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Edited by
Shela Hirani
University of Regina, Canada
Reviewed by
Solvig Ekblad
Department of Learning, Informatics, Management and Ethics, Karolinska
Institutet (KI), Sweden
Palmira Immordino
University of Palermo, Italy
M. Alvi Syahrin
Immigration Polytechnic, Indonesia
Table of contents

 * Abstract
 * 1 Introduction
 * 2 Materials and methods
 * 3 Results
 * 4 Discussion
 * 5 Limitations
 * 6 Conclusion
 * Data availability statement
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 * Acknowledgments
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ORIGINAL RESEARCH ARTICLE

Front. Public Health, 28 January 2024
Sec. Disaster and Emergency Medicine
Volume 12 - 2024 | https://doi.org/10.3389/fpubh.2024.1337299
This article is part of the Research Topic World Refugee Day 2023 View all 16
articles


EXPLORING REFUGEES’ HEALTH CARE ACCESS IN TIMES OF COVID-19: A QUANTITATIVE
STUDY IN THE LISBON REGION, PORTUGAL

Vanessa Portela1*Sousan Hamwi2Maria R. Oliveira Martins3
 * 1Institute of Hygiene and Tropical Medicine, NOVA University of Lisbon,
   Lisbon, Portugal
 * 2NOVA National School of Public Health, Public Health Research Centre, NOVA
   University of Lisbon, Lisbon, Portugal
 * 3Global Health and Tropical Medicine, Institute of Hygiene and Tropical
   Medicine, NOVA University of Lisbon, Lisbon, Portugal

Background: To address the health needs of refugees, health services must be
culturally competent and facilitate this population’s access to health care,
especially in a context prone to the amplification of social inequities, such as
the COVID-19 pandemic. However, few quantitative studies exist in the European
Union, and to the extent of our knowledge, there are no published quantitative
studies exploring refugees’ access to health care during the pandemic in
Portugal. The objective of this study is to describe the demographic and
socioeconomic characteristics of refugees living in Lisbon and to explore their
healthcare access patterns during the COVID-19 pandemic.

Methods: We conducted a cross-sectional, descriptive, and quantitative study
from May to November 2022. Using Levesque’ s theory on health care access, we
designed and applied a 38-item questionnaire through face-to-face interviews
with refugees living in Lisbon for at least 12 months, and used descriptive
statistics to characterize sociodemographic and healthcare access profiles
during the pandemic.

Results: The mean age of the 36 recruited refugees was 35 years (SD = 10.24),
the majority were male (56%), married (72%), had at least a secondary education
(69%), were unemployed (77.8%), and had a median length of stay in Portugal of
17 months (IQR = 45). All were registered in a primary care center, and 94% used
healthcare services during the pandemic. The majority never tested positive for
the coronavirus (58%) and one out of the positive was admitted to hospital due
to severe COVID-19. A total of 97% received COVID-19 vaccination, of which 69%
had an incomplete schedule. A quarter of the participants did not have access to
information about COVID-19 in a language they understood, and although 97%
needed health care during the pandemic, more than half (63%) did not seek it
because of structural and cultural barriers. Half of the respondents had
difficulty getting medical advice by phone or email, and 39.4% could not afford
a medical examination or treatment. Only 18.2% sought counseling services. A
total of 58.8% of the participants felt like healthcare professionals did not
always show respect towards their culture, and 64.7% reported that healthcare
professionals did not always discuss treatment options with them.

Conclusion: This study’s findings highlight the need to endow inclusive
communication, cultural competency, and patient involvement in health care,
alongside improving the socioeconomic condition of refugees. Identified
population characteristics and barriers to health care access by refugees in
this study may inform future research on the health care needs of refugees in
Portugal and ultimately assist in the devising of strategies to reduce
inequalities in health care access.




1 INTRODUCTION

With the increasing global migratory flows, health care access by migrant
populations has been a subject of international and national research. The
concept of access to health care in the literature encompasses diverse
definitions. Some definitions view access as the attributes of health services,
users, or both, while others focus on the relationship between the supply and
demand for health care (1). Levesque’s Conceptual Framework for Heath Care
Access analyzes access as a product of the relationship between five dimensions
of accessibility of services (Approachability, Acceptability, Availability and
Accommodation, Affordability, and Appropriateness) and five abilities of persons
(Ability to perceive, Ability to seek, Ability to reach, Ability to pay, and
Ability to engage) (2). This multidimensional and integrative approach of the
theory may provide means to characterize health care access more comprehensively
and accurately. Long-standing barriers to health care access by refugees and
migrants are robustly documented in the literature. Nested within cultural,
social, and financial factors, lie obstacles such as language differences,
discrimination, unawareness about individual rights to health or available
healthcare services, economic insufficiency and out-of-pocket expenditures (3),
bureaucracy and lack of refugee documentation status, and long distances to
healthcare facilities (3–6).

The additional burden of the COVID-19 pandemic on refugees’ social determinants
of health through the loss of jobs, increased poverty, discrimination, and
social isolation, along with COVID-19 prevention and control measures, led to a
disproportionate impact of the pandemic on this vulnerable group (7).
Constraints in services such as childcare, language classes, and provision of
resettlement services (8) accounted for the weakening of social support
networks. Pre-existing healthcare barriers further compromised refugees’ access
to health care, namely in accessing COVID-19 information (9) or testing (10).
Social distancing and lockdowns enhanced the reliance on technology for the
delivery of health care services. Studies with refugees show that while the use
of technology provided advantages in some aspects of access (i.e., users’
convenience in travelling-associated costs and time, especially for people
living in remote areas) (11), it also presented several challenges. In this
context, a different set of health care access barriers emerged, such as
technology costs and complexity, technical and operational issues (i.e.,
connectivity problems), interference with quality of care (communication and
development of a trustful relationship with providers) (11), lack in technology
literacy, issues with communication and cultural mediation services, and privacy
concerns (8).

In Portugal, there are published studies on health care access and utilization
by the overall immigrant population, which show the presence of systemic
barriers both before and during the pandemic. In a 2018 study involving 1,375
immigrants and 320 professionals from primary care centers in Lisbon, Dias et
al. explored the perceptions of both groups on the access and utilization of
healthcare services. Economic, cultural, linguistic, and discriminatory
obstacles were identified (12). These constraints led to an underutilization of
healthcare services by the immigrant population (13–16). A 2021 survey on health
care access by immigrants in Portugal underscored the unmet needs for medical
care due to financial constraints, long waiting lists, lack of time due to
occupational or family responsibilities, dissatisfaction, and lack of trust in
public healthcare services (17). O Martins et al. through a cross-sectional
study in Lisbon’s Metropolitan Area, highlighted the disproportionate
socioeconomic impact of the COVID-19 pandemic on immigrants compared with
natives. Findings revealed that COVID-19’s effects amplified immigrants’
previous hardships leading to greater job loss, lay-offs, and income losses,
with a consequential impact on livelihoods. Moreover, in the early stages of the
pandemic, immigrants had increased difficulties in accessing healthcare services
in comparison with natives. Immigrants were more likely to face hindrances in
obtaining medical appointments, in complying with children’s vaccinations, and
in the acquisition of pharmaceuticals (18, 19).

Although there has been a substantial increase in the number of people in need
of international protection in Portugal since 2015 (20), little is known about
refugees’ reality, namely in what concerns their health care. Despite the
aforementioned research on health care access by the overall immigrant
population in Portugal, to the extent of our knowledge, there are no published
quantitative studies addressing this issue in refugees, particularly during the
COVID-19 pandemic. As such, this study may provide valuable initial information
about the subject.

Although in Portugal asylum seekers and refugees’ rights to health care are
enshrined in the national Asylum Act (21), it is essential to understand if this
translates into an effective and equitable access to health care, particularly
in the midst of a pandemic. Furthermore, as other migrants in vulnerable
situations, assurance of access to health care by refugees is imperative, as
their needs differ from the host population due to the cumulative effect of risk
factors to poor health, which act throughout the migration process (22).
Therefore, host countries need to define evidence-based interventions that
protect this vulnerable group’ s health.

Within this context, we may ask: what have been the main difficulties in health
care access by refugees in Lisbon during the COVID-19 pandemic? The objective of
our study is to describe the demographic and socioeconomic characteristics of
refugees living in Lisbon and to explore their health care access patterns
during the COVID-19 pandemic.

The outcomes of this study will potentially provide preliminary information
about barriers experienced by refugees, which may serve as a basis to larger
studies, and assist in the devising of vertical health policies to improve their
health care access.


2 MATERIALS AND METHODS


2.1 STUDY DESIGN AND SETTING

We conducted a cross-sectional, descriptive, and quantitative study in Lisbon,
between May and November 2022. We found this type of study the most suited to
explore the unknown reality of health care access among refugees in Portugal and
to address the multidimensional and multivariable nature of the chosen framework
on health care access, while saving time and resources.

Although the reception and geographical distribution of asylum-seekers and
international protection beneficiaries in Portugal is tendentially
decentralized, Lisbon has been the district receiving the greatest number of
refugees through all programmed entry mechanisms globally (2018–2021) (20). To
recruit the participants, we collaborated with the community intervention
organization CRESCER, within the scope of the organization’s projects “É UMA
VIDA [IT’S A LIFE]” and “NO Border.” CRESCER develops assistance projects for
vulnerable populations in the greater Lisbon area. Since 2016, they have also
cooperated with Lisbon’s Municipal Refugee Reception Program (PMAR Lx) during
its second phase, facilitating the transition of refugees and asylum seekers
from the Refugee Reception Center to temporary autonomous housing granted by the
municipality. Additionally, CRESCER provides assistance in areas like employment
search, legal and psychosocial support, medical and psychological care, housing,
mediation, and translation. This comprehensive support is delivered by a
technical team of social workers, interpreters, a psychiatrist, a psychologist,
and a lawyer (23).


2.2 PARTICIPANTS AND SAMPLING

The target population was adult refugees as defined by the United Nations
Convention relating to the Status of Refugees (24). Participation in the study
required the fulfillment of the eligibility criteria, which consisted of being a
refugee, aged 18 or more, living in Lisbon, with a length of stay in Portugal of
at least 12 months, and receiving assistance from the community intervention
association CRESCER. From late April to November 2022, CRESCER’s professionals
contacted potential participants during the social support appointments at the
organization’s headquarters or during the technical teams’ weekly home visits.
Individuals were excluded from the study if there was no interpretation
available for their languages. For this exploratory study, we used a
non-probabilistic convenience sample, as it was the most cost-effective method
to meet the study’s objectives within a short period. Interviews were conducted
at the home of the “É UMA VIDA” project beneficiaries or CRESCER’s headquarters
in the case of the “NO Border” project recipients. In all cases, the interview
place was chosen considering the participants’ convenience and in alignment with
CRESCER’s engagement context for each project.


2.3 MEASUREMENT INSTRUMENT AND VARIABLES

We designed a structured 38-item questionnaire, which was translated from
Portuguese into English and Arabic by the research team and interpreted into the
other languages of the refugees in the sample (i.e., Kurdish and French), with
the collaboration of the organization’s cultural mediators. The questionnaire
referred to the period between the beginning of the COVID-19 pandemic in
Portugal (March 2020) and the moment of the interview and was structured in two
domains for content organization and analysis facilitation purposes: (1)
sociodemographic-, migration-, healthcare services-, and COVID-19-related
variables and (2) dimensions of access to health care, using Levesque’s theory
on health care access. Levesque’s theory identifies two main components:
“accessibility of services” and “abilities of persons.” The “accessibility of
services” encompasses five dimensions: Approachability, Acceptability,
Availability and Accommodation, Affordability, and Appropriateness.
Correspondingly, the “abilities of persons” include the abilities to Perceive,
to Seek, to Reach, to Pay, and to Engage in healthcare. The dimensions of
“accessibility of services” interact with the corresponding dimensions in
“abilities of persons” to generate access (2), as shown in Figure 1. This
multidimensional approach and the holistic view of access illustrate the complex
interactions that generate access and stand for the comprehensive nature of the
theory. Drawing on Levesque’s framework, we selected variables from established
public health surveys, with the intent of capturing the determinants of all
health care access dimensions among refugees during the COVID-19 pandemic,
albeit with a focus on the abilities of persons. We classified the variables
into the dimensions they best reflect, according to the categorization used in
the literature and the research team’s interpretation of the framework, as
follows:


Figure 1

Figure 1. Levesque’s framework of access to health care Adapted from:
patient-centred access to health care: conceptualizing access at the interface
of health systems and populations, Levesque et al. (2) (p.5).




2.3.1 APPROACHABILITY

We explored this dimension using the determinant “information.” Namely, we
assessed whether health services conveyed information about COVID-19,
considering audiences from diverse cultural backgrounds. By making information
culturally adequate and available in different languages, recipients can
identify and use healthcare services according to their health needs. For
example, clear information in several languages about COVID-19 testing
procedures could enhance testing adherence among refugees not proficient in
Portuguese or English.

2.3.2 ABILITY TO PERCEIVE

This ability was analyzed through the determinants “health literacy” and “health
beliefs,” both of which influence the individual’s perception of health issues
and the realization of the need for care. We used the variables “source of
information about COVID-19,” “knowledge of symptoms of COVID-19,” and
“asymptomatic spread of COVID-19” to assess health literacy, the variable
“prevention of COVID-19 by eating spicy food” to assess health beliefs, and the
variable “need for health care during the pandemic” to explore both.

2.3.3 ACCEPTABILITY

We used the variable “cultural competence in health care provided” to explore
this dimension. For health care to be accepted, the provision of services must
be culturally adequate to engage users in seeking care. Likewise, healthcare
professionals need to be equipped with skills that stimulate cultural awareness
when delivering care to people from diverse backgrounds.

2.3.4 ABILITY TO SEEK

The variables “sought health care every time needed” and “reasons for not
seeking health care during the pandemic” were used to assess the determinants of
autonomy, personal and social values, and individual rights. Understanding why
individuals in need of care do not seek it helps identify barriers to their
autonomous decision-making regarding seeking healthcare. To explore users’
awareness of different health care modalities, we examined the variables “type
of healthcare providers sought during the pandemic,” “type of healthcare
services sought during the pandemic,” and “knowledge about line SNS 24″. The
awareness of “line SNS 24″ (Portuguese national health system phone and online
platform) was particularly important during the pandemic. This line was
designated as the primary point of contact between the public and the health
system, alongside providing advice and guidance on COVID-19 preventive measures,
symptoms, contacts, testing, quarantine, and when necessary, referral for
medical observation. Therefore, awareness of its existence was essential to
access some key healthcare services.

2.3.5 AVAILABILITY AND ACCOMMODATION

With the establishment of public health measures (such as social distancing) and
with the need to avoid health system saturation during the pandemic, healthcare
services were required to diversify the ways of providing care, by swiftly
investing in remote or virtual modalities of contact with users. Thus, the
variable “get medical advice by email/phone” was chosen to assess the
availability of alternative methods to in-person healthcare service provision.

2.3.6 ABILITY TO REACH

This ability was analyzed through the variable “travel to healthcare facility”
which explores the easiness with which people can get to the healthcare unit in
case of need. It is determined by the concept of personal mobility and
availability of transport (2). Another important determinant to reach health
care is occupational flexibility, which was assessed by “medical
appointment/perform exams during working hours.”

2.3.7 AFFORDABILITY

The variable “pay for healthcare services” was used to assess the direct costs
of services, namely if refugees were required to pay for any healthcare
services.

2.3.8 ABILITY TO PAY

This ability translates to the economic capability to pay for health care
without incurring expenses that endanger the supply of basic needs (2). It was
analyzed through the variable “could not afford medical examination/treatment.”

2.3.9 APPROPRIATENESS

The determinant adequacy of care was assessed using the variable particularly if
the provided healthcare addressed the specific linguistic needs of refugees. The
variable “discussion of treatment options/side effects” was used to assess the
technical and interpersonal quality of care, namely if healthcare professionals
provided holistic information about treatment options and involved refugees in
treatment decisions.

2.3.10 ABILITY TO ENGAGE

The variables “vaccination against COVID-19” and “preventive measures
SARS-CoV-2” were used to analyze the determinant adherence, namely if refugees
were involved in COVID-19 precautionary actions.


2.4 ETHICAL CONSIDERATIONS

The study’s protocol was approved by the Ethics Committee of Institute of
Hygiene and Tropical Medicine, NOVA University of Lisbon (IHMT) and guided by
the ethical principles of the Declaration of Helsinki (25). A written informed
consent was obtained from the individuals to participate in the study, which
consisted of answering a face-to-face questionnaire applied by the research
team. Participation in the study was voluntary, and data was treated
confidentially and anonymously. The informed consent was translated from
Portuguese into English, Arabic, and French by the research team, and into
Kurdish by a cultural mediator from CRESCER, to allow a comprehensive
understanding of the information. Whenever the participant was illiterate, the
informed consent was read by the cultural mediator in the participant’s language
in the presence of a witness (usually a family member). Participants’ privacy,
in the case of the “NO Border” project, was ensured by conducting the interviews
in a separate room at the organization’s headquarters.


2.5 STATISTICAL METHODS

We summarized data using descriptive statistics: we computed frequencies and
proportions for qualitative (nominal and ordinal) variables, and the mean and
standard deviation (SD), or the median and interquartile range, for quantitative
variables, according to their distribution. A database was created and analyzed
using the IBM®SPSS® Statistics version 28.


3 RESULTS


3.1 PARTICIPANTS

A total of 37 refugees were identified by CRESCER as meeting the eligibility
criteria for the study and were invited to participate. One participant declined
participation due to a lack of time to answer the questionnaire, resulting in a
final sample size of 36.


3.2 SOCIOECONOMIC AND DEMOGRAPHIC CHARACTERISTICS

As shown in Table 1, the mean age of the participants was 35 years
(SD = 10.24 years), with over half being male (n = 20, 55.6%), 26 (72.2%) were
married, and the majority had an Islamic religious background (n = 25, 69.4%).
The participants were from seven countries across the Middle East, Asia, and
Africa (mainly Afghanistan, Iraq, and Syria) and had all been integrated into
the government’s Refugee Reception Program. The median length of their stay in
Portugal was 17 months (IQR = 45) by the time the questionnaire was applied.
Most participants had at least a secondary school education (n = 25, 69.4%), and
were not verbally proficient in Portuguese (n = 23, 63.9%) or in English (n
= 27, 75%). In six interviews where the house representatives were fluent in
English, they acted as an interpreter for the other family member(s) included in
the study. Concerning employment, the majority of participants were unemployed
(n = 28, 77.8%), including nine (25%) housewives. With a median of four persons
living in the same household (IQR = 4), all the participants expressed some
degree of difficulty making ends meet, of which 19 (52.8%) indicated great
difficulty. All 36 participants were registered in a primary healthcare center
and, during the pandemic, 34 (94.4%) used healthcare services. Regarding
infection with SARS-CoV-2, only two participants were never tested during the
study period. Of those tested, the majority never tested positive (n = 21,
58.3%), while a total of 13 (36.1%) tested positive at least once. Among the
latter, only one required hospitalization due to severe COVID-19 symptoms.


Table 1

Table 1. 1st domain: sociodemographic-, migration-, healthcare services-, and
COVID-19-related variables.





3.3 HEALTH CARE ACCESS PROFILES DURING THE COVID-19 PANDEMIC

3.3.1 APPROACHABILITY AND ABILITY TO PERCEIVE

In this study, 25% of the participants reported not accessing information about
COVID-19 in a language they understood. Almost a third of the participants
relied on social media and family/friends to obtain information (n = 11, 30.5%).
Almost all participants (n = 35, 97.2%) needed some kind of health care during
the pandemic. Most participants (over 86%) were able to identify the most common
symptoms of COVID-19 (i.e., fever/chills, cough, fatigue, loss of taste and/or
smell), and over 69% recognized three of the less common symptoms (i.e.,
muscle/body aches, sore throat, congestion/runny nose) (26). However, the
identification of gastrointestinal symptoms, specifically nausea or vomiting and
diarrhea, varied among participants, with only 44.4 and 38.9% recognizing them
correctly (respectively). When presented with false symptoms, 22 (61.1%)
correctly identified constipation as unrelated to COVID-19, while 26 (72.2%) did
the same for bleeding. Most participants (n = 21, 58.4%) either did not know or
incorrectly believed that an asymptomatic person could not spread the virus.
Additionally, one-sixth (n = 6, 16.7%) held the misconception that COVID-19 can
be prevented by eating spicy food.

3.3.2 ACCEPTABILITY AND ABILITY TO SEEK

As shown in Table 2, when receiving health care, 58.8% of the participants felt
like healthcare professionals did not always show respect towards their culture,
including 17.6% who rarely or never felt respected. More than half of the
participants (n = 22, 62.9%) did not seek health care every time they needed it.
Of the mentioned reasons for not seeking health care, most were related to the
difficulty of getting a medical appointment, whether due to a long waiting list
(n = 16, 72.7%) or because the appointment got canceled/postponed (n = 6,
27.3%). Language difficulties were pointed out by 13 (59.1%) respondents, and 12
(54.5%) considered their health problem not to be serious enough to justify
seeking health care. A total of 10 (45.4%) respondents did not know what to do
or where to go for health care. The main healthcare providers sought by the
participants during the pandemic were family doctors (n = 23, 69.7%),
pharmacists (n = 19, 57.6%), hospital specialist doctors (n = 17, 51.5%) and
emergency rooms (n = 17, 51.5%). Only six (18.2%) sought counseling services.
Most participants relied on the public sector, namely primary care centers (n
= 27, 81.8%) and public hospitals (n = 26, 78.8%), to get health care. Half of
the participants (n = 18, 50%) were unaware there was a national health line
(linha SNS24).


Table 2

Table 2. Acceptability and ability to seek results.




3.3.3 AVAILABILITY AND ACCOMMODATION AND ABILITY TO REACH

Of the 26 respondents who contacted the healthcare center by phone or email,
half (n = 13, 50%) found it was very difficult to get medical advice through
those channels of communication. When considering the physical mobility to the
health center, most participants reported that it was very easy (n = 17, 51.5%)
or somewhat easy (n = 9, 27.3%) to get to the primary care center or hospital.
Out of the six employed refugees who needed care during work hours, four had the
occupational flexibility to go to a medical appointment or perform an exam.

3.3.4 AFFORDABILITY AND ABILITY TO PAY

When it comes to the direct costs of health care, over half of the participants
(n = 19, 54.5%) reported having paid for health care (including medication). A
total of 13 (39.4%) respondents experienced times when they could not afford a
medical examination or treatment.

3.3.5 APPROPRIATENESS AND ABILITY TO ENGAGE

Table 3 reports the dimensions of appropriateness and the ability to engage.
Over a third of the participants (n = 11, 35.5%) were not offered an
interpreting service when receiving health care, and for the ones who were,
interpretation was provided by the organization CRESCER or a family member
proficient in English. A total of 22 (64.7%) participants reported that when
receiving health care during the pandemic, healthcare professionals did not
discuss with them treatment options or treatment side effects. Most participants
(n = 35, 97.2%) had received vaccination against COVID-19, of which 25 (69.4%)
had an incomplete vaccination schedule. In what concerns COVID-19 preventive
measures, all the participants wore face masks, and the large majority (n = 30,
83.3%) used sanitizers, washed their hands for 20 s, and kept social distance.
Around 30% of participants changed their diet or took over-the-counter medicines
to protect themselves from SARS-CoV-2 infection.


Table 3

Table 3. Appropriateness and ability to engage results.





4 DISCUSSION


4.1 SOCIODEMOGRAPHIC CHARACTERISTICS

This article aimed to describe the sociodemographic, migration, and COVID-19
characteristics of refugees living in Lisbon, and to describe the dimensions of
their health care access during the COVID-19 pandemic in consistent with
Levesque’s Patient-Centered Framework. A total of 36 refugees participated in
the study, with a mean age of 35 years, and over half were male (n = 20). The
participants were from seven countries across the Middle East, Asia, and Africa,
had all been integrated into the government’s Refugee Reception Program, and had
a median length of stay in Portugal of 17 months. Of the 36 participants, 26
were married, with a median of four persons living in the same dwelling, and the
majority had an Islamic religious background (n = 25). Most had at least a
secondary school education (n = 25) and were not verbally proficient in
Portuguese (n = 23) or English (n = 27). The large majority were unemployed
(n = 28) and all expressed some degree of difficulty making ends meet. All were
registered in a primary healthcare center and, during the pandemic, 34 used
healthcare services. Most of them never tested positive for SARSCoV-2 (n = 21),
and one was admitted to hospital due to severe COVID-19.

Sociodemographic data on refugees and asylum seekers resettled in Portugal is
dispersed and often incomplete. According to available national data from the
last 5 years (which corresponds to the longest length of stay of this study’s
participants), the sociodemographic distribution of refugees was overall similar
to that in this study’s sample. For example, most refugees - including children
- were male (around 68% in 2018, around 60% in 2020 and 52% in 2021 compared to
55.6% in the sample) (20, 27). Additionally, the most representative age group
among adult refugees (over 18) was 19–39 years (89% in 2018, 78% in 2019, 76% in
2020, and 66% in 2021) (20), similar to the age distribution of the study (in
which n = 27, 75% aged 21–38 years). The most frequent countries of origin
(Afghanistan, Iraq, Syria, and Eritrea) are also among the main five countries
of origin of refugees and asylum-seekers in Portugal in the last 5 years (27).
National data concerning the educational attainment of refugees is limited. In
2021, the educational level of up to 40% of refugees arriving in Portugal was
unknown, including those from Afghanistan—the most prevalent group at the time.
For those whose educational level was documented, most had only completed
primary school. This contrasts with the findings of our study, where the
majority had at least a secondary school education (20). Regarding employment,
in 2020 and 2021, around 40% of the refugees were still unemployed at the end of
the integration program, whilst in our study, unemployment almost reached an
astounding 78%. Similarly to the findings of this research, there were high
percentages of registration of newly arrived refugees in the National Health
System (SNS) in 2021, namely over 80% in all official entry mechanisms (except
for the Afghans, which was 69.4%) (20). Although our sample is not intended to
be representative, a comparison with the limited data available at the national
level shows that the age, gender, and country of origin of the refugees in our
study do not differ considerably from the national picture.


4.2 APPROACHABILITY AND ABILITY TO PERCEIVE

When considering healthcare services’ approachability, especially in public
health emergencies such as the COVID-19 pandemic, services must devise
strategies of communication in which information is available, clear, and
adequate to the audience it serves, so that preventive and control measures can
be promptly and efficiently followed. Inclusive communication in health care
should take into consideration not only the diverse cultural backgrounds of the
recipients (namely by making information culturally adequate and available in
different languages) but also ensure that it reaches the intended public
promptly, so that services can be identified by users. Although several entities
such as the Directorate-General of Health, non-governmental organizations, the
International Organization for Migration, and particularly the High Commission
for Migration publicized multilingual information about COVID-19, 25% of the
participants in this study stated not to have had access to information about
COVID-19 in an understandable language. Studies in countries such as the United
Kingdom and Brazil similarly showed that there was insufficient communication
effectiveness with asylum seekers, due to a lack of culturally and
linguistically adequate information about the pandemic (28).

The Ability to perceive the need for care is highly influenced by health
literacy, knowledge, and beliefs about health (2). The main sources of
information on COVID-19 chosen by the participants were informal, such as social
media and friends/family, which accounted for almost a third of the responses.
This finding is in line with other studies, which outline the role of social
media as a source of information about COVID-19 (29–31). Factors such as age,
language proficiency, education, economic resources, and length of stay in the
country may all have played a part in the choice of the information source.
Healthcare services that are not approachable, due to their failure to convey
culturally and linguistically appropriate information, can negatively affect
people’s ability to access and perceive reliable health information. People may
then turn to sources of information that are readily available and free of
language barriers, like social media, as outlined in a systematic review on the
use of social media during the pandemic by ethnic minorities and migrants
(including refugees) (31). Social media channels may, in turn, become a vehicle
for health misinformation, particularly during public health emergencies like
the COVID-19 pandemic, with negative impacts on people’s health behavior, such
as increasing vaccine hesitancy and the use of unproven treatments (31–33).

In this study, most participants were knowledgeable about the most common
symptoms of COVID-19, which can be partially explained by the high level of
education of the participants and the study’s timing (circa 2 years of
pandemic). Nevertheless, a lack of awareness about asymptomatic transmission of
the virus was also common, and up to one-sixth of respondents held the
misconception that COVID-19 can be prevented by eating spicy food. The
literature on the levels of knowledge about transmission and symptoms of
COVID-19 among forcibly displaced people is heterogeneous but generally shows
that lower levels of knowledge and health literacy are more likely in refugees
with low educational attainment (30, 34–36). Other factors that probably
influence knowledge levels include the different study settings (camps versus
urban resettlements), timing of the studies/time elapsed since the beginning of
the pandemic (and thus production of knowledge about the novel virus), and
language proficiency.


4.3 ACCEPTABILITY AND ABILITY TO SEEK

When receiving health care, most participants of this study felt like healthcare
professionals did not always show understanding and respect towards their
culture, including almost a fifth who rarely or never felt culturally respected.
This finding elicits a lack of cultural competence, which is defined as the
ability of systems to provide care to patients with diverse values, beliefs, and
behaviors, including tailoring delivery to meet patients’ social, cultural, and
linguistic needs (37). Lack of cultural competence in the provision of
healthcare services compromises its acceptability by users (38). Cultural and
religious differences between participants and their healthcare providers may
have played a role in this dimension, as most refugees were of Islamic
background, in contrast with the predominant Christian-embedded culture of
Portugal. There is a paucity of data in the literature on refugees’ input on
cultural competence in the healthcare setting (39). Findings of the qualitative
arm of a European study on the healthcare of migrants and refugees highlighted a
perceived cultural competence inadequacy among healthcare providers in all ten
participating countries (Portugal not included) (40). Similarly, studies with
healthcare professionals in Portugal acknowledged the cultural challenges in
providing care to migrants, including the lack of cultural competence training
(41) and the need to incorporate cultural mediators in healthcare services (42,
43). Healthcare professionals’ lack of awareness and preparedness regarding
certain cultural aspects of refugees and other migrants may lead to feelings of
rejection and imperil health care access through the avoidance of healthcare
providers (3, 44), thus endangering acceptability. Additionally, disrespect
towards the culture of migrants and refugees, in the form of discrimination or
xenophobia, is also a well-known barrier to health care (3, 38, 40, 45), further
compromising access. Results from a training program on cultural and individual
diversity for primary healthcare providers in Portugal during the COVID-19
pandemic showed an improvement in cultural diversity awareness, knowledge, and
skills, and contributed to reducing feelings of discrimination among healthcare
professionals (46).

The Ability to Seek care was also compromised in this research as most
participants did not seek health care every time they needed it. Structural
barriers to health care, such as long waiting times, cancellation or postponing
of medical appointments, language difficulties, and unfamiliarity with the
health system, were appointed by refugees as the main reasons for not seeking
care, similar to other studies on migrants and refugees’ health care (6, 12, 40,
44, 47). It is indisputable that the COVID-19 pandemic put overwhelming pressure
upon health care systems, limiting their capacity to respond. This was
particularly evident in Portugal, where unmet needs for medical care in the
first year of the pandemic were the second highest among the Organization for
Economic Co-operation and Development (OECD) countries, affecting more than a
third of the population and especially impacting people in the lowest quintile
of income (48). Nevertheless, the persistent nature of the health care barriers
encountered by migrants and refugees is attested by their presence long before
the pandemic, both globally (38), and in several Portuguese studies among
migrants (12, 15, 47), suggesting that major interventions are necessary to
reduce health systems inequalities.

Half of the participants were unaware of the existence of a national health line
(linha SNS24). During the pandemic, and particularly during lockdown, this phone
line was mandated as the primary contact with the national health system to
alleviate pressure on health services. It acted as a source of information about
preventive measures, provided case and contacts management, quarantine,
isolation, and vaccination guidance, and, when applicable, access to the
respective certifications of work absence. Also of particular importance, it
allowed free testing to people registered in the national health system,
provided the initial management of people with COVID-19 symptoms, and served as
a referral system to healthcare providers according to the severity of symptoms
(49). A non-COVID-19 line was also available to assess and direct people to
medical consultation if justified. Lack of awareness of refugees about this
telephone line may have impaired knowledge about health care options and modes
of navigating the health system during the pandemic.

While the majority of healthcare providers sought by participants were family
doctors, pharmacists, emergency doctors, and hospital specialist doctors, only a
small percentage sought counseling services. These findings are in line with a
systematic review of the underutilization and access to mental health services
among refugees and asylum seekers in Europe (50). The distressing experiences
faced by refugees act as risk factors for mental disease (51–53), doubling their
risk of suffering from post-traumatic stress disorder and depression compared
with economic migrants (50). The detrimental effect of the COVID-19 pandemic
control measures on mental health further accentuated this vulnerability in
asylum-seekers and other migrants (28). Moreover, increased perceptions of
discrimination, socioeconomic difficulties, and unmet needs for medical care
among refugees and migrants due to the pandemic also contributed to worsening
their mental health outcomes (54). The discrepancy between refugees’ mental
health needs and the actual mental care they receive can be attributed to
several factors, rooted in the aforementioned barriers, namely language
difficulties, unavailability or lack of timely appointments, unawareness
regarding providers’ services, or constraints to virtual care access during the
pandemic (11, 50, 52). Additionally, cultural barriers, stigma, low
self-perceptions, and awareness about mental disease are also important
impediments to access, probably contributing to the low rates of mental
help-seeking among refugees (50, 52).

Regarding health services, most participants relied on the public sector to get
health care, which is probably explained by the economic insufficiency reported
in the study.


4.4 AVAILABILITY AND ACCOMMODATION AND ABILITY TO REACH

During the pandemic, half of the respondents who contacted the healthcare center
found it very difficult to get medical advice by phone or email. Restrictions on
social contacts, especially during lockdowns, forced healthcare services into a
fast transition to alternative and non-face-to-face modalities of contact with
users. In this study, there was limited availability and accommodation of
services for refugees during the pandemic, as the offered means of obtaining a
medical consultation were ineffective.

When considering the ability to reach, namely the physical mobility to the
health center, most participants reported that it was easy to get to the primary
care center or hospital. This is probably partially because all respondents live
in an urban setting, specifically in the country’s capital, where there is a
greater concentration of services and resources, including public
transportation. As of November 2022, of the 1,294 primary care units of the
country, approximately 68% were concentrated in Porto and Lisbon regions (514
and 362 respectively) (55). Likewise, in 2021, most of the 107 country’s public
hospitals were in the Lisbon Metropolitan Area (24 hospitals) (56). In a study
among immigrants living in the Lisbon Metropolitan Area, the geographic
proximity of the healthcare centers was found to be the main reason for their
utilization (12). Another factor that may have facilitated responders’ mobility
was the use of public transportation for free, as refugees are attributed a
gratuitous monthly travel pass during the monitoring phase of PMAR Lx. The
intent to assess the ability to reach through occupational flexibility was
limited in this study, as the great majority of responders were unemployed, and
out of the few who were employed, not all needed health care.


4.5 AFFORDABILITY AND ABILITY TO PAY

Over half of the participants reported paying for health care, despite refugees
being exempt from user fees in the SNS. The lack of affordability in this study
was mainly related to paying for medication and, to a lesser extent, dental
care. These findings are consistent with a study among immigrants in Portugal
that showed greater financial difficulties for immigrants to acquire
pharmaceuticals compared to natives (19). The Portuguese SNS covers several but
limited services, namely medical appointments in primary care and specialized
outpatient care, pharmaceuticals, and other services prescribed by physicians
(57). Despite refugees’ entitlement to user fee exemption, which enables them to
receive the aforementioned services without costs, the SNS coverage for
pharmaceuticals operates under a coinsurance scheme in which a portion is paid
by the user (58). In 2020, pharmaceuticals and other medical goods constituted
the main reason for out-of-pocket expenditures in OECD countries, due to a
lesser extent of governments’ coverage comparatively to inpatient/outpatient
care. Moreover, in Portugal, coverage for pharmaceuticals was below the average
of 59% of the OECD countries (59). Nevertheless, the extensive offer of generic
medications should theoretically allow people with scarce economic resources to
maintain their treatment at sometimes considerably lower costs. Concurrently,
access to the government’s cost-sharing in the acquisition of pharmaceuticals
requires the presentation of a medical prescription (which is usually provided
subsequently to a medical appointment). A study of the results from the 2014
National Health Survey in Portugal showed that migrants were more likely than
natives to use medications without a prescription (60). Obstacles to medical
appointments observed in this study, and therefore inability to obtain a
prescription, may have contributed to refugees resorting to over-the-counter
pharmaceuticals (which are not covered by the SNS). Dental care is mainly
provided by dentists in the private sector despite its inclusion in the SNS in
2016 (58, 61). In cases of oral cancer suspicion and some situations of social
vulnerability (62), within which refugees are not included, SNS offers a dental
paycheck that covers treatments free of charge (58).

Assessment of ability to pay showed that up to 40% of responders experienced
times when they could not afford a medical examination/treatment, which can be
understood in the context of the high percentages of unemployment and difficulty
in making ends meet reported by the participants. Costs associated with dental
care, medical appointments, or exams in the private sector (as an attempt to
cover health needs in a timely manner), and medications were some of the cited
reasons for the inability to pay.


4.6 APPROPRIATENESS AND ABILITY TO ENGAGE

In terms of appropriateness and adequacy of services, over a third of the
participants were not offered an interpreting service when receiving health care
during the pandemic, even though the large majority were not proficient in
Portuguese or English. In cases where interpretation was offered, it was mainly
provided by the cultural mediators of the organization CRESCER, which could
partially be explained by the participants’ median stay of 17 months in the
country (which coincides with the monitoring phase of PMAR Lx). Lack of adequate
communication between healthcare professionals and refugees leads to
misunderstandings and misdiagnosis (3, 44). In addition, it generates feelings
of emotional distress, distrust, and perceptions of exclusion, and propels
disconnection and underutilization of services by refugees and immigrants (44,
51). Although interpretation services provided by CRESCER organization may
contribute to the fulfillment of most refugees’ linguistic needs when
articulating with healthcare services during the monitoring phase of the PMAR
Lx, devising long-term strategies to address this issue is warranted. With the
intent to bridge the communication gap between migrants and institutions, the
High Commission for Migration provides a toll-free interpretation telephone
service (63). Nevertheless, the line is not available 24/7 and it is not
specific for health care purposes, making it unsuitable for emergencies and
prone to the inadequate interpretation of medical terminology. Most participants
reported that when receiving health care during the pandemic, healthcare
professionals did not discuss with them treatment options or treatment side
effects. Poor technical and interpersonal quality of care contributes to
restricting access (2). A review of primary care access among immigrants in
Canada showed that the lack of patient involvement in treatment decision-making
results in service dissatisfaction and, eventually, change in healthcare
providers (44). Conversely, a study with refugees and immigrants in Denmark
during the pandemic underscored the importance of the coproduction of health as
a means to deliver quality healthcare service to this vulnerable population,
sustained by trustful relationships with healthcare providers, which enhanced
patient participation in decisions as well as their overall health care (64).

The large majority of participants were vaccinated against COVID-19 and adopted
preventive measures against infection, denoting significant participation in
public health recommendations and an ability to engage in health care. The
participants’ high level of education probably played a role in this engagement.
Although there was a high percentage of vaccination at the time of the study,
most participants had an incomplete schedule. The findings on following
precautions against SARS-CoV2 infection in this study were similar to those in a
World Health Organization worldwide survey of refugees and migrants on the
self-reported impact of COVID-19 (29). In the latter, there was also a high
adherence to measures such as increased hand washing, social distancing, and
covering the nose and mouth. However, the ability to follow these precautions
varied across regions, with refugees and migrants from Africa and Southeast Asia
showing higher noncompliance percentages due to the lack of suitable living
conditions (29).


5 LIMITATIONS

Although this research was designed to comprehensively address all dimensions of
access as contemplated in Levesque’s theoretical framework, it could not
encompass all the underlying determinants of access, highlighting the complexity
of the subject at hand. This complexity extended to the methodology of
characterizing the dimensions of the framework. The process of allocating a
variable and corresponding question to a specific dimension or ability within
the framework proved challenging, as some questions applied to more than one
dimension or ability (65). The non-probabilistic and small sample limits the
generalization of the findings, and focusing on just one refugee reception
organization, to save time and resources, may have resulted in a selection bias
(66). Additionally, the questionnaire refers to a timeline of more than 2 years,
which may have compromised the accuracy of memories regarding the studied events
and have led to a recall bias (66). Finally, the cross-sectional nature of the
study does not allow for causality to be established: for that purpose, it would
be necessary to carry out another type of study design (i.e., cohort study).


5.1 IMPLICATIONS FOR FUTURE RESEARCH

Identified population characteristics and barriers to health care access in this
research may inform future studies on the health care needs of refugees in
Portugal and suggest how health services could be improved to meet those needs.
Findings in this research also shed light on persistent challenges that require
the development of strategies and policies aimed at reducing inequalities in
health care access. However, a deeper understanding of the specificities of the
refugee population in Portugal is essential for designing targeted interventions
that facilitate access to health care. Studies with larger samples, involving
more refugee hosting entities, and in different geographic locations of the
country, would allow for better representativeness of the refugee population in
Portugal, thus providing a more comprehensive understanding of health care
access. Likewise, to better understand the complexity of health care access, it
is also necessary to explore the perceptions and experiences of both refugees
and healthcare providers. Qualitative studies could allow for in-depth insights
into the specificities and needs of both access agents, therefore enabling
effective and context-specific strategies.


6 CONCLUSION

To the extent of our knowledge, this is the first quantitative study exploring
health care access among refugees in Portugal during the COVID-19 pandemic. It
also provided a platform for refugees’ input on the subject, using a
comprehensive framework on health care access, exploring both supply- and
demand-side determinants. Although all the participants were registered in the
national health system and most had received at least one dose of vaccination
against COVID-19, our study also suggests constraints in several dimensions of
access:- an insufficiency of inclusive communication by healthcare
services/authorities, as language-appropriate information about COVID-19 did not
reach all of the participants;- a paucity of cultural competence, as more than
half of the refugees felt like healthcare professionals did not always show
respect towards their culture; −an underutilization of mental health services,
considering the minority of refugees that sought counseling; −a lack in the
coproduction of health care, as the majority of refugees felt they were not
involved in their health care process decision making. Table 4 summarizes
possible policy implications from the aforementioned barriers. The outcomes of
this study will potentially make visible difficulties refugees experience in
health care access and thus inform future studies with larger and representative
samples. Vertical health policies with multilevel strategies are essential to
improve access to health care by refugees. To this end, the establishment of
work alliances with refugee communities’ representatives would be an unvaluable
asset to ensure an open channel of communication with the target population and
the alignment of measures with people’s specific needs.


Table 4

Table 4. Extracted policy implications from the study.





DATA AVAILABILITY STATEMENT

The original contributions presented in the study are included in the
article/Supplementary material, further inquiries can be directed to the
corresponding author.


ETHICS STATEMENT

The studies involving humans were approved by Ethics Committee of Institute of
Hygiene and Tropical Medicine of New University of Lisbon. The studies were
conducted in accordance with the local legislation and institutional
requirements. The participants provided their written informed consent to
participate in this study.


AUTHOR CONTRIBUTIONS

VP: Conceptualization, Data curation, Formal analysis, Investigation,
Methodology, Resources, Supervision, Visualization, Writing – original draft,
Writing – review & editing. SH: Conceptualization, Methodology, Supervision,
Writing – review & editing. MO: Conceptualization, Data curation, Funding
acquisition, Methodology, Project administration, Resources, Supervision,
Writing – review & editing.


FUNDING

The author(s) declare financial support was received for the research,
authorship, and/or publication of this article. This study was funded by
Fundação para a Ciência e Tecnologia: ref. PTDC/SAU-SER/4664/2020 and Fundação
para a Ciência e a Tecnologia, GHTM - UID/04413/2020 and LA-REAL –
LA/P/0117/2020.


ACKNOWLEDGMENTS

We acknowledge the support given by Global Health and Tropical Medicine,
Instituto de Higiene e Medicina Tropical and Fundação para a Ciência e
Tecnologia, CRESCER Association and Professor Jean-Frederic Levesque.


CONFLICT OF INTEREST

The authors declare that the research was conducted in the absence of any
commercial or financial relationships that could be construed as a potential
conflict of interest.

The author(s) declared that they were an editorial board member of Frontiers, at
the time of submission. This had no impact on the peer review process and the
final decision.


PUBLISHER’S NOTE

All claims expressed in this article are solely those of the authors and do not
necessarily represent those of their affiliated organizations, or those of the
publisher, the editors and the reviewers. Any product that may be evaluated in
this article, or claim that may be made by its manufacturer, is not guaranteed
or endorsed by the publisher.


SUPPLEMENTARY MATERIAL

The Supplementary material for this article can be found online at:
https://www.frontiersin.org/articles/10.3389/fpubh.2024.1337299/full#supplementary-material


REFERENCES

1. Travassos, C, and Martins, M. A review of concepts in health services access
and utilization. Cad saúde pública / Ministério da Saúde, Fundação Oswaldo Cruz,
Esc Nac Saúde Pública. (2004) 20:S190–8. Available at:
http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0102-311X2004000800014&lng=en&nrm=iso&tlng=pt

Google Scholar

2. Levesque, JF, Harris, MF, and Russell, G. Patient-centred access to health
care: Conceptualising access at the interface of health systems and populations.
Int J Equity Health. (2013) 12:18. doi: 10.1186/1475-9276-12-18

Crossref Full Text | Google Scholar

3. Shehata, B, Heidelberg, U, Akter, S, and Maxwell, L. The health needs of
non-camp-based refugees in the Middle East and North Africa. J Migr Health.
(2022)

Google Scholar

4. Brandenberger, J, Tylleskär, T, Sontag, K, Peterhans, B, and Ritz, N. A
systematic literature review of reported challenges in health care delivery to
migrants and refugees in high-income countries-the 3C model. BMC Public Health.
(2019) 19:755. doi: 10.1186/s12889-019-7049-x

PubMed Abstract | Crossref Full Text | Google Scholar

5. Kang, C, Tomkow, L, and Farrington, R. Access to primary health care for
asylum seekers and refugees: a qualitative study of service user experiences in
the UK | enhanced reader. Br J Gen Pract. (2019) 69:e537–45. doi:
10.3399/bjgp19X701309

PubMed Abstract | Crossref Full Text | Google Scholar

6. Leh, F, Chuah, H, Tan, ST, Yeo, J, and Legido-Quigley, H. The health needs
and access barriers among refugees and asylum-seekers in Malaysia: a qualitative
study. Int J Equity Health. (2018) 17:120. doi: 10.1186/s12939-018-0833-x

PubMed Abstract | Crossref Full Text | Google Scholar

7. Palattiyil, G, Kisaakye, P, Mwenyango, H, Katongole, S, Mulekya, F, Sidhva,
D, et al. Access to HIV/AIDS or TB care among refugees in Kampala, Uganda:
exploring the enablers and barriers during the COVID-19 pandemic. J Migr Health.
(2022) 5:100098. doi: 10.1016/j.jmh.2022.100098

PubMed Abstract | Crossref Full Text | Google Scholar

8. Benjamen, J, Girard, V, Jamani, S, Magwood, O, Holland, T, Sharfuddin, N, et
al. Access to refugee and migrant mental health care services during the first
six months of the covid-19 pandemic: A Canadian refugee clinician survey. Int J
Environ Res Public Health. (2021) 18:5266. doi: 10.3390/ijerph18105266

Crossref Full Text | Google Scholar

9. Healey, SJR, Ghafournia, N, Massey, PD, Andrich, K, Harrison, J, Taylor, K,
et al. Ezidi voices: the communication of COVID-19 information amongst a refugee
community in rural Australia- a qualitative study. Int J Equity Health. (2022)
21:10–14. doi: 10.1186/s12939-022-01618-3

PubMed Abstract | Crossref Full Text | Google Scholar

10. Ghaddar, A, Khandaqji, S, Kansoun, R, and Ghassani, A. Access of Syrian
refugees to COVID-19 testing in Lebanon. East Mediterr Health J. (2023)
29:15–23. doi: 10.26719/emhj.23.001

PubMed Abstract | Crossref Full Text | Google Scholar

11. Hynie, M, Jaimes, A, Oda, A, Rivest-Beauregard, M, Perez Gonzalez, L, Ives,
N, et al. Assessing virtual mental health access for refugees during the
COVID-19 pandemic using the Levesque client-centered framework: what have we
learned and how will we plan for the future? Int J Environ Res Public Health.
(2022) 19:5001. doi: 10.3390/ijerph19095001

Crossref Full Text | Google Scholar

12. Dias, S, Gama, A, Silva, AC, Cargaleiro, H, Horta, R, Lemos, M, et al.
Atitudes e representações face à saúde, doença e acesso aos cuidados de saúde
nas populações imigrantes. Observatório das Migracoes. (2018) 62 Available at:
www.om.acm.gov.pt/om@acm.gov.pt

Google Scholar

13. Dias, S, Gama, A, Silva, AC, Cargaleiro, H, and Martins, MO. Barreiras no
acesso e utilização dos serviços de saúde pelos imigrantes a perspectiva dos
profissionais de saúde. Acta Med Port. (2011) 24:511–6. Available at:
www.actamedicaportuguesa.com

Google Scholar

14. Dias, S, Fronteira, I, Gama, A, Gróz, AP, Mardin, D, Simões, J, et al.
Health policies, patterns and barriers to migrants’ access to primary health
care In: Springer briefs in public health : Ed. Rosano, A. Springer
International Publishing (2018). 99–109. doi: 10.1007/978-3-319-73630-3_9

Crossref Full Text | Google Scholar

15. Matos, IC, Alarcão, V, Lopes, E, Oiko, C, and Carreira, M. Estudo
SAIMI-Saúde e Acesso aos Serviços de Saúde dos Imigrantes do Subcontinente
Indiano em Lisboa: Que Recomendações para Cuidados de Saúde Equitativos e
Culturalmente Adaptados? SAIMI Study-Health and Health Care Access by Immigrants
from the Indian Su. Acta Med Port. (2015) 28:164–76. doi: 10.20344/amp.5583

Crossref Full Text | Google Scholar

16. Rosano, A, Dauvrin, M, Buttigieg, SC, Ronda, E, Tafforeau, J, and Dias, S.
Migrant’s access to preventive health services in five EU countries. BMC Health
Serv Res. (2017) 17:588. doi: 10.1186/s12913-017-2549-9

Crossref Full Text | Google Scholar

17. Casquilho-Martins, I, and Ferreira, S. Migrants’ Health policies and access
to health Care in Portugal within the European framework. Societies. (2022)
12:55. Available at: https://www.mdpi.com/2075-4698/12/2/55/htm

Google Scholar

18. O Martins, MR, Shaaban, AN, Abecasis, A, Muggli, Z, Amado, R, Vaz, D, et al.
Are immigrants more vulnerable to the socioeconomic impact of COVID-19? A
cross-sectional study in Amadora municipality, Lisbon metropolitan area. Front
Public Health. (2022) 10:920308. doi: 10.3389/fpubh.2022.920308

PubMed Abstract | Crossref Full Text | Google Scholar

19. Conceicao, M. Estudo do Impacto Socioeconómico e das Dificuldades de Acesso
aos Cui-dados de Saúde Durante a Pandemia da COVID-19 nas Famílias Imigran-tes e
Nativas do Concelho de Amadora ao longo dos anos 2020 e 2021. Instituto de
Higiene e Medicina Tropical: Universidade Nova de Lisboa (2022).

Google Scholar

20. Reis Oliveira, C. Requerentes e Beneficiários de Proteção Internacional em
Portugal: Relatório Estatístico do Asilo 2022. Imigração em Números,
Observatório das Migrações [Internet]. (2022) Available at:
https://www.om.acm.gov.pt/publicacoes-om/colecao-imigracao-em-numeros/relatorios-asilo

Google Scholar

21. Assembleia da República. Lei do Asilo. Lei n. 26/2014, (2014). Available at:
https://files.dre.pt/1s/2014/05/08500/0260602637.pdf

Google Scholar

22. Health of migrants: resetting the agenda. Report of the 2nd Global
Consultation, Colombo, Sri Lanka, 21–23 February 2017, Part 2, Thematic
Sessions, Theme 2 Vulnerability and Resilience. Geneva: International
Organization for Migration. 31–33. (2017).

Google Scholar

23. CRESCER. Relatório e Contas 2020 [Internet]. Lisboa: (2021) Available from:
https://drive.google.com/file/d/1O49inz92EDkTIy7kxD9bWyysJL084hmN/view.

Google Scholar

24. United Nations. UNHCR - convention and protocol relating to the status of
refugees [internet]. (1951). Available at: https://www.unhcr.org/3b66c2aa10.html

Google Scholar

25. The World Medical Association. WMA declaration of Helsinki – ethical
principles for medical research involving human subjects [internet]. (2018).
Available at:
https://www.wma.net/policies-post/wma-declaration-of-helsinki-ethical-principles-for-medical-research-involving-human-subjects/

Google Scholar

26. Centers for Disease Control and Prevention. Symptoms of COVID-19. CDC
[Internet] COVID-19. (2021) Available at:
https://www.cdc.gov/coronavirus/2019-ncov/symptoms-testing/symptoms.html

Google Scholar

27. UNHCR. Refugee Data Finder [Internet]. UNHCR - Refugee Statistics. (2022).
Available at: https://www.unhcr.org/refugee-statistics/

Google Scholar

28. Mengesha, Z, Alloun, E, Weber, D, Smith, M, and Harris, P. Lived the
pandemic twice: A scoping review of the unequal impact of the COVID-19 pandemic
on asylum seekers and undocumented migrants. Int J Environ Res Public Health.
(2022) 19:6624. doi: 10.3390/ijerph19116624

Crossref Full Text | Google Scholar

29. World Health Organization. Apart Together survey: Preliminary overview of
refugees and migrants self-reported impact of COVID-19 [internet]. Geneva:
(2020) Available at: https://www.who.int/publications/i/item/9789240017924.

Google Scholar

30. Jubayer, F, Limon, MTI, Rana, MM, Kayshar, MS, Arifin, MS, Uddin, AHMM, et
al. COVID-19 knowledge, attitude, and practices among the Rohingya refugees in
Cox’s bazar, Bangladesh. Health Promot. (2022) 3:100227. doi:
10.1016/j.puhip.2022.100227

PubMed Abstract | Crossref Full Text | Google Scholar

31. Goldsmith, LP, Rowland-Pomp, M, Hanson, K, Deal, A, Crawshaw, AF, Hayward,
SE, et al. Use of social media platforms by migrant and ethnic minority
populations during the COVID-19 pandemic: a systematic review. BMJ Open. (2022)
12:e061896. doi: 10.1136/bmjopen-2022-061896

Crossref Full Text | Google Scholar

32. World Health Organization. Infodemics and misinformation negatively affect
people’s health behaviours. News. (2022) Available at:
https://www.who.int/europe/news/item/01-09-2022-infodemics-and-misinformation-negatively-affect-people-s-health-behaviours--new-who-review-finds

Google Scholar

33. Deal, A, Hayward, SE, Huda, M, Knights, F, Crawshaw, AF, Carter, J, et al.
Strategies and action points to ensure equitable uptake of COVID-19
vaccinations: A national qualitative interview study to explore the views of
undocumented migrants, asylum seekers, and refugees. J Migr Health. (2021)
4:100050. doi: 10.1016/j.jmh.2021.100050

PubMed Abstract | Crossref Full Text | Google Scholar

34. Alawa, J, al-Ali, S, Walz, L, Wiles, E, Harle, N, Awale, MA, et al.
Knowledge and perceptions of COVID-19, prevalence of pre-existing conditions and
access to essential resources in Somali IDP camps: a cross-sectional study. BMJ
Open. (2021) 11:e044411. doi: 10.1136/bmjopen-2020-044411

Crossref Full Text | Google Scholar

35. Claude, KM, Serge, MS, Alexis, KK, and Hawkes, MT. Prevention of COVID-19 in
internally displaced persons camps in war-torn north Kivu, Democratic Republic
of the Congo: A mixed-methods study. Glob Health Sci Pract. (2020) 8:638–53.
doi: 10.9745/GHSP-D-20-00272

Crossref Full Text | Google Scholar

36. Kananian, S, Al-Sari, S, and Stangier, U. Perceived vulnerability to
disease, knowledge and preventive behavior related to COVID-19 in Farsi and
Arabic speaking refugees. J Immigr Minor Health. (2022) 24:1245–50. doi:
10.1007/s10903-021-01322-4

PubMed Abstract | Crossref Full Text | Google Scholar

37. Betancourt, JR, Green, AR, and Carrillo, JE. Cultural competence in health
care: emerging frameworks and practical approaches [internet]. (2002). Available
at: www.cmwf.org

Google Scholar

38. Abubakar, I, Aldridge, RW, Devakumar, D, Orcutt, M, Burns, R, Barreto, ML,
et al. The UCL-Lancet Commission on migration and health: the health of a world
on the move. Lancet. (2018) 392:2606–54. Available from:
https://www.thelancet.com/

Google Scholar

39. Lau, LS, and Rodgers, G. Cultural competence in refugee service settings: A
scoping review. Health Equity. (2021) 5:124–34. doi: 10.1089/heq.2020.0094

PubMed Abstract | Crossref Full Text | Google Scholar

40. Karnaki, P., Riza, E., Nikolakopoulos, S., Zota, K., and Linos, A. The
Mig-HealthCare physical and mental health profile of vulnerable
migrants/refugees in the EU including needs, expectations and capacities of
service providers survey and interview findings [internet]. (2018). Available
at: https://www.mighealthcare.eu/e-library

Google Scholar

41. Bracons, H. Comunicação intercultural nos cuidados de saúde. Uma abordagem
exploratória da interação entre assistentes sociais e doentes imigrantes. Comun
Pública. (2020) 15:10968. doi: 10.4000/cp.10968

Crossref Full Text | Google Scholar

42. Coutinho, E, Domingos, AR, Reis, A, and Parreira, V. Ser Enfermeiro Obstetra
e Mediador Intercultural na interação com mulheres grávidas migrantes. New
Trends Qual Res. (2022) 13:e731–1. Available at:
https://publi.ludomedia.org/index.php/ntqr/article/view/731

Google Scholar

43. Reis, A. Mediação intercultural em contextos de cuidados de saúde – projeto
meios. Rev da UI_IPSantarém. (2020) 8:3–16. Available at:
https://revistas.rcaap.pt/uiips/article/view/19873

Google Scholar

44. Bajgain, BB, Bajgain, KT, Badal, S, Aghajafari, F, Jackson, J, and Santana,
MJ. Patient-reported experiences in accessing primary healthcare among immigrant
population in Canada: A rapid literature review. Int J Environ Res Public Heal.
(2020) 17:8724. Available at: https://www.mdpi.com/1660-4601/17/23/8724/htm

Google Scholar

45. World Health Organization. Interim guidance for refugee and migrant health
in relation to COVID-19 in the WHO European region [internet]. (2020) Available
at:
https://www.euro.who.int/__data/assets/pdf_file/0008/434978/Interim-guidance-refugee-and-migrant-health-COVID-19.pdf

Google Scholar

46. Alarcão, V, Roberto, S, França, T, and Moleiro, C. Standing up for
culturally competent Care in Portugal: the experience of a “health in
equality” online training program on individual and cultural diversity.
Societies. (2022) 12:80. Available at:
https://www.mdpi.com/2075-4698/12/3/80/htm

Google Scholar

47. Dias, SF, Severo, M, and Barros, H. Determinants of health care utilization
by immigrants in Portugal. BMC Health Serv Res. (2008) 8:207. Available at:
http://www.biomedcentral.com/1472-6963/8/207

Google Scholar

48. OCDE. Health at a glance 2021 OECD INDICATORS [internet]. Paris: OCDE
Publishing (2021).

Google Scholar

49. DGS. SNS 24 COVID-19 [Internet]. Doenças Infecciosas. (2022) Available at:
https://www.sns24.gov.pt/tema/doencas-infecciosas/covid-19/

Google Scholar

50. Satinsky, E, Fuhr, DC, Woodward, A, Sondorp, E, and Roberts, B. Mental
health care utilisation and access among refugees and asylum seekers in Europe:
A systematic review. Health Policy. (2019) 123:851–63. doi:
10.1016/j.healthpol.2019.02.007

PubMed Abstract | Crossref Full Text | Google Scholar

51. Bradby, H., Hamed, S., and Lebano, A. The Mig-HealthCare migrants’ access to
healthcare in Europe: A literature review. (2018).

Google Scholar

52. Fauk, NK, Ziersch, A, Gesesew, H, Ward, P, Green, E, Oudih, E, et al.
Migrants and service providers’ perspectives of barriers to accessing mental
health Services in South Australia: A case of African migrants with a refugee
background in South Australia. Int J Environ Res Public Health. (2021) 18:8906.
doi: 10.3390/ijerph18178906

Crossref Full Text | Google Scholar

53. World health Organization. Report on the health of refugees and migrants in
the WHO European region: no public health without refugee and migrant health
World health Organization (2018) Available at:
https://www.euro.who.int/en/publications/abstracts/report-on-the-health-of-refugees-and-migrants-in-the-who-european-region-no-public-health-without-refugee-and-migrant-health-2018.

Google Scholar

54. Spiritus-Beerden, E, Verelst, A, Devlieger, I, Langer Primdahl, N, Botelho
Guedes, F, Chiarenza, A, et al. Mental health of refugees and migrants during
the COVID-19 pandemic: the role of experienced discrimination and daily
stressors. Int J Environ Res Public Health. (2021) 18:6354. doi:
10.3390/ijerph18126354

Crossref Full Text | Google Scholar

55. Serviços Partilhados do Ministério da Saúde. Bilhete de Identidade dos
Cuidados de Saúde Primários [Internet]. (2022) Available at:
https://bicsp.min-saude.pt/pt/Paginas/default.aspx

Google Scholar

56. Instituto Nacional de Estatística. Portal do INE [Internet]. Hospitais (No.)
por Localizaçã0 geográfica (NUTS - 2013) e Natureza institucional: Anual).
(2021) Available at:
https://www.ine.pt/xportal/xmain?xpid=INE&xpgid=ine_indicadores&indOcorrCod=0008101&contexto=bd&selTab=tab2

Google Scholar

57. OCDE. Estado da Saúde na UE: Portugal (2021) [Internet]. Portugal: Perfil de
Saúde do País 2021, Estado da Saúde na UE. Bruxelas. (2021). doi:
10.1787/ae3016b9-en

Crossref Full Text | Google Scholar

58. De Almeida, J, Augusto, GF, and Fronteira, C. Portugal. Port Heal Syst Rev.
Health Systems in Transition. (2017) 19, 1–184.

Google Scholar

59. OECD. State of health in the EU cycle [internet]. Europe: Health at a Glance
(2022) Available from:
https://read.oecd-ilibrary.org/social-issues-migration-health/health-at-a-glance-europe-2022_507433b0-en.

Google Scholar

60. Shaaban, AN, Morais, S, and Peleteiro, B. Healthcare services utilization
among migrants in Portugal: results from the National Health Survey 2014. J
Immigr Minor Health. (2019) 21:219–29. doi: 10.1007/s10903-018-0744-3

PubMed Abstract | Crossref Full Text | Google Scholar

61. Pinto, S. A satisfação profissional dos médicos dentistas em Portugal:
estudo de comparação entre o serviço público (Serviço Nacional de Saúde) e
privado. [Vila Nova de Gaia]: ISLA (Gaia) - Instituto Politécnico de Gestão e
Tecnologia. (2020)

Google Scholar

62. Direção-Geral da Saúde. Programa Nacional de Promoção da Saúde Oral
2021–2025 [Internet]. Lisboa: (2021) Available at: www.dgs.pt.

Google Scholar

63. Alto Comissariado para as Migrações. Serviço de Tradução Telefónica (STT)
[Internet]. (n.d.) Available at:
https://www.acm.gov.pt/ru/-/servico-de-traducao-telefonica

Google Scholar

64. Radl-Karimi, C, Nielsen, DS, Sodemann, M, Batalden, P, and von Plessen, C.
“When I feel safe, I dare to open up”: immigrant and refugee patients’
experiences with coproducing healthcare. Patient Educ Couns. (2022) 105:2338–45.
doi: 10.1016/j.pec.2021.11.009

PubMed Abstract | Crossref Full Text | Google Scholar

65. Cu, A, Meister, S, Lefebvre, B, and Ridde, V. Assessing healthcare access
using the Levesque’s conceptual framework– a scoping review. Int J Equity
Health. (2021) 20:116–4. doi: 10.1186/s12939-021-01416-3

PubMed Abstract | Crossref Full Text | Google Scholar

66. Bowling, A. Research methods in health: Investigating health and health
services. McGraw Hill Education: Fourth edi. Open University Press (2002).

Google Scholar



Keywords: refugees, migrants, health care access, COVID-19, Portugal

Citation: Portela V, Hamwi S and Oliveira Martins MR (2024) Exploring refugees’
health care access in times of COVID-19: a quantitative study in the Lisbon
region, Portugal. Front. Public Health. 12:1337299. doi:
10.3389/fpubh.2024.1337299

Received: 12 November 2023; Accepted: 04 January 2024;
Published: 29 January 2024.

Edited by:

Shela Hirani, University of Regina, Canada

Reviewed by:

Palmira Immordino, University of Palermo, Italy
Solvig Ekblad, Karolinska Institutet (KI), Sweden
M. Alvi Syahrin, Immigration Polytechnic, Indonesia

Copyright © 2024 Portela, Hamwi and Oliveira Martins. This is an open-access
article distributed under the terms of the Creative Commons Attribution License
(CC BY). The use, distribution or reproduction in other forums is permitted,
provided the original author(s) and the copyright owner(s) are credited and that
the original publication in this journal is cited, in accordance with accepted
academic practice. No use, distribution or reproduction is permitted which does
not comply with these terms.

*Correspondence: Vanessa Portela, nessyport@hotmail.com



Disclaimer: All claims expressed in this article are solely those of the authors
and do not necessarily represent those of their affiliated organizations, or
those of the publisher, the editors and the reviewers. Any product that may be
evaluated in this article or claim that may be made by its manufacturer is not
guaranteed or endorsed by the publisher.




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