Community health action and COVID-19 in Barcelona neighbourhoods: responses and challenges.

The COVID-19 pandemic exacerbated pre-existing social, economic and political inequalities. The evidence describes the use of community engagement approaches to support appropriate COVID-19 prevention and control measures. We aimed to delve deeper into the community response to COVID-19 in Barcelona neighbourhoods with different pre-existing levels of development of community health action (CHA). A qualitative phenomenological study was conducted in six Barcelona neighbourhoods with different types of CHAs. The sample included 37 in-depth interviews with community agents with good knowledge of the territory. The content analysis focused on three dimensions: symbolic (conceptions motivating action), substantive (the content and resources of the action) and operational (interactions between agents). Regardless of their CHA typology, all neighbourhoods responded to the needs generated by the pandemic. Symbolic: strong-CHA development, characterized by well-established participatory structures, facilitated responses to the crisis. In medium-CHA neighbourhoods, the emergency exacerbated previous tensions. In emerging-CHA neighbourhoods, previous participatory structures, although not health-specific, favoured the coordination of responses. Substantive: technology influenced the way CHA activities were conducted. Operative: in the strong-CHA neighbourhood, new participants were able to join previous participatory structures. In medium-CHA neighbourhoods, power dynamics hindered coordination. In conclusion, strong CHA can play a key role in addressing the adverse consequences of social and health crisis. Empowering citizens and communities should be a primary objective of public policy that integrates the 'health-in-all-policies' approach. This approach entails allocating public resources to strengthen the role of community action and power.

Community-Based Interventions to Reduce Alcohol Consumption and Alcohol-Related Harm in Adults.

Alcohol consumption was associated with 3 million deaths worldwide in 2016. Although community action has proven to be effective and has become a priority area of the global strategy to reduce alcohol consumption, there is a gap in the knowledge of community interventions to reduce alcohol use among adults. This study aims to analyze the evidence on effective community-based interventions to reduce alcohol consumption and harm among adults and to identify their components and underlying theories. Search strategy involved five databases (January 2000-March 2020). We included multicomponent, evaluated, and community interventions addressing to adults in urban settings of high-income countries. Furthermore, two conceptual frameworks were adapted to identify the social determinants of alcohol related harms and modifiable factors through community interventions. The initial search yielded 164 articles. The final sample included eight primary studies. Six of them were effective and shared three components (community mobilization; law enforcement and media campaigns), they combined approaches at individual and environmental levels addressing structural determinants of health and some cultural aspects related to consumption. Health outcomes focused mainly on reducing consumption, modifying patterns and acute effects on health. Few studies addressed social problems arising from harmful consumption. This review has identified several effective community-based interventions to reduce harmful use of alcohol among adults as well as some mechanisms and theories supporting them. It also provides a framework to guide new designs, with potential evidence of factors, as well as possible combinations of methods to improve health at community level across different settings and contexts.

Improving mental health and wellbeing in elderly people isolated at home due to architectural barriers: A community health intervention.

OBJECTIVES: To explore the health effects of a community health intervention on older people who are isolated at home due to mobility problems or architectural barriers, to identify associated characteristics and to assess participants' satisfaction. DESIGN: Quasi-experimental before-after study. SETTING: Five low-income neighbourhoods of Barcelona during 2010-15. PARTICIPANTS: 147 participants, aged ≥59, living in isolation due to mobility problems or architectural barriers were interviewed before the intervention and after 6 months. INTERVENTION: Primary Health Care teams, public health and social workers, and other community agents carried out a community health intervention, consisting of weekly outings, facilitated by volunteers. MEASUREMENTS: We assessed self-rated health, mental health using the General Health Questionnaire (GHQ-12), and quality of life through the EuroQol scale. Satisfaction with the programme was evaluated using a set of questions. We analysed pre and post data with McNemar tests and fitted lineal and Poisson regression models. RESULTS: At 6 months, participants showed improvements in self-rated health and mental health and a reduction of anxiety. Improvements were greater among women, those who had not left home for ≥4 months, those with lower educational level, and those who had made ≥9 outings. Self-rated health [aRR: 1.29(1.04-1.62)] and mental health improvements [ß: 2.92(1.64-4.2)] remained significant in the multivariate models. Mean satisfaction was 9.3 out of 10. CONCLUSION: This community health intervention appears to improve several health outcomes in isolated elderly people, especially among the most vulnerable groups. Replications of this type of intervention could work in similar contexts.

Effects of a health information system data quality intervention on concordance in Mozambique: time-series analyses from 2009-2012.

BACKGROUND: We assessed the effects of a three-year national-level, ministry-led health information system (HIS) data quality intervention and identified associated health facility factors. METHODS: Monthly summary HIS data concordance between a gold standard data quality audit and routine HIS data was assessed in 26 health facilities in Sofala Province, Mozambique across four indicators (outpatient consults, institutional births, first antenatal care visits, and third dose of diphtheria, pertussis, and tetanus vaccination) and five levels of health system data aggregation (daily facility paper registers, monthly paper facility reports, monthly paper district reports, monthly electronic district reports, and monthly electronic provincial reports) through retrospective yearly audits conducted July-August 2010-2013. We used mixed-effects linear models to quantify changes in data quality over time and associated health system determinants. RESULTS: Median concordance increased from 56.3% during the baseline period (2009-2010) to 87.5% during 2012-2013. Concordance improved by 1.0% (confidence interval [CI]: 0.60, 1.5) per month during the intervention period of 2010-2011 and 1.6% (CI: 0.89, 2.2) per month from 2011-2012. No significant improvements were observed from 2009-2010 (during baseline period) or 2012-2013. Facilities with more technical staff (aß: 0.71; CI: 0.14, 1.3), more first antenatal care visits (aß: 3.3; CI: 0.43, 6.2), and fewer clinic beds (aß: -0.94; CI: -1.7, -0.20) showed more improvements. Compared to facilities with no stock-outs, facilities with five essential drugs stocked out had 51.7% (CI: -64.8 -38.6) lower data concordance. CONCLUSIONS: A data quality intervention was associated with significant improvements in health information system data concordance across public-sector health facilities in rural and urban Mozambique. Concordance was higher at those facilities with more human resources for health and was associated with fewer clinic-level stock-outs of essential medicines. Increased investments should be made in data audit and feedback activities alongside targeted efforts to improve HIS data in low- and middle-income countries.

Evaluation of a Community Intervention to Reduce Harmful Alcohol Consumption among Adult Population: A Study Protocol.

Harmful alcohol consumption is shaped by a complex range of structural, social, and individual determinants that interact with inequality axes, which can be addressed at the community level. Under the framework of Barcelona Health in the Neighborhoods, which is a community strategy to reduce health inequalities in Barcelona's most deprived neighborhoods, a community steering group will co-design a multicomponent community intervention. Aims: to assess its effects on: (1) alcohol accessibility, availability, and consumption at the environmental level, and (2) psychosocial and cognitive determinants of harmful alcohol consumption at the individual level. Methods: Quasi-experimental design with a comparison group, and pre- and post-intervention measures. Three Barcelona neighborhoods will be assigned to the intervention or comparison group based on three criteria: healthcare data on alcohol use, socioeconomic characteristics, and population size. The intervention includes activities promoting community mobilization, law enforcement, and communication campaigns in the intervened neighborhoods. Non-participant observations in standardized census sections will be performed in public spaces to collect information on three outcomes: alcohol accessibility, availability, and signs of alcohol consumption. Data collection includes a survey to a sample of 622 subjects to detect differences on these outcomes: risk awareness, knowledge, and self-efficacy about harmful alcohol consumption and drinking patterns. Discussion: This protocol to assess the effects of a multicomponent community intervention on harmful alcohol consumption at the environmental and population level will provide evidence on effective community health interventions and enable informed decisions for policy makers. This protocol could also be used as an implementation guide for studies aimed at reducing harmful drinking in cities with similar characteristics.

Barcelona Salut als Barris: Twelve years' experience of tackling social health inequalities through community-based interventions.

Community health can reduce inequalities in health and improve the health of the most disadvantaged populations. In 2007, Barcelona Salut als Barris (Barcelona Health in the Neighbourhoods) was launched, a community health programme to reduce social inequalities in health. In 2018, this programme reached the 25 most disadvantaged neighbourhoods of the city. This article shares the lessons learned after 12 years of work. The programme was initially funded by a research grant and the funds were maintained during the economic crisis and were tripled when the programme became a political priority in the last municipal government. During the 12-year period, partnerships with stakeholders were generally stable and productive. Maximum community participation was obtained in the detection of health assets and needs and in action plans. During 2018, Barcelona Salut als Barris worked with more than 460 agents that co-produced 183 interventions involving more than 13,600 people. Most of the interventions assessed showed improvements in the health of participants, which could help to reduce health inequalities. The greatest difficulties were: a) citizen participation, b) the sustainability of working groups over the years, c) conflicts of interest, d) the sustainability of interventions, e) reaching certain minority groups and f) evaluation. The increase in resources in the last period contributed to the maturity and expansion of the programme. Key factors in its scope and results were political will, strong technical capacity and methodology, strong intersectoral partnerships and continued community work.

Invisible work, unseen hazards: The health of women immigrant household service workers in Spain.

BACKGROUND: Household service work has been largely absent from occupational health studies. We examine the occupational hazards and health effects identified by immigrant women household service workers. METHODS: Exploratory, descriptive study of 46 documented and undocumented immigrant women in household services in Spain, using a phenomenological approach. Data were collected between September 2006 and May 2007 through focus groups and semi-structured individual interviews. Data were separated for analysis by documentation status and sorted using a mixed-generation process. In a second phase of analysis, data on psychosocial hazards were organized using the Copenhagen Psychosocial Questionnaire as a guide. RESULTS: Informants reported a number of environmental, ergonomic and psychosocial hazards and corresponding health effects. Psychosocial hazards were especially strongly present in data. Data on reported hazards were similar by documentation status and varied by several emerging categories: whether participants were primarily cleaners or carers and whether they lived in or outside of the homes of their employers. Documentation status was relevant in terms of empowerment and bargaining, but did not appear to influence work tasks or exposure to hazards directly. CONCLUSIONS: Female immigrant household service workers are exposed to a variety of health hazards that could be acted upon by improved legislation, enforcement, and preventive workplace measures, which are discussed.

Extending a model of precarious employment: A qualitative study of immigrant workers in Spain.

BACKGROUND: Since the 1980s, changes in the labor market have modified power relations between capital and labor, leading to greater levels of precarious employment among workers. Globalization has led to a growth in migration, as people leave their countries in search of work. We aimed to describe the dimensions of precarious employment for immigrant workers in Spain. METHODS: Qualitative study using analytic induction. Criterion sampling was used to recruit 129 immigrant workers in Spain with documented and undocumented administrative status. Data quality was ensured by triangulation. RESULTS: Immigrant workers reported that precarious employment is characterized by high job instability, a lack of power for negotiating employment conditions, and defenselessness against high labor demands. They described insufficient wages, long working hours, limited social benefits, and difficulty in exercising their rights. Undocumented workers reported greater defenselessness and worse employment conditions. CONCLUSIONS: This study allowed us to describe the dimensions of precarious employment in immigrant workers.

Perceived pathways between tourism gentrification and health: A participatory Photovoice study in the Gòtic neighborhood in Barcelona.

Tourism gentrification is as process of urban change and neighborhoods transformation, according to the needs of affluent visitors, increasing in some global cities. However, the link between tourism gentrification and resident's health is still an understudied topic. Using Photovoice, a participatory action research method, the aim of this study was to identify the perceived pathways that underlie the relationship between tourism gentrification and health among residents of Gòtic neighborhood, in Barcelona. The study was conducted between January 2018 and January 2019. Thirteen residents, recruited from two neighborhood organizations, took photographs of how tourism gentrification of the neighborhood was affecting their health. Participants analyzed and critically discussed their photographs in small group sessions. Through a consensus-building process, participants categorized 35 photographs and identified 7 emerging categories acknowledged as possible pathways between tourism gentrification and health, in Gòtic neighborhood: 1) decline of social networks; 2) loss of identity; 3) environmental changes; 4) pollution; 5) changes in services and stores; 6) property speculation/eviction and; 7) activism by residents. This Photovoice study recognizes important pathways underlying the relationship between tourism gentrification in the Gòtic neighborhood and the health of its residents, by altering the built environment, the social environment or psychological factors. Among them, six pathways were related to negative health outcomes, both physical and mental (respiratory diseases; worse nutrition habits; sleep deprivation; stress, anxiety and depression). 'Activism by residents' was perceived to buffer the negative health effects of living in a touristic area. The study also provides recommendations to tackle this serious urban health issue.

Discrimination, work and health in immigrant populations in Spain.

One of the most important social phenomena in the global context is the flow of immigration from developing countries, motivated by economic and employment related issues. Discrimination can be approached as a health risk factor within the immigrant population's working environment, especially for those immigrants at greater risk from social exclusion and marginalisation. The aim of this study is to research perceptions of discrimination and the specific relationship between discrimination in the workplace and health among Spain's immigrant population. A qualitative study was performed by means of 84 interviews and 12 focus groups held with immigrant workers in five cities in Spain receiving a large influx of immigrants (Madrid, Barcelona, Valencia, Alicante and Huelva), covering representative immigrant communities in Spain (Romanians, Moroccans, Ecuadorians, Colombians and Sub-Saharan Africans). Discourse narrative content analysis was performed using pre-established categories and gradually incorporating other emerging categories from the immigrant interviewees themselves. The participants reported instances of discrimination in their community and working life, characterised by experiences of racism, mistreatment and precarious working conditions in comparison to the Spanish-born population. They also talked about limitations in terms of accessible occupations (mainly construction, the hotel and restaurant trade, domestic service and agriculture), and described major difficulties accessing other types of work (for example public administration). They also identified political and legal structural barriers related with social institutions. Experiences of discrimination can affect their mental health and are decisive factors regarding access to healthcare services. Our results suggest the need to adopt integration policies in both the countries of origin and the host country, to acknowledge labour and social rights, and to conduct further research into individual and social factors that affect the health of the immigrant populations.

[Occupational health of immigrant workers in Spain [ITSAL Project]: key informants survey]. / Condiciones de trabajo y salud en inmigrantes (Proyecto ITSAL): entrevistas a informantes clave.

OBJECTIVE: To describe the characteristics, working conditions, and occupational health situation of immigrant workers in Spain through key informants. METHOD: We performed a qualitative, exploratory and descriptive study using indepth interviews carried out in 2006. Organizations and associations working with immigrant collectives in Alicante, Barcelona, Huelva, Madrid and Valencia were identified and the most representative and accessible entities in each location were selected. Fortythree interviews were performed with key informants from 34 different organisms. A narrative content analysis was performed. RESULTS: Informants described difficulties in having health problems recognized as workrelated, due to irregular and precarious employment, employers' and insurance companies' reluctance, and immigrants' lack of knowledge. Informants coincided in reporting that the occupational risks for immigrant workers did not differ from those affecting Spanish workers in the same occupations and circumstances. However, exposure to occupational risks was exacerbated in immigrants because of their greater presence in unqualified jobs and their economic need to prolong working hours. Immigrants had little knowledge of their occupational health and safetyrelated rights, although some informants detected an increase in empowerment in this area, mostly through greater participation in trade unions. CONCLUSIONS: This first step allowed us to identify some of the general factors influencing the health and safety of immigrant workers in Spain. This information will be used in a longterm, ongoing research project [Project Immigration, Work and Health (Proyecto Inmigración, Trabajo y Salud [ITSAL]), which aims to evaluate occupational health problems in inmigrants working in Spain through both qualitative and quantitative methods.

Has the quality of health care for the immigrant population changed during the economic crisis in Catalonia (Spain)? Opinions of health professionals and immigrant users.

OBJECTIVE: To analyse changes in health professionals' and immigrant users' perceptions of the quality of care provided to the immigrant population during the crisis. METHODS: A qualitative descriptive-interpretative and exploratory study was conducted in two areas of Catalonia. Semi-structured individual interviews were used with a theoretical sample of medical (n=24) and administrative (n=10) professionals in primary care (PC) and secondary care (SC), and immigrant users (n=20). Thematic analysis was conducted and the results were triangulated. RESULTS: Problems related to technical and interpersonal quality emerged from the discourse of both professionals and immigrants. These problems were attributed to cutbacks during the economic crisis. Regarding technical quality, respondents reported an increase in erroneous or non-specific diagnoses, inappropriate use of diagnostic tests and non-specific treatments, due to reduction in consultation times as a result of cuts in human resources. With regard to interpersonal quality, professionals reported less empathy, and users also reported worse communication, due to changes in professionals' working conditions and users' attitudes. Finally, a reduction in the resolution capacity of the health services emerged: professionals described unnecessary repeated PC visits and limited responses in SC, while young immigrants reported an insufficient response to their health problems. CONCLUSION: The results indicate a deterioration in perceived technical and interpersonal quality during the economic crisis, due to cutbacks mainly in human resources. These changes affect the whole population, but especially immigrants.

Changes in access to health care for immigrants in Catalonia during the economic crisis: Opinions of health professionals and immigrant users.

Policy measures introduced in Spain during the economic crisis included a reduction in public health expenditure and in healthcare entitlements (RDL16/2012), which affected the general population as a whole, but especially immigrants. This paper analyzes changes in immigrants' access to health care during the economic crisis from the perspective of health professionals (medical and administrative) and immigrants. A qualitative descriptive-interpretative study was conducted in Catalonia through individual interviews with a theoretical sample of health professionals (n=34) and immigrant users (n=20). Thematic analysis was conducted and data quality was ensured through triangulation. Informants described barriers to enter the health system related to reduced healthcare entitlements and a stricter enforcement of administrative requirements: while medical professionals highlighted restrictions to accessing the healthcare continuum, immigrants accentuated barriers to obtaining the individual health card. With regard to use of services, an increase in waiting times due to cutbacks in human resources dominated the informants' discourse. Health professionals pointed out organizational changes to increase efficiency that may improve access to primary care. Informants related lower health services utilization to a deterioration in immigrants' living and working conditions. According to health professionals, these conditions limited the use of services during working hours and led to delays in seeking care and treatment interruptions. Results show an aggravation of pre-existing barriers to health services utilization and, simultaneously, the appearance of new barriers to enter the system. These changes in the healthcare services contradict the equity principles of the national health system (NHS), thus policy decisions are needed to address this problem.

Was access to health care easy for immigrants in Spain? The perspectives of health personnel in Catalonia and Andalusia.

Until April 2012, all Spanish citizens were entitled to health care and policies had been developed at national and regional level to remove potential barriers of access, however, evidence suggested problems of access for immigrants. In order to identify factors affecting immigrants' access to health care, we conducted a qualitative study based on individual interviews with healthcare managers (n=27) and professionals (n=65) in Catalonia and Andalusia, before the policy change that restricted access for some groups. A thematic analysis was carried out. Health professionals considered access to health care "easy" for immigrants and similar to access for autochthons in both regions. Clear barriers were identified to enter the health system (in obtaining the health card) and in using services, indicating a mismatch between the characteristics of services and those of immigrants. Results did not differ among regions, except for in Catalonia, where access to care was considered harder for users without a health card, due to the fees charged, and in general, because of the distance to primary health care in rural areas. In conclusion, despite the universal coverage granted by the Spanish healthcare system and developed health policies, a number of barriers in access emerged that would require implementing the existing policies. However, the measures taken in the context of the economic crisis are pointing in the opposite direction, towards maintaining or increasing barriers.

Wait and consult times for primary healthcare services in central Mozambique: a time-motion study.

BACKGROUND: We describe wait and consult times across public-sector clinics and identify health facility determinants of wait and consult times. DESIGN: We observed 8,102 patient arrivals and departures from clinical service areas across 12 public-sector clinics in Sofala and Manica Provinces between January and April 2011. Negative binomial generalized estimating equations were used to model associated health facility factors. RESULTS: Mean wait times (in minutes) were: 26.1 for reception; 43.5 for outpatient consults; 58.8 for antenatal visits; 16.2 for well-child visits; 8.0 for pharmacy; and 15.6 for laboratory. Mean consultation times (in minutes) were: 5.3 for outpatient consults; 9.4 for antenatal visits; and 2.3 for well-child visits. Over 70% (884/1,248) of patients arrived at the clinic to begin queuing for general reception prior to 10:30 am. Facilities with more institutional births had significantly longer wait times for general reception, antenatal visits, and well-child visits. Clinics in rural areas had especially shorter wait times for well-child visits. Outpatient consultations were significantly longer at the smallest health facilities, followed by rural hospitals, tertiary/quaternary facilities, compared with Type 1 rural health centers. DISCUSSION: The average outpatient consult in Central Mozambique lasts 5 min, following over 40 min of waiting, not including time to register at most clinics. Wait times for first antenatal visits are even longer at almost 1 h. Urgent investments in public-sector human resources for health alongside innovative operational research are needed to increase consult times, decrease wait times, and improve health system responsiveness.

Immigration, work and health in Spain: the influence of legal status and employment contract on reported health indicators.

OBJECTIVE: To analyze the relationship of legal status and employment conditions with health indicators in foreign-born and Spanish-born workers in Spain. METHODS: Cross-sectional study of 1,849 foreign-born and 509 Spanish-born workers (2008-2009, ITSAL Project). Considered employment conditions: permanent, temporary and no contract (foreign-born and Spanish-born); considered legal statuses: documented and undocumented (foreign-born). Joint relationships with self-rated health (SRH) and mental health (MH) were analyzed via logistical regression. RESULTS: When compared with male permanently contracted Spanish-born workers, worse health is seen in undocumented foreign-born, time in Spain ≤3 years (SRH aOR 2.68, 95% CI 1.09-6.56; MH aOR 2.26, 95% CI 1.15-4.42); in Spanish-born, temporary contracts (SRH aOR 2.40, 95% CI 1.04-5.53); and in foreign-born, temporary contracts, time in Spain >3 years (MH: aOR 1.96, 95% CI 1.13-3.38). In females, highest self-rated health risks are in foreign-born, temporary contracts (aOR 2.36, 95% CI 1.13-4.91) and without contracts, time in Spain >3 years (aOR 4.63, 95% CI 1.95-10.97). CONCLUSIONS: Contract type is a health determinant in both foreign-born and Spanish-born workers. This study offers an uncommon exploration of undocumented migration and raises methodological issues to consider in future research.

[Precarious employment in undocumented immigrants in Spain and its relationship with health]. / La precariedad laboral en inmigrantes en situación irregular en España y su relación con la salud.

OBJECTIVE: To describe the characteristics of precarious employment in undocumented immigrants in Spain and its relationship with health. METHODS: A qualitative study was conducted using analytic induction. Criterion sampling, based on the Immigration, Work and Health project (Inmigración, Trabajo y Salud [ITSAL]) criterion (current definitions of 'legal immigrant' in Spain and in the literature) was used to recruit 44 undocumented immigrant workers from four different countries, living in four Spanish cities. RESULTS: The characteristics of precariousness perceived by undocumented immigrants included high job instability; disempowerment due to lack of legal protection; high vulnerability exacerbated by their legal and immigrant status; perceived insufficient wages and lower wages than coworkers; limited social benefits and difficulty in exercising their rights; and finally, long hours and fast-paced work. Our informants reported they had no serious health problems but did describe physical and mental problems associated with their employment conditions and legal situation. CONCLUSIONS: Our results suggest that undocumented immigrants' situation may not fit the model of precarious employment exactly. However, the model's dimensions can be expanded to better represent undocumented immigrants' situation, thus strengthening the general model. Precarious employment in this group can be defined as <>, as it affects their working and social lives. If these workers continue to be exposed to such precarious conditions, the impact on their health may increase.

[The migratory process, working conditions and health in immigrant workers in Spain (the ITSAL project)]. / Proceso migratorio, condiciones laborales y salud en trabajadores inmigrantes en España (proyecto ITSAL).

OBJECTIVE: To describe the migratory process (reasons for migrating, time of residence), legal status and the personal, working and health characteristics of the immigrants with work experience in Spain. METHODS: We performed a cross sectional survey in a sample stratified by country of origin (Colombia, Ecuador, Morocco and Romania), legal status and sex. Personal interviews were conducted with 2434 workers (57.4% men). Information on the migratory process, working conditions, health profile, and work and life expectations was analyzed. A frequency comparison by country of origin was carried out. RESULTS: Ninety percent of the sample was aged<45 years and most had secondary education (51%). Most of the people surveyed had migrated for economic and working reasons and 63% had economic dependents. They were working in jobs that were below their educational level and reported problems concerning the type of contract, salaries, and the length of the working week, which was often more than 40 hours. The immigrants frequently reported general health problems (18%), mental health problems (27%), absence from work due to health problems (48%) and occupational injuries requiring medical care (23%). A 51% of them wanted to stay in Spain and 48% reported that their expectations of emigration to Spain had been met. CONCLUSIONS: The immigrant workers included in this study had limited opportunities for work and experienced precarious conditions and social vulnerability. The data varied by country of origin. The special needs of this collective should be taken into account to establish public health policies and strategies.