Inequalities in adherence to cervical cancer screening in Portugal.

Cervical cancer is the second cancer with the highest incidence and mortality in women aged 15-44 living in Europe. Screening is an effective strategy to reduce these rates, although in Portugal, as in other European countries, adherence to screening still presents significant disparities. Thus, this study aimed to assess the prevalence and factors associated with cervical cancer screening (CCS) nonadherence in Portugal. Cross-sectional data from 5929 women aged 25-64 included in the 2014 Portuguese National Health Survey (2014 NHS) were analyzed. The prevalence of CCS nonadherence was estimated. The association between multiple factors and CCS nonadherence was analyzed, using logistic regression, adjusting for age and educational level. The weighted prevalence of nonadherence was 13.2% [95% confidence interval (CI): 12.0-14.0]. Additionally, 10.5% of women had performed the last cervical cytology 3 years ago or more. Higher odds of nonadherence to screening were found for younger women, with low levels of education and income, unemployed, single, born outside Portugal, who never had a medical appointment or had over 12 months ago, who were never pregnant and who had never had a mammography. No association was found with other variables studied, including having public/private health insurance, BMI or smoking status. This study showed that inequalities in CCS adherence in Portugal persist. These findings reinforce the need for developing strategies to reduce inequalities in CCS adherence.

High Mobility and STIs/HIV among Women Informal Cross Border Traders in Southern Mozambique: Exploring Knowledge, Risk Perception, and Sexual Behaviors.

High circular mobility creates vulnerability and elevates risk for sexually transmitted infections (STIs) including Human Immunodeficiency Virus (HIV). We aim to explore knowledge, perceptions of risk, and sexual behaviors in relation to STIs/HIV, in Mozambican women involved in an informal cross border trade (ICBT) and residing in South Mozambique. A cross-sectional quantitative study, in 200 women cross border traders (WICBT), affiliated to the Mukhero Association, using a structured, face-to-face questionnaire, was conducted. Descriptive statistics and Pearson's Chi-square test were used. The median age of participants was 37.0 years (interquartile range (IQR): 31.0-43.0), 100% were literate, travelled on average six times a month. WICBT with a high education level were more likely to have awareness of Gonorrhea, Syphilis, and Candidiasis; to self-perceive being at risk of getting HIV, Syphilis, and Human Papilloma Virus (HPV); and to test for HIV and Syphilis. Those with a low education level were more likely to have misconceptions about HIV and ever have sex in exchange for money/goods/services. Married participants were more likely to know how to prevent HIV. Participants with a high income were more likely to know about HPV; to self-perceive being at risk of getting Syphilis; to point sex workers as being at higher risk of getting HPV; and to ever test for HIV. WICBT with a low income were more likely to have sex in exchange for money/goods/services. Low and inconsistent knowledge and misconceptions of STIs/HIV, high sexual risky behavior, low perception of risk of getting STIs/HIV among this neglected and key population suggests their increased vulnerability to the STIs/HIV.

Behavioural and demographic correlates of undiagnosed HIV infection in a MSM sample recruited in 13 European cities.

BACKGROUND: Reducing the number of people with undiagnosed HIV infection is a major goal of HIV control and prevention efforts in Europe and elsewhere. We analysed data from a large multi-city European bio-behavioural survey conducted among Men who have Sex with Men (MSM) for previously undiagnosed HIV infections, and aimed to characterise undiagnosed MSM who test less frequently than recommended. METHODS: Data on sexual behaviours and social characteristics of MSM with undiagnosed HIV infection from Sialon II, a bio-behavioural cross-sectional survey conducted in 13 European cities in 2013/2014, were compared with HIV-negative MSM. Based on reported HIV-testing patterns, we distinguished two subgroups: MSM with a negative HIV test result within 12 months prior to the study, i.e. undiagnosed incident infection, and HIV positive MSM with unknown onset of infection. Bivariate and multivariate associations of explanatory variables were analysed. Distinct multivariate multi-level random-intercept models were estimated for the entire group and both subgroups. RESULTS: Among 497 participants with HIV-reactive specimens, 234 (47.1%) were classified as previously diagnosed, 106 (21.3%) as incident, and 58 (11.7%) as unknown onset based on self-reported status and testing history. MSM with incident HIV infection were twice as likely (odds ratio (OR) = 2.22, 95% confidence interval (95%CI): 1.17-4.21) to have used recreational substances during their last anal sex encounter and four times more likely (OR = 3.94, 95%CI: 2.14-7.27) not to discuss their HIV status with the last anal sex partner(s). MSM with unknown onset of HIV infection were 3.6 times more likely (OR = 3.61, 95%CI: 1.74-7.50) to report testing for a sexually transmitted infection (STI) during the last 12 months. CONCLUSIONS: Approximately one third of the study participants who are living with HIV were unaware of their infection. Almost two-third (65%) of those with undiagnosed HIV appeared to have acquired the infection recently, emphasizing a need for more frequent testing. Men with the identified behavioural characteristics could be considered as primary target group for HIV Pre-Exposure Prophylaxis (PrEP) to avoid HIV infection. The increased odds of those with unknown onset of HIV infection to have had an STI test in the past year strongly suggests a lost opportunity to offer HIV testing.

Labor market integration, immigration experience, and psychological distress in a multi-ethnic sample of immigrants residing in Portugal.

OBJECTIVES: This study aims at examining how factors relating to immigrants' experience in the host country affect psychological distress (PD). Specifically, we analyzed the association among socio-economic status (SES), integration in the labor market, specific immigration experience characteristics, and PD in a multi-ethnic sample of immigrant individuals residing in Lisbon, Portugal. DESIGN: Using a sample (n = 1375) consisting of all main immigrant groups residing in Portugal's metropolitan area of Lisbon, we estimated multivariable linear regression models of PD regressed on selected sets of socio-economic independent variables. A psychological distress scale was constructed based on five items (feeling physically tired, feeling psychologically tired, feeling happy, feeling full of energy, and feeling lonely). RESULTS: Variables associated with a decrease in PD are being a male (demographic), being satisfied with their income level (SES), living with the core family and having higher number of children (social isolation), planning to remain for longer periods of time in Portugal (migration project), and whether respondents considered themselves to be in good health condition (subjective health status). Study variables negatively associated with immigrants' PD were job insecurity (labor market), and the perception that health professionals were not willing to understand immigrants during a clinical interaction. CONCLUSION: The study findings emphasized the importance of labor market integration and access to good quality jobs for immigrants' psychological well-being, as well as the existence of family ties in the host country, intention to reside long term in the host country, and high subjective (physical) health. Our research suggests the need to foster cross-national studies of immigrant populations in order to understand the social mechanisms that transverse all migrant groups and contribute to lower psychological well-being.

HIV serostatus knowledge and serostatus disclosure with the most recent anal intercourse partner in a European MSM sample recruited in 13 cities: results from the Sialon-II study.

BACKGROUND: Knowledge of HIV status can be important in reducing the risk of HIV exposure. In a European sample of men-who-have-sex-with-men (MSM), we aimed to identify factors associated with HIV serostatus disclosure to the most recent anal intercourse (AI) partner. We also aimed to describe the impact of HIV serostatus disclosure on HIV exposure risks. METHODS: During 2013 and 2014, 4901 participants were recruited for the bio-behavioural Sialon-II study in 13 European cities. Behavioural data were collected with a self-administered paper questionnaire. Biological specimens were tested for HIV antibodies. Factors associated with HIV serostatus disclosure with the most recent AI partner were examined using bivariate and multilevel multivariate logistic regression analysis. We also describe the role of serostatus disclosure for HIV exposure of the most recent AI partner. RESULTS: Thirty-five percent (n = 1450) of the study participants reported mutual serostatus disclosure with their most recent AI partner or disclosed having HIV to their partner. Most of these disclosures occurred between steady partners (74%, n = 1077). In addition to the type of partner and HIV diagnosis status, other factors positively associated with HIV serostatus disclosure in the multilevel multivariate logistic regression model were recent testing, no condom use, and outness regarding sexual orientation. Disclosure rates were lowest in three south-eastern European cities. Following condom use (51%, n = 2099), HIV serostatus disclosure (20%, n = 807) was the second most common prevention approach with the most recent AI partner, usually resulting in serosorting. A potential HIV exposure risk for the partner was reported by 26% (111/432) of HIV antibody positive study participants. In 18% (20/111) of exposure episodes, an incorrect HIV serostatus was unknowingly communicated. Partner exposures were equally distributed between steady and non-steady partners. CONCLUSIONS: The probability of HIV exposure through condomless AI is substantially lower after serostatus disclosure compared to non-disclosure. Incorrect knowledge of one's HIV status contributes to a large proportion of HIV exposures amongst European MSM. Maintaining or improving condom use for anal intercourse with non-steady partners, frequent testing to update HIV serostatus awareness, and increased serostatus disclosure particularly between steady partners are confirmed as key aspects for reducing HIV exposures amongst European MSM.

Hard-to-reach populations of men who have sex with men and sex workers: a systematic review on sampling methods.

BACKGROUND: In public health, hard-to-reach populations are often recruited by non-probabilistic sampling methods that produce biased results. In order to overcome this, several sampling methods have been improved and developed in the last years. The aim of this systematic review was to identify all current methods used to survey most-at-risk populations of men who have sex with men and sex workers. The review also aimed to assess if there were any relations between the study populations and the sampling methods used to recruit them. Lastly, we wanted to assess if the number of publications originated in middle and low human development (MLHD) countries had been increasing in the last years. METHODS: A systematic review was conducted using electronic databases and a total of 268 published studies were included in the analysis. RESULTS: In this review, 11 recruitment methods were identified. Semi-probabilistic methods were used most commonly to survey men who have sex with men, and the use of the Internet was the method that gathered more respondents. We found that female sex workers were more frequently recruited through non-probabilistic methods than men who have sex with men (odds = 2.2; p < 0.05; confidence interval (CI) [1.1-4.2]). In the last 6 years, the number of studies based in middle and low human development countries increased more than the number of studies based in very high and high human development countries (odds = 2.5; p < 0.05; CI [1.3-4.9]). CONCLUSIONS: This systematic literature review identified 11 methods used to sample men who have sex with men and female sex workers. There is an association between the type of sampling method and the population being studied. The number of studies based in middle and low human development countries has increased in the last 6 years of this study.

Sexual and gender-based violence in the European asylum and reception sector: a perpetuum mobile?

BACKGROUND: Refugees, asylum seekers and undocumented migrants are at risk of sexual and gender-based violence (SGBV) and subsequent ill-health in Europe; yet, European minimum reception standards do not address SGBV. Hence, this paper explores the nature of SGBV occurring in this sector and discusses determinants for 'Desirable Prevention'. METHODS: Applying community-based participatory research, we conducted an SGBV knowledge, attitude and practice survey with residents and professionals in eight European countries. We conducted logistic regression using mixed models to analyse the data in R. RESULTS: Of the 562 respondents, 58.3% reported cases of direct (23.3%) or peer (76.6%) victimization. Our results indicate that when men were involved, it most likely concerned sexual perpetration (adjusted odds ratio [aOR]: 4.09, confidence interval [CI]: 1.2; 13.89) and physical victimization (aOR: 2.57, CI: 1.65; 4), compared with females, who then rather perpetrated emotional violence (aOR: 1.85, CI: 1.08; 3.13) and underwent sexual victimization (aOR: 7.14, CI: 3.33; 16.67). Compared with others, asylum seekers appeared more likely to perpetrate physical (aOR 7.14, CI: 4; 12.5) and endure socio-economic violence (aOR: 10, CI: 1.37; 100), whereas professionals rather bore emotional (aOR: 2.01, CI: 0.98; 4.12) and perpetrated socio-economic violence (aOR: 25.91, CI: 13.41; 50.07). When group perpetration (aOR: 2.13, CI: 1.27; 3.58) or victimization (aOR: 1.84, CI: 1.1; 3.06) occurred, it most likely concerned socio-economic violence. CONCLUSION: Within the European asylum reception sector, residents and professionals of both sexes experience SGBV victimization and perpetration. Given the lack of prevention policies, our findings call for urgent Desirable Prevention programmes addressing determinants socio-ecologically.

Condom use with steady partners among heterosexual people living with HIV in Europe: testing the information-motivation-behavioral skills model.

Guided by a modified information-motivation-behavioral skills model, this study identified predictors of condom use among heterosexual people living with HIV with their steady partners. Consecutive patients at 14 European HIV outpatient clinics received an anonymous, standardized, self-administered questionnaire between March and December 2007. Data were analyzed using descriptive statistics and two-step backward elimination regression analyses stratified by gender. The survey included 651 participants (n = 364, 56% women; n = 287, 44%). Mean age was 39 years for women and 43 years for men. Most had acquired HIV sexually and more than half were in a serodiscordant relationship. Sixty-three percent (n = 229) of women and 59% of men (n = 169) reported at least one sexual encounter with a steady partner 6 months prior to the survey. Fifty-one percent (n = 116) of women and 59% of men (n = 99) used condoms consistently with that partner. In both genders, condom use was positively associated with subjective norm conducive to condom use, and self-efficacy to use condoms. Having a partner whose HIV status was positive or unknown reduced condom use. In men, higher education and knowledge about condom use additionally increased condom use, while the use of erectile-enhancing medication decreased it. For women, HIV disclosure to partners additionally reduced the likelihood of condom use. Positive attitudes to condom use and subjective norm increased self-efficacy in both genders, however, a number of gender-related differences appeared to influence self-efficacy. Service providers should pay attention to the identified predictors of condom use and adopt comprehensive and gender-related approaches for preventive interventions with people living with HIV.

Determinants of health care utilization by immigrants in Portugal.

BACKGROUND: The increasing diversity of population in European Countries poses new challenges to national health systems. There is a lack of data on accessibility and use of health care services by migrants, appropriateness of the care provided, client satisfaction and problems experienced when confronting the health care system. This limits knowledge about the multiple determinants of the utilization of health services. The aim of this study was to describe the access of migrants to health care and its determinants in Portugal. METHODS: The study sample included 1513 immigrants (53% men), interviewed at the National Immigrant Support Centre, in Lisbon. Data were collected using questionnaires. The magnitude of associations between use of National Health Service and socio-demographic variables was estimated by means of odds ratios (OR) at 95% confidence intervals, calculated using logistic regression. RESULTS: Among participants, 3.6% stated not knowing where to go if facing a health problem. Approximately 20% of the respondents reported that they had never used the National Health Service, men more than women. Among National Health Service users, 35.6% attended Health Centres, 12% used Hospital services, and 54.4% used both. Among the participants that ever used the health services, 22.4% reported to be unsatisfied or very unsatisfied. After adjusting for all variables, utilization of health services, among immigrant men, remained significantly associated with length of stay, legal status, and country of origin. Among immigrant women, the use of health services was significantly associated with length of stay and country of origin. CONCLUSION: There is a clear need to better understand how to ensure access to health care services and to deliver appropriate care to immigrants, and that special consideration must be given to recent and undocumented migrants. To increase health services use, and the uptake of prevention programs, barriers must be identified and approaches to remove them developed, through coherent and comprehensive strategies.

AIDS-related stigma and attitudes towards AIDS-infected people among adolescents.

UNLABELLED: This research examined the co-occurrence of accurate and inaccurate knowledge about HIV transmission among adolescents. Analyses were also conducted to examine the way in which variables related to demographic factors, personal characteristics, parent and peer relationships, and school involvement are associated with attitudes towards HIV/AIDS-infected people. Social and psychological processes that contribute to AIDS-related stigma are also described. METHODS: Data were collected from the Portuguese sample of the 'Health Behaviour in School-Aged Children - 2002 - a collaborative WHO study'. The study provided data representative of 6137 Portuguese adolescents at national level. Based on these results, we conducted 14 focus groups discussions. RESULTS: Adolescents presented high levels of knowledge about HIV transmission. However, the proportion of young people who hold misperceptions is also high. A multiple regression analysis identified several associations with attitudes towards HIV-infected persons. The focus groups showed that adolescents believe that people with AIDS experienced discrimination and social exclusion. Adolescents' opinions for HIV-infected persons were mostly positive and tolerant, although some adolescents showed an ambivalent attitude and undefined fears. CONCLUSION: These findings have significant implications to implement and design comprehensive interventions with impact in adolescents' attitudes towards people with HIV/AIDS.

Preventing HIV transmission in adolescents: an analysis of the Portuguese data from the Health Behaviour School-aged Children study and focus groups.

BACKGROUND: There is recognition of the need to examine psychosocial and ecological determinants contributing to both risk and protective factors related to adolescents' sexual behaviour and HIV/AIDS. METHODS: The study utilized mixed quantitative and qualitative methods. Data were collected from the Portuguese sample of the Health Behaviour in School-aged Children (HBSC) 2002. Based on these results, 14 focus group discussions were conducted. RESULTS: A substantial minority of young people continue to engage in high-risk practices. Thus, female gender, older age, reporting easy to talk with father, not getting drunk and not getting involved in fights are significantly associated with protected sexual behaviour (using condom during last sexual intercourse). According to these results, being female and a comprehensive grade student are both related to a significantly more positive attitude towards infected people. It was concluded that these adolescents view sexual behaviour, sexual partners and condom use as elements within a complex script that governs heterosexual interactions. Several themes related to condom used emerged. Despite HIV/AIDS knowledge, young people underestimate their own risk of becoming infected with HIV. The majority of adolescents believe that HIV-infected people experience discrimination and social exclusion. Adolescents' opinions of HIV-infected people were mostly positive. Although most participants knew that HIV cannot be transmitted through social contact, undefined fears concerning the infection exist. CONCLUSIONS: These findings have important implications for the implementation of a comprehensive programme on HIV/AIDS education in secondary schools.