Patterns of healthcare use among children with immigrant and non-immigrant backgrounds in 2019 and 2020: evidence from the CRIAS cohort study in the metropolitan area of Lisbon, Portugal.

BACKGROUND: International migrant families may face various barriers in the access and use of health services. Evidence on immigrant children's health care or prevention facilities' utilisation patterns is scarce in Portugal. Therefore, the objectives of this study were to compare health services use between immigrant and non-immigrant children in the Metropolitan Area of Lisbon in 2019-2020 with the aim of informing public policies towards equitable access to, and use of health services. METHODS: The CRIAS (Health Trajectories of Immigrant Children) prospective cohort study enrolled 420 children (51.6% immigrant) born in 2015 and attending primary health care (PHC) services in 2019. We compared primary health care facilities and hospital paediatric emergency department (ED) utilisation patterns in the public National Health Service, together with reported private practitioners use, between immigrant and non-immigrant children in 2019 and 2020. The Pearson chi-squared test, Fisher-Freeman-Halton Exact test, two-proportion z-test and Mann‒Whitney U test were used to examine the differences between the two groups. RESULTS: In 2019, no significant differences in PHC consultations attendance between the two groups were observed. However, first-generation immigrant children (children residing in Portugal born in a non-European Union country) accessed fewer routine health assessments compared to non-immigrant children (63.4% vs. 79.2%). When children were acutely ill, 136 parents, of whom 55.9% were parents of non-immigrant children, reported not attending PHC as the first point of contact. Among those, nearly four times more non-immigrant children sought healthcare in the private sector than immigrant children (p < 0.001). Throughout 2019, immigrant children used ED more often than non-immigrant children (53.5% vs. 40.4%, p = 0.010), as their parents reported difficulties in accessing PHC. In 2020, during the COVID-19 pandemic, fewer immigrant children accessed PHC compared to non-immigrant children (70% vs. 80%, p = 0.018). Both non-immigrant and immigrant children reduced ED use by 2.5 times, with a higher decrease among immigrant children (46% vs. 34%). In both 2019 and 2020, over 80% of immigrant and non-immigrant children used ED for conditions classified as having low clinical priority. CONCLUSION: Beyond identifying health care use inequalities between immigrant and non-immigrant children, the study points to urgent needs for public policy and economic investments to strengthen PHC for all children rather than for some.

Cohort profile: Health trajectories of Immigrant Children (CRIAS)-a prospective cohort study in the metropolitan area of Lisbon, Portugal.

PURPOSE: The CRIAS (Health trajectories of Immigrant Children in Amadora) cohort study was created to explore whether children exposed to a migratory process experience different health risks over time, including physical health, cognitive, socioemotional and behavioural challenges and different healthcare utilisation patterns. PARTICIPANTS: The original CRIAS was set up to include 604 children born in 2015, of whom 50% were immigrants, and their parents. Recruitment of 420 children took place between June 2019 and March 2020 at age 4/5 years, with follow-up carried out at age 5/6 years, at age 6/7 years currently under way. FINDINGS TO DATE: Baseline data at age 4/5 years (2019-2020) suggested immigrant children to be more likely to belong to families with less income, compared with non-immigrant children. Being a first-generation immigrant child increased the odds of emotional and behavioural difficulties (adjusted OR 2.2; 95% CI: 1.06 to 4.76); more immigrant children required monitoring of items in the psychomotor development test (38.5% vs 28.3%). The prevalence of primary care utilisation was slightly higher among immigrant children (78.0% vs 73.8%), yet they received less health monitoring assessments for age 4 years. Utilisation of the hospital emergency department was higher among immigrants (53.2% vs 40.6%). Age 5 years follow-up (2020-2021) confirmed more immigrant children requiring monitoring of psychomotor development, compared with non-immigrant children (33.9% vs 21.6%). Economic inequalities exacerbated by post-COVID-19 pandemic confinement with parents of immigrant children 3.2 times more likely to have their household income decreased. FUTURE PLANS: Further follow-up will take place at 8, 10, 12/13 and 15 years of age. Funds awarded by the National Science Foundation will allow 900 more children from four other Lisbon area municipalities to be included in the cohort (cohort-sequential design).

Migration as a Determinant in the Development of Children Emotional and Behavior Problems: A Quantitative Study for Lisbon Region, Portugal.

The role of migration as a determinant in child mental health has been demonstrated in a number of studies. However, results are not always consistent, and the research continues to be scarce, especially in Portugal. We examined the association between sociodemographic profiles and the chance for the development of emotional and behavioral difficulties in a group of 420 children, immigrant (n = 217) and born in Portugal to Portuguese born parents (n = 203). We used a structured questionnaire to obtain sociodemographic information and the Strength and Difficulties Questionnaire (SDQ). Descriptive statistics were used to characterize children and their families; variables were compared between groups using the Chi-squared, Fisher's Exact Test, or the Mann-Whitney U test and logistic regression was used to analyze the association between socio-demographic factors and emotional and behavioral difficulties. Results showed a pattern of social and mental health inequalities with immigrant children at a disadvantage: they are more often part of families with low income and where parents had low skilled jobs. Internalizing behaviors are more frequent in immigrants than in children born in Portugal to Portuguese-born parents (p = 0.001) whereas a high total SDQ difficulties score (p = 0.039) and externalizing behaviors were more frequent in 1st generation immigrant children (p = 0.009). A low family income (aOR 4.5; 95% CI: 1.43-13.95), low parental education level (aOR 2.5; 95% CI: 1.11-5.16), and being a first-generation immigrant child (aOR 2.2; 95% CI: 1.06-4.76) increased significantly the chance of developing emotional and behavioral difficulties. This study contributes to the identification of children vulnerable to mental health problems who can benefit from monitoring, early detection and preventive interventions in order to mitigate possible negative outcomes in the future.

Evaluation of detectors for acquisition of pristine depth-dose curves in pencil beam scanning.

Acquisition of quasi-monoenergetic ("pristine") depth-dose curves is an essential task in the frame of commissioning and quality assurance of a proton therapy treatment head. For pencil beam scanning delivery modes this is often accomplished by measuring the integral ionization in a plane perpendicular to the axis of an unscanned beam. We focus on the evaluation of three integral detectors: two of them are plane-parallel ionization chambers with an effective radius of 4.1 cm and 6.0 cm, respectively, mounted in a scanning water phantom. The third integral detector is a 6.0 cm radius multilayer ionization chamber. The experimental results are compared with the corresponding measurements under broad field conditions, which are performed with a small radius plane-parallel chamber and a small radius multilayer ionization chamber. We study how a measured depth-dose curve of a pristine proton field depends on the detection device, by evaluating the shape of the depth-dose curve, the relative charge collection efficiency, and intercomparing measured ranges. Our results show that increasing the radius of an integral chamber from 4.1 cm to 6.0 cm increases the collection efficiency by 0%-3.5% depending on beam energy and depth. Ranges can be determined by the large electrode multilayer ionization chamber with a typical uncertainty of 0.4 mm on a routine basis. The large electrode multilayer ionization chamber exhibits a small distortion in the Bragg Peak region. This prohibits its use for acquisition of base data, but is tolerable for quality assurance. The good range accuracy and the peak distortion are characteristics of the multilayer ionization chamber design, as shown by the direct comparison with the small electrode counterpart.

Use of a novel two-dimensional ionization chamber array for pencil beam scanning proton therapy beam quality assurance.

The need to accurately and efficiently verify both output and dose profiles creates significant challenges in quality assurance of pencil beam scanning (PBS) proton delivery. A system for PBS QA has been developed that combines a new two-dimensional ionization chamber array in a waterproof housing that is scanned in a water phantom. The MatriXX PT has the same detector array arrangement as the standard MatriXX(Evolution) but utilizes a smaller 2 mm plate spacing instead of 5mm. Because the bias voltage of the MatriXX PT and Evolution cannot be changed, PPC40 and FC65-G ionization chambers were used to assess recombination effects. The PPC40 is a parallel plate chamber with an electrode spacing of 2mm, while the FC65-G is a Farmer chamber FC65-G with an electrode spacing of 2.8 mm. Three bias voltages (500, 200, and 100 V) were used for both detectors to determine which radiation type (continuous, pulse or pulse-scanned beam) could closely estimate Pion from the ratios of charges collected. In comparison with the MatriXX(Evolution), a significant improvement in measurement of absolute dose with the MatriXX PT was observed. While dose uncertainty of the MatriXX(Evolution) can be up to 4%, it is < 1% for the MatriXX PT. Therefore the MatriXX(Evolution) should not be used for QA of PBS for conditions in which ion recombination is not negligible. Farmer chambers should be used with caution for measuring the absolute dose of PBS beams, as the uncertainty of Pion can be > 1%; chambers with an electrode spacing of 2 mm or smaller are recommended.

A novel technique for measuring the low-dose envelope of pencil-beam scanning spot profiles.

To investigate the profile measurement capabilities of an IBA-Dosimetry scintillation detector and to assess its feasibility for determining the low-intensity tails of pencil-beam scanning spots, the responses of the scintillation detector and Gafchromic EBT2 film to a 115 MeV proton spot were measured in-air at the isocenter. Pairs of irradiations were made: one lower-level irradiation insufficient to cause saturation, and one higher-level irradiation which deliberately saturated the central region of the spot, but provided magnification of the tails. By employing the pair/magnification technique, agreement between the film and scintillation detector measurements of the spot profile can be extended from 4% of the central spot dose down to 0.01%. Gamma analysis between these measurements shows 95% and 99% agreement within a ±9 cm bound using criteria of 3 mm/3% and 5 mm/5%, respectively. Above 4%, our 115 MeV proton spot can be well-described by Gaussian function; below 4%, non-Gaussian, diamond-shaped tails predominate.

WHO and the future of disease control programmes.

Huge increases in funding for international health over the past two decades have led to a proliferation of donors, partnerships, and health organisations. Over the same period, the global burden of non-communicable diseases has increased absolutely and relative to communicable diseases. In this changing landscape, national programmes for the control of HIV/AIDS, tuberculosis, malaria, and neglected tropical diseases must be reinforced and adapted for three reasons: the global burden of these communicable diseases remains enormous, disease control programmes have an integral and supporting role in developing health systems, and the health benefits of these control programmes go beyond the containment of specific infections. WHO's traditional role in promoting communicable disease control programmes must also adapt to new circumstances. Among a multiplicity of actors, WHO's task is to enhance its normative role as convenor, coordinator, monitor, and standard-setter, fostering greater coherence in global health.

What's said and what's done: the reality of sexually transmitted disease consultations.

OBJECTIVE: Indirect data collection methods, or approaches which disturb usual practice, are generally used in health care evaluation. We have compared what doctors report at interview what is observed by an identified researcher with an unobtrusive measure of their usual practice. DESIGN: Private practitioners who provide a service to sexually transmitted disease (STD) patients were interviewed regarding their usual case management. An identified researcher carried out structured observations of consultations between physicians and patients. Simulated clients then sought consultations, presenting a standardised history and symptom profile. Structured reporting of the history taking, examination, treatment and counselling aspects of these consultations was undertaken. SUBJECTS: Eighteen private practitioners in Madras (now Chennai), India. MAIN OUTCOME MEASURES: Comparisons between interviews, observations by identified researchers and the experiences of simulated clients were carried out. RESULTS: Interviews with physicians and observations by identified researchers indicated more favourable practice than was seen during simulated client visits. These differences were substantial and would lead to a severe misrepresentation of the actual situation-and thus of intervention needs, if data from interviews or observations were relied upon. CONCLUSIONS: The usual methods used in the evaluation of medical services and in carrying out medical audit may produce highly unreliable findings. STD services in the study area are failing to realise their potential of improving the sexual health of populations. The methodological and substantive findings of this study could be combined through the introduction of simulated client visits in the monitoring, improvement and licensing of STD (and perhaps other medical) services.

Causes of adult deaths in developing countries : A review of data and methods / Causes of adult deaths in developing countries : A review of data and methods

Little is known about the causes of adult death in most developing countries. The authors recommend developing and validating diagnostic algorithms to determine the causes of adult deaths, using lay interviewers to conduct retrospective interviews of relatives of the deceased