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 / Barcelona Salut als Barris: la experiencia de doce años abordando las desigualdades sociales en salud a través de intervenciones comunitarias

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. (AU)

La salud comunitaria puede reducir las inequidades en salud y mejorar la salud de las poblaciones más desfavorecidas. En 2007 se inició Barcelona Salut als Barris (Barcelona Salud en los Barrios), un programa de salud comunitaria para reducir las desigualdades sociales en salud. En 2018, el programa alcanzó los 25 barrios más desfavorecidos de la ciudad. Este artículo comparte las lecciones aprendidas tras 12 años de trabajo. Los primeros fondos del programa procedieron de una beca de investigación, se mantuvieron durante la crisis económica y se triplicaron cuando pasó a ser una prioridad política en el último gobierno municipal. Durante estos 12 años, las alianzas con las partes interesadas se mantuvieron, en general, estables y productivas. La máxima participación comunitaria se obtuvo en la detección de activos y necesidades en salud y en los planes de acción. Durante 2018, Barcelona Salut als Barris trabajó con más de 460 agentes que coprodujeron 183 intervenciones en las que participaron más de 13.600 personas. Gran parte de las intervenciones evaluadas mostraron mejoras en la salud de las personas participantes, pudiendo contribuir a la reducción de desigualdades. Las mayores dificultades fueron: a) la participación ciudadana, b) la sostenibilidad de los grupos de trabajo a lo largo de los años, c) los conflictos de intereses, d) la sostenibilidad de las intervenciones, e) acceder a algunos grupos minoritarios y e) la evaluación. El aumento de los recursos del último periodo contribuyó a la madurez y la extensión del programa. La voluntad política, una sólida capacidad técnica y metodológica, consolidadas alianzas intersectoriales y el trabajo comunitario continuado han sido factores clave de su alcance y resultados. (AU)

Improving mental health and wellbeing in elderly people isolated at home due to architectural barriers: A community health intervention / Mejorando la salud mental y el bienestar de las personas mayores aisladas en casa debido a las barreras arquitectónicas: una intervención de salud comunitaria

Objetivos: Explorar los efectos sobre la salud de una intervención de salud comunitaria en personas mayores aisladas en casa debido a problemas de movilidad o a barreras arquitectónicas, identificar las características asociadas y evaluar la satisfacción de las personas participantes. Diseño: Estudio cuasi-experimental antes-después. Emplazamiento: Cinco barrios de baja renta de Barcelona durante 2010-15. Participantes: Se entrevistó a 147 participantes, ≥59 años, antes y 6 meses después de la intervención. Intervención: Equipos de atención primaria, trabajadores sociales, de salud pública y otros agentes comunitarios desarrollaron una intervención que consistía en salidas semanales, facilitadas por voluntarios. Mediciones: Se evalúo la salud autopercibida, la salud mental utilizando la escala GHQ-12 y la calidad de vida mediante la escala EuroQol. La satisfacción se evaluó mediante un conjunto de preguntas. Analizamos los datos previos y posteriores con pruebas de McNemar y modelos de regresión lineal y de Poisson ajustados. Resultados: A los 6 meses, los participantes mostraron mejoras en la salud percibida, en la salud mental y en la reducción de la ansiedad. Las mejoras fueron mayores entre las mujeres, las personas que no habían salido de casa durante ≥4 meses, las de bajo nivel educativo y las que habían realizado ≥9 salidas. La salud percibida (aRR: 1,29 [1,04-1,62]) y las mejoras en salud mental [(β: 2,92 [1,64-4,2]) permanecieron significativas en los modelos multivariados. La satisfacción media fue de 9,3 sobre 10. Conclusión: Esta intervención de salud comunitaria parece mejorar varios resultados de salud en las personas mayores aisladas, especialmente en los grupos más vulnerables. Replicar este tipo de intervención podría funcionar en contextos similares.(AU)

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 [β: 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.(AU)

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.

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.

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.

Efectos de un programa de formación profesional para jóvenes de barrios desfavorecidos en la salud autopercibida, la autoestima y los consumos / Effects of an occupational training programme for young people from disadvantaged neighbourhoods on self-perceived health, self-esteem and substance use

OBJETIVOS: Evaluar la efectividad de una intervención comunitaria de formación profesional para jóvenes en riesgo de exclusión social, en la salud autopercibida, la autoestima y el consumo de sustancias (alcohol, tabaco y cannabis). Evaluar la satisfacción de los participantes. MÉTODOS: Diseño: estudio de intervención pre-post. Emplazamiento: tres barrios de renta baja de Barcelona durante 2013-2017. Participantes: 185 participantes, de 21 años de media y predominio masculino (65,5%). Intervención: programa de 4 meses de formación profesional de diferentes disciplinas e itinerarios orientados a la inserción laboral. Mediciones principales: análisis bivariado (McNemar) para datos apareados, comparando la salud autopercibida, autoestima y consumos pre-post intervención. Modelos de regresión de Poisson para las variables resultado, ajustando por variables explicativas. Además, se evaluó la satisfacción con el programa a través de un cuestionario y una discusión grupal. RESULTADOS: la salud autopercibida era elevada antes de la intervención (87,7% hombres y 82,1% mujeres) y se mantuvo tras ella (90,6% y 83,9% respectivamente). Los niveles elevados de autoestima previos a la intervención (92,8% en hombres y 92,9% mujeres) aumentaron tras ella (95,5% y 100% respectivamente), de forma significativa en las mujeres (p < 0,05). El consumo de sustancias no varió tras la intervención. La satisfacción con el programa fue elevada. CONCLUSIÓN: la intervención parece haber mejorado la autoestima en las mujeres, un colectivo con elevado desempleo y normalmente infrarrepresentado en los programas formativos. Esta intervención no incidió en el consumo de sustancias. Los programas de inserción laboral para jóvenes pueden promover factores beneficiosos para la salud mental

OBJECTIVES: To evaluate the effectiveness of a community occupational training intervention for young people at risk of social exclusion on self-perceived health, self-esteem and substance use (alcohol, tobacco and cannabis). To assess participant's satisfaction. METHODS: Design: Quasi-experimental before-after study. Setting: Three low-income neighbourhoods in Barcelona during 2013-2017. Participants: 185 participants with an average age of 21 years and mainly males (65.5%). Intervention: Four-month programme on specific occupational skills and itineraries oriented towards occupational integration. Most important measurements: Bivariate analysis (McNemar test) for paired data to compare self-rated health and self-esteem pre-intervention and post-intervention. Poisson regression models for result variables, adjusting for explanatory variables. In addition, satisfaction with the programme was evaluated by means of a questionnaire and group discussion. RESULTS: Pre-intervention self-rating was good (87.7% men and 82.1% women) and remained good post-intervention (90.6% and 83.9% respectively). Pre-intervention self-esteem was good (92.8% in men and 92.9% in women) and increased after the intervention (95.5% and 100% respectively). This was statistically significant in women (P<0.05). Substance use was unaltered after the intervention. Satisfaction with the programme was high. CONCLUSION: The intervention appears to have improved self-esteem among young women, who are an important group among the unemployed, as they are usually underrepresented in training and professional programmes. Programmes that foster young people moving into working life may also promote factors beneficial to mental health

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.

Salud comunitaria confinada: reflexiones y experiencias desde la salud pública local / Confined community health: reflections and experiences from the local public health

Este artículo pretende compartir las reflexiones sobre la acción comunitaria en que la Agència de Salut Pública de Barcelona ha estado involucrada en la emergencia de COVID-19. El trabajo realizado puede ordenarse en tres etapas, frecuentemente solapadas: detectar necesidades o problemas, e informar; contactar con las personas participantes y agentes territoriales para valorar qué hacer y cómo hacerlo; y adaptar las intervenciones a la "nueva normalidad" y generar respuestas con los activos comunitarios a las necesidades detectadas. Los problemas emergentes incluyeron: no poder realizar el confinamiento (por falta de casa, condiciones materiales, vivir en situación de violencia); brecha digital (falta de conocimientos, dispositivos, acceso a Wifi); mayor exposición al COVID-19 en los trabajos esenciales pero precarizados, feminizados y racializados (cuidados, limpieza, alimentación), frecuentes en los barrios en que trabajamos; barreras idiomáticas y culturales para seguir las recomendaciones; pérdida de empleo; ingresos insuficientes para cubrir necesidades básicas; dificultades de conciliación; aislamiento social; y deterioro de la salud emocional provocado por la situación. Durante el proceso, algunas intervenciones se adaptaron para continuar de forma telemática, y se intentaron cubrir las necesidades primarias sobre conocimientos y dispositivos de algunas personas participantes a través de las redes solidarias y recursos existentes. La acción comunitaria en salud, desde una mirada crítica, interseccional y local, mediante trabajo intersectorial y la participación de la comunidad, puede contribuir a: facilitar una respuesta adaptada al contexto en caso de crisis sanitaria y mitigar los efectos derivados de esta crisis económica y social

This paper aims to share the reflections related to the community actions in which the Agència de Salut Pública de Barcelona has been involved during the emergency of COVID-19. The tasks carried out can be arranged in three stages, frequently overlapping: detection of needs and problems; contact with key stakeholders to assess what to do and how to do it; adaptation of the interventions to the "new normal" and generation of new responses. The emerging problems included: not being able to do the confinement (due to homelessness, material conditions, living in a situation of violence); digital gap (lack of knowledge, devices, access to Wifi); greater exposure to COVID-19 in the essential but precarious, feminized and racialized jobs (care, cleaning, food shops) that are the most frequent in the neighborhoods in where we work; language and cultural barriers that preclude to follow recommendations; to lose employment; insufficient income to cover basic needs; social isolation; and the deterioration of emotional health caused by the situation. During the process, some interventions were adapted to be delivered on-line. Solidarity networks and local resources were key to meet basic needs, but also other needs related to lack of digital knowledge or device. Community action in health, from a critical, intersectional and local perspective, and with intersectoral work and community participation, can contribute to: facilitate a contextualized response in the event of a health crisis; mitigate the effects derived from its economic and social crisis

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 / ¿Ha cambiado la calidad de la atención a la población inmigrante durante la crisis económica en Cataluña (España)? Opinión de profesionales e inmigrantes

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

Objetivo: Analizar los cambios en la calidad percibida de la atención a la población inmigrante durante la crisis económica, desde la perspectiva de profesionales e inmigrantes. Métodos: Estudio cualitativo descriptivo-interpretativo y exploratorio en dos áreas de Cataluña, mediante entrevistas individuales semiestructuradas a una muestra teórica de médico/as (n=24) y administrativas (n=10) de atención primaria (AP) y secundaria (AS), e inmigrantes (n=20). Se realizó un análisis temático de contenido y se triangularon los resultados. Resultados: Del discurso de profesionales e inmigrantes emergen problemas en la calidad técnica e interpersonal, que relacionan con la reducción de recursos durante la crisis. Respecto a la calidad técnica, los/las informantes describen un aumento de diagnósticos erróneos o inespecíficos, un uso inadecuado de pruebas y tratamientos inespecíficos, debido a la disminución del tiempo de consulta por la reducción de recursos humanos. Respecto a la calidad interpersonal, los/las profesionales señalaron menor empatía, mientras que los/las inmigrantes, además, una peor comunicación, que atribuyeron al cambio en las condiciones laborales de los/las profesionales y en la actitud de los/las inmigrantes. Finalmente, emergió la disminución de la capacidad resolutiva de los servicios: según los/las profesionales, por la repetición de consultas innecesarias en AP y limitadas en AS; según los/las inmigrantes jóvenes, por respuestas limitadas a sus problemas de salud. Conclusiones: Los resultados apuntan a un empeoramiento de la calidad técnica e interpersonal durante la crisis, por reducción de recursos, principalmente humanos, que afectan al conjunto de la población, pero en especial a las personas inmigrantes

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.

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.

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.

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.

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

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. 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 2010­2013. We used mixed-effects linear models to quantify changes in data quality over time and associated health system determinants. Median concordance increased from 56.3% during the baseline period (2009­2010) to 87.5% during 2012­2013. Concordance improved by 1.0% (confidence interval [CI]: 0.60, 1.5) per month during the intervention period of 2010­2011 and 1.6% (CI: 0.89, 2.2) per month from 2011­2012. No significant improvements were observed from 2009­2010 (during baseline period) or 2012­2013. Facilities with more technical staff (aß: 0.71; CI: 0.14, 1.3), more firstantenatal 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. 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.

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.

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.

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.

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

Objetivo: Describir las características de la precariedad laboral en inmigrantes irregulares en España y su relación con la salud. Métodos: Estudio cualitativo que utiliza los principios de la inducción analítica. Se definió una submuestra del proyecto ITSAL, cuya muestra teórica se identificó a partir de la definición de inmigrante en España y de la literatura. Las áreas de estudio fueron 4 ciudades de España. La muestra final fue de 44 trabajadores inmigrantes irregulares, de 4 nacionalidades. Resultados: Algunas características de la precariedad laboral percibidas por los inmigrantes irregulares fueron: elevada inestabilidad laboral; ausencia total de empoderamiento en tanto no cuentan con un marco de protección legal; elevada vulnerabilidad agudizada por su situación legal y su estatus de inmigrante; nivel de ingresos insuficiente y más bajo que el del resto de los compañeros; ausencia total de derechos laborales y escaso poder para exigir mejores condiciones; y finalmente un tiempo de trabajo extenso y a un ritmo acelerado. Reportaron no haber tenido problemas de salud graves, aunque destacan problemas de salud física y mental que relacionan con sus condiciones de empleo y situación legal. Conclusiones: Los resultados sugieren que la situación de los inmigrantes irregulares, si bien no se ajusta exactamente al constructo de precariedad laboral, ha permitido adaptarlo, ampliando sus dimensiones y robusteciendo el modelo general. La precariedad laboral en este colectivo podría definirse como «extrema» en tanto afecta a su vida laboral y social. Si estos trabajadores continúan expuestos a tales condiciones de precariedad, las repercusiones sobre su salud podrían ser mayores (AU)

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 «extreme», 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 (AU)