41.91 (14.17) years, with 60.4% having immigration background with an average of 4.8 (4.2) years since arrival in Spain. No differences were found in the subjective health status, however, native homeless participants reported significantly higher prevalence of heart disease (87.5% vs. 12.5%), hypertension (84.6% vs. 15.4%), psychological illness (63.6% vs. 36.4%) and were also more often smokers (73.5% vs. 28.8%), reported smoking more cigarettes per day (12.0 vs. 7.4) and were more often illegal drug users (17.6% vs. 2.0%). Immigrant participants were significantly more often not insured, reported more problems in healthcare access and had lower rates of visits to general practitioners and less hospital admissions. Differences were also observed in social status with the native homeless more often reporting receiving income, and living in less crowded accommodations. Our results show a variety of issues that the immigrant homeless population in Spain is confronted with that also prevents adequate social inclusion and achieving good health. However, the immigrant population engaged less often in risky health behaviour. More, and continuous, monitoring of social, mental and physical health of the homeless population is necessary. Public health interventions aiming at health promotion in the immigrant homeless populations need to focus on increasing overall social integration.

Association between Anxious and Depressive Symptomatology and Sexual Activity in Spain: A Cross-Sectional Study during the COVID-19 Quarantine.

INTRODUCTION: Evidence on sexual behaviour and COVID-19 shows a change in sexual habits; however, there is no research on the association between mental health and sexual activity. AIM: To examine the relationship between mental health and sexual activity during the quarantine in Spanish adults. METHODS: A sample of 305 adults filled out an online questionnaire. Sexual activity was assessed with one question. Anxiety and depression symptoms were assessed using the Beck Anxiety Inventory (BAI) and the Beck Depression Inventory (BDI), respectively. To check associations between levels of both anxiety and depressive symptoms (exposure) and weekly prevalence of sexual activity (outcome), we conducted multiple logistic regression adjusted for control variables (marital status, employment, average household annual income, place of living, pre-COVID-19 sexual activity, current smoking, current alcohol consumption, chronic physical conditions, chronic psychiatric conditions, physical symptoms, and days of confinement). RESULTS: Higher depression level was associated with lower weekly sexual activity in a dose-response fashion in the three implemented models. Participants with higher levels of depression were associated with significantly lower sexual activity in the fully adjusted model (OR: 0.09, 95% CI 0.01-0.61). Mild anxiety-level participants consistently presented significantly lower ORs for lower sexual activity than their minimal-anxiety category counterparts. Particularly, the fully adjusted model showed the lower values (OR: 0.40, 95% CI 0.19-0.84). CONCLUSION: The results of this study support existing evidence stressing the association between mental health and sexual activity in quarantined adults.

Comparison of physical activity levels in Spanish adults with chronic conditions before and during COVID-19 quarantine.

BACKGROUND: This is the first study analyzing levels of physical activity in a sample of quarantined adults with chronic conditions. The aim of this study was to compare moderate- and vigorous-intensity physical activity levels in Spanish adults with chronic conditions before and during coronavirus disease 2019 (COVID-19) quarantine. METHODS: A cross-sectional online survey was administered during the COVID-19 quarantine in Spain. A total of 163 participants with chronic conditions (113 females and 47 males; age range 18-64 years) completed the survey. A total of 26 chronic conditions were included. Participants self-reported average minutes/day of moderate and vigorous physical activity before and during quarantine. Differences in moderate- and vigorous-intensity physical activity levels before and during COVID-19 quarantine (overall, by gender, by age, by number of chronic conditions and by each chronic condition) were assessed by Wilcoxon-signed rank test. RESULTS: During COVID-19 quarantine, there was a significant decrease of moderate-intensity physical activity in Spanish people with chronic conditions (in both males and females, in those aged 18-24, 25-34, 35-44 and 55-64 years, in those with multimorbidity, in those with one/two chronic condition/s, and in those diagnosed with asthma/hypercholesterolaemia/chronic skin disease/haemorrhoids). Also, there was a significant decrease of vigorous-intensity physical activity in Spanish males with chronic conditions and in those with multimorbidity. CONCLUSIONS: These results should be considered to develop effective strategies of physical activity promotion targeting these specific groups when new quarantine or restriction measures are implemented, in order to avoid new significant decreases of physical activity in these vulnerable populations.

Health-Related Behaviors Among School-Aged Children and Adolescents During the Spanish Covid-19 Confinement.

In response to the coronavirus disease 2019 (Covid-19) world pandemic, affected countries such as Spain enacted measures comprising compulsory confinement as well as restrictions regarding free movement. Such measures likely influence children's and adolescents' lifestyles. Our study aimed to investigate the impact that the Covid-19 confinement has on health-related behaviors (HRBs) among Spanish children and adolescents. An online survey was administered to 516 parents to collect data about 860 children and adolescents (49.2% girls) aged between 3 and 16 years in relation to physical activity, screen exposure, sleep time, and fruit and vegetable consumption during the Covid-19 confinement. Respectively, t-paired test and t-test between groups served to check differences between HRBs levels before and during the confinement as well as between strict and relaxed confinement. Significant differences were found for a reduction of weekly minutes of physical activity during the confinement (-102.5, SD 159.6) (p < 0.001), an increase of daily hours of screen exposure (2.9, SD 2.1) (p < 0.001), and a reduction of daily fruit and vegetable consumption (-0.2, SD 1.6) (p < 0.001). Sleep time showed a significant difference between strict and relaxed confinement (-0.3, SD 0.1) (p < 0.05), whereas binomial logistic regression adjusted for covariates (age, sex, education of the parents, siblings, current condition, exposure to Covid-19, and previous health risk behavior) showed significantly lower odds for screen exposure risk behavior with relaxed confinement (OR 0.60, 95%CI 0.40-0.91). The present study suggests that Covid-19 confinement reduced physical activity levels, increased both screen exposure and sleep time, and reduced fruit and vegetable consumption. Therefore, most HRBs worsened among this sample of Spanish children and adolescents. Closure of schools, online education, and the lack of policies addressing the conciliation between labor and family life could have played an important role in HRBs worsening among pupils, which might be mitigated with adequate conciliation policies, parental guidance, and community support.

Determinants of Refugee and Migrant Health Status in 10 European Countries: The Mig-HealthCare Project.

In this study, we collect and synthesize information on the health status of the refugee/migrant population in ten European countries in order to map refugee/migrant health needs. With this information, we identify areas of intervention and healthcare system strengthening to provide the basis for future health planning and effective healthcare provision to migrants, asylum-seekers and refugees in the European Union (EU). METHODS: 1407 migrants in ten European Union countries (consortium members of the Mig-HealthCare project) were surveyed on general health, mental health, and specific diseases using an interviewer-administered questionnaire. Descriptive statistics and multivariable linear regression analyses were conducted to investigate the risk factors on general quality of life for migrants and refugees in the EU. RESULTS: Mean age was 31.9 (±11.05) years and 889 (63.1%) participants were males. The majority came from Syria, Afghanistan, Iraq, Nigeria, and Iran. Having a mental health disorder or a chronic disease such as a heart or respiratory disease was associated with worse general health. On the other hand, having permission to stay in the country of interview and being interviewed in the country of final destination was associated with better general health. Access to health care services was fragmented or unavailable for some interviewees because of linguistic, cultural, or administrative barriers. CONCLUSIONS: The management of chronic diseases and mental health conditions in European migrants and refugees is a key priority for health service provision. Further efforts should be made to guarantee healthcare access for migrant and refugee populations.

Migrants' and refugees' health status and healthcare in Europe: a scoping literature review.

BACKGROUND: There is increasing attention paid to the arrival of migrants from outwith the EU region to the European countries. Healthcare that is universally and equably accessible needs to be provided for these migrants throughout the range of national contexts and in response to complex and evolving individual needs. It is important to look at the evidence available on provision and access to healthcare for migrants to identify barriers to accessing healthcare and better plan necessary changes. METHODS: This review scoped 77 papers from nine European countries (Austria, Cyprus, France, Germany, Greece, Italy, Malta, Spain, and Sweden) in English and in country-specific languages in order to provide an overview of migrants' access to healthcare. The review aims at identifying what is known about access to healthcare as well as healthcare use of migrants and refugees in the EU member states. The evidence included documents from 2011 onwards. RESULTS: The literature reviewed confirms that despite the aspiration to ensure equality of access to healthcare, there is evidence of persistent inequalities between migrants and non-migrants in access to healthcare services. The evidence shows unmet healthcare needs, especially when it comes to mental and dental health as well as the existence of legal barriers in accessing healthcare. Language and communication barriers, overuse of emergency services and underuse of primary healthcare services as well as discrimination are described. CONCLUSIONS: The European situation concerning migrants' and refugees' health status and access to healthcare is heterogeneous and it is difficult to compare and draw any firm conclusions due to the scant evidence. Different diseases are prioritised by different countries, although these priorities do not always correspond to the expressed needs or priorities of the migrants. Mental healthcare, preventive care (immunization) and long-term care in the presence of a growing migrant older population are identified as priorities that deserve greater attention. There is a need to improve the existing data on migrants' health status, needs and access to healthcare to be able to tailor care to the needs of migrants. To conduct research that highlights migrants' own views on their health and barriers to access to healthcare is key.

Cost and effects of integrated care: a systematic literature review and meta-analysis.

BACKGROUND: Health and care services are becoming increasingly strained and healthcare authorities worldwide are investing in integrated care in the hope of delivering higher-quality services while containing costs. The cost-effectiveness of integrated care, however, remains unclear. This systematic review and meta-analysis aims to appraise current economic evaluations of integrated care and assesses the impact on outcomes and costs. METHODS: CINAHL, DARE, EMBASE, Medline/PubMed, NHS EED, OECD Library, Scopus, Web of Science, and WHOLIS databases from inception to 31 December 2019 were searched to identify studies assessing the cost-effectiveness of integrated care. Study quality was assessed using an adapted CHEERS checklist and used as weight in a random-effects meta-analysis to estimate mean cost and mean outcomes of integrated care. RESULTS: Selected studies achieved a relatively low average quality score of 65.0% (± 18.7%). Overall meta-analyses from 34 studies showed a significant decrease in costs (0.94; CI 0.90-0.99) and a statistically significant improvement in outcomes (1.06; CI 1.05-1.08) associated with integrated care compared to the control. There is substantial heterogeneity in both costs and outcomes across subgroups. Results were significant in studies lasting over 12 months (12 studies), with both a decrease in cost (0.87; CI 0.80-0.94) and improvement in outcomes (1.15; 95% CI 1.11-1.18) for integrated care interventions; whereas, these associations were not significant in studies with follow-up less than a year. CONCLUSION: Our findings suggest that integrated care is likely to reduce cost and improve outcome. However, existing evidence varies largely and is of moderate quality. Future economic evaluation should target methodological issues to aid policy decisions with more robust evidence on the cost-effectiveness of integrated care.

Policy Makers', NGO, and Healthcare Workers' Accounts of Migrants' and Refugees' Healthcare Access Across Europe-Human Rights and Citizenship Based Claims.

Freely available healthcare, universally accessible to the population of citizens, is a key ideal for European welfare systems. As labor migration of the twentieth century gave way to the globalized streams of the twenty-first century, new challenges to fulfilling these ideals have emerged. The principle of freedom of movement, together with large-scale forced migration have led to large scale movements of people, making new demands on European healthcare systems which had previously been largely focused on meeting sedentary local populations' needs. Drawing on interviews with service providers working for NGOs and public healthcare systems and with policy makers across 10 European countries, this paper considers how forced migrants' healthcare needs are addressed by national health systems, with factors hindering access at organizational and individual level in particular focus. The ways in which refugees' and migrants' healthcare access is prevented are considered in terms of claims based on citizenship and on the human right to health and healthcare. Where claims based on citizenship are denied and there is no means of asserting the human right to health, migrants are caught in a new form of inequality.