Tuberculosis and Migrant Pathways in an Urban Setting: A Mixed-Method Case Study on a Treatment Centre in the Lisbon Metropolitan Area, Portugal
Abstract
:1. Introduction
2. Materials and Methods
2.1. Study Setting
2.2. Study Design
2.3. Data Collection and Analysis
- Migrant—a person who is born outside Portugal independently of legal status. In Portugal TB in foreign-born citizens is accounted by country of birth.
- Recent migrant—a migrant being diagnosed with TB within a 2 year-period following arrival in Portugal [TB diagnosis within two years following arrival (yes)]
- Long-term migrant—a migrant being diagnosed of TB after 2 year-period following arrival in Portugal. [Total TB foreign-born per year minus TB diagnosis within two years following arrival]
- Autochthonous TB–TB in Portuguese-born individuals.
2.4. Ethical Considerations
3. Results
3.1. Secondary Quantitative Data Analysis
3.2. Primary Qualitative Data Analysis
“They could give me medication not appropriate for me… I have heard of people… taking medication not appropriate for their pathology and having consequences, sometimes even more serious… it was the case of my father, he almost died… these issues I have seen there, made me risk everything and come to check what is going on with me, to be sure. Then I thought about Portugal”.(P1)
“(…) In Senegal… they gave me treatment and I felt better, I thought everything was fine, but then I continued with pain, it got worse, I could not even get out of bed in the morning, walk, or work, and then I came here”.(P4)
“If it wasn’t through Primary Health Care it would be too expensive, and I could not make it…”[P10 took advice from a friend]
“Private clinics… there you go ask for an appointment, the doctor comes register things, you go, you have results, the doctor explains it, then you go on with other things…”(P8)
“I chose Portugal because here I know how to speak the language, and also because it is the country which colonised Guinea-Bissau, I have more rights here than in other countries…”(P3)
“I thought about Portugal as the easiest… I have family here and the local language is Portuguese… there is a connection… we have a very good impression as people doing consultations return, cured, healed… I saw myself in this condition, I came to have a good consultation and get cured”(P1)
“I was not so worried, as if I were in Angola… I would have thought “I will die tomorrow”. As I was here, I did not worry… I felt taken care of…”(P2)
“There… if you don’t have someone in the family who is a doctor, or someone important… you die easily”.(P7)
“Many times, we just have the consultation itself… there is no medicine in the hospital, and sometimes even syringes, needles, alcohol to disinfect… patient’s family has to buy it in the pharmacy out of the hospital and it is very complicated… we must buy all disposable materials”(P5)
“To give birth I prefer the clinic, there is a better service because you are going to pay… in the public hospital there is no service… they respond badly to people, they don’t help people”.(P4)
“In Angola it was difficult… to acquire medicines was a fight… to get it I would visit several pharmacies, contact anonymous resellers… the prescribed medicines were not available in the pharmacies. Sometimes I would remain 2–3 weeks without medication… and when we had the drugs, medicines were very expensive”.(P1)
“In this hospital… medicine must be given to patients for free, but I think they sold it… you have to do “business” with nurses or technicians … they themselves are the ones taking from the hospital and selling”.(P7)
“To get medicines is the most difficult, people say come “tomorrow”, “tomorrow”, and if you pay, there is medication, especially in the case of TB, because HIV drugs are still for free”(P10)
“I was not confident; I was not sure… I have seen people sick of TB… but the way it happened to me, to fall and faint, I have never seen it. I was not believing it… because TB on the head, I have never heard of it”(P8)
“Until now they don’t believe it, first they start with my lifestyle-“She eats fruits, eats on time, she takes care” … then I did not have contact with infectiology... We are Africans… they prefer to look at other little things than believe X had TB… even with the report… it worries me until now. Myself I did not believe it was TB”[P11, talking about her workplace]
“I was very scared, lots of fear, of not holding on until here, because I went to the healthcare centre and when I arrived there, I did not say anything to the doctor [HIV diagnosis]. I just told it here. I just said I was sick of tuberculosis… I feel a lot of shame”(P3)
“Everything was upside down, my daughter had to drop school and come here rapidly, financially we had to toughen up to be able to stay here”(P11)
“I cannot deny anything because they said everything was proven by laboratory exams, then I accepted it”(P4)
“In Portugal it is better, there is variety, it is cheaper also [food]… For instance, here people eat meat every day, there is fruit with vitamins. In Guinea [Bissau] we eat meat every 2, 3 or 6 months… only fish, but of low quality. There are vegetables but no fruit. There, it is more expensive, even after money conversion”(P4)
4. Discussion
5. Conclusions
Author Contributions
Funding
Institutional Review Board Statement
Informed Consent Statement
Data Availability Statement
Acknowledgments
Conflicts of Interest
Appendix A. Interview Topic Guide for Semi-Structured Interviews with TB Patients
- Imagine a situation where you got sick (or a family member, your children), how was it? What did you do?
- Regarding the previous situation, where did you search for help? How did you go to the place (transport)? Which exams did you do and how was it (cost, waiting time, complexity)? How did you get the medicines?
- How would you qualify the healthcare you received? (Waiting times, satisfaction…)
- Tell me how was the beginning of this illness episode? How was it for you?
- Where did you search for help? (Consultations, exams, treatment, family support)
- What were the main difficulties you have faced? (Transport, financial, literacy…)
- What has helped you in this process?
- Since you started feeling sick until the doctors told you were sick of tuberculosis how long has it passed? Tell me how did you live this period of your life, how was it for you?
- What did you feel when doctors told you this diagnosis?
- Who was the first person you told the diagnosis? How was it?
- How was it at work?
- What have been the most difficult for you in this process?
- What has helped you the most?
- What do you think about the healthcare you have received? (3 positive and 3 negative aspects)
- Is there something you would like to be different?
- What are the motifs leading you to migrate, can you explain it to me?
- Which reasons influences the choice of Portugal?
- How was the preparation process for the trip (work, visa…)? How long did it take?
- What were the main obstacles that emerged in the process?
- Which help/support did you get? (Work, family, institutions…)
- How was the arrival in Portugal?
- When did you have the first consultation in Portugal? And where was it?
- Did you have to go to the migration office? Tell me how it was.
- In this period, you have been in Portugal, which were the main difficulties you faced? Tell me 2 or 3.
- What has helped you the most?
- What do you miss the most in your country? Are you organizing the return home?
Appendix B
P1 | PHC–CDP Treatment initiation in Angola in private clinic, 2 consultations with 2 different clinicians until diagnosis, 2 months of treatment facing financial and logistic constraints to acquire drugs. Decision to come to Portugal in VFF condition. It takes 1 month in Portugal to search for healthcare. Entry point: primary healthcare whereafter directly referred to CDP, restarting TB treatment. |
P2 | Screening at refugee asylum-ER–H–CDP Symptoms started in Angola, being neglected, and seen as “normal” for months. One consultation was done, and “vitamins” were prescribed. Family imposed travelling to Portugal where the participant entered a refugee asylum. In the context of a screening program, participant presented an abnormal X-ray being referred to the emergency room, then hospitalised, then followed ambulatory consultations and TB treatment was started. |
P3 | PHC–CDP HIV diagnosis was performed in the context of pregnancy in Brazil. Antiretroviral treatment was taken during pregnancy and stopped afterwards, because of perception of good health. Cough symptoms started, 2 months later, initial private healthcare was sought, then referred to public healthcare for hospitalisation with AIDS and TB. Because of lack of family support and difficulties to take care of the baby, participant decided to come to Europe (not Portugal) to regroup with family after hospitalisation. HIV medication was given for three months in order to travel. Language barrier was the main motivation to move to Portugal. Entry point: PHC being directly referred to the CDP and forward referred to HIV consultations. |
P4 | Private clinic–CDP–ER–H–CDP Pain symptoms first appeared in Guinea-Bissau where TB diagnosis was suggested, however there was no trust in the proposed diagnosis. Decision to travel to Dakar-Senegal as VFF, for better healthcare where participant has treated and got partially improved. When symptoms restarted, the decision to come to Portugal was made. Participant came legally through bilateral agreement between countries for treatment of medical conditions (evacuated). HIV was diagnosed once hospitalised in Portugal. Entry point: private clinic where participant followed several medical diagnostic exams being referred to CDP and to the ER, being hospitalised, then referred back to the CDP. |
P5 | ER–H–CDP Studying for master’s degree was the reason to come to Portugal. Six months following arrival, during a period of financial difficulties, symptoms began. Participant resorts directly to the ER of a known hospital (because of studies), being hospitalised. Entry point: ER being hospitalised then referred to the CDP |
P6 | ER–H–CDP The reason to come to Portugal was family re-grouping and the desire to start a new life. Participant was working and living outside Lisbon. The illness process obliged the participant to seek increased family support, causing participant to move to Lisbon. Following a sudden pain episode, after months of feeling sick, participant resorts directly to the ER and was hospitalised. |
P7 | PHC–ER–H–CDP In Angola participant finds out about HIV in the context of health check for the desire of getting pregnant. Antiretroviral treatment was initiated and stopped, by then cough had started but diagnostic studies were inconclusive. Participant decided to restart antiretroviral treatment and gets better. Participant also starts TB medication, but stops as she travels to Portugal, where she had lived previously, with the aim to start a new life with better healthcare conditions. In the context of pregnancy, in Portugal, participant starts to feel sick again. She consults primary healthcare, however as referral takes a long time participant decides to go to the ER, being hospitalised. |
P8 | Ambulance–ER–H–CDP Participant came to Portugal, a frequent travel destination, for shopping and tourism as VFF. In a public place, participant suddenly fell ill (inaugural convulsion), being taken to the ER and then hospitalised. |
P9 | ER–H–CDP In Angola, participant experiences strong backpain while on vacations. Initially private healthcare was sought, and several treatments were given without being effective. Traditional medicine was tried but not effective either. Healthcare proved expensive and ineffective. Thus, participant travelled to Portugal as VFF, in search of better healthcare. Entry point: ER, being hospitalised. |
P10 * | PHC–CDP In Angola HIV positive participant had been previously diagnosed with TB; difficulties in acquiring medication led to treatment discontinuation. Participants’ child was diagnosed of HIV and treatment was initiated. Participant explains strong secondary effect from child’s antiretroviral treatment, reason which motivated travelling to Portugal in search of better healthcare for her child. Participant was advised by a friend, who had experienced good results, to do so. Entry point: primary healthcare then referred to CDP. Participant’s child was hospitalised. |
P11 | Private clinic–ER–H–CDP Cough and fever started, and being a health professional, participant initially sought care via colleagues initiating treatment with little result. Having health professionals as relatives, participant was advised to attend a private healthcare consultation, without effective treatment. They decided to seek specialist healthcare in the capital, Luanda, however as condition worsened, participant decided to come to Portugal where participant was familiar with private healthcare. Following a specialist private consultation, participant was referred to the public system for hospitalisation. Entry point: private consultation then referred to the ER of a public hospital, then hospitalised then referred to the CDP. |
P12 * | PHC–ER–CDP Following belly pain, participant seeks private healthcare in Angola where surgery was proposed but refused, as it was deemed too expensive. Participant had a prebooked flight to Portugal for tourism. Upon arrival, participant felt progressively weaker and attended a consultation in PHC. Participant had lived in Portugal previously. Ambulatory exams were requested in PHC and participant was referred to the ER, then sent home, then returned to the ER, underwent ambulatory exams at hospital level, and was referred to the CDP afterwards. |
P13 | Private clinic–Private ER–Private H–CDP Experiencing cough symptoms and anorexia started years earlier. Participant sought medical consultations in Angola, and in Namibia as VFF, being diagnosed with a mental condition. Symptoms subsequently wore off. Following a chest-X-ray for another reason, participant is advised to travel to Portugal and search for a medical team in a private hospital. Participant is submitted to lung surgery in Portugal and returns to Angola. Follow-up consultation in Portugal took longer than advised, and after one and half years, participant is submitted to a new surgery. A few months after the second surgery, participant runs a high fever, resorts to ER, and is hospitalised in private hospital where TB is suspected, then participant is referred to CDP. |
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Estimated TB Incidence Rate + | # Notified TB Cases | TB-HIV Co-Infection + | TB Treatment Coverage ^ | Treatment Success Rate ~ | |
---|---|---|---|---|---|
Portugal | 16 (13–18) | 1445 | 1.5 (1.2–1.9) | 88% (76–100) | 71% |
Brazil | 45 (38–52) | 82,930 | 5 (4.3–5.8) | 78% (67–91) | 69% |
Cabo Verde | 39 (30–50) | 210 | 5.1 (3.1–7.6) | 95% (75–120) | 89% |
Romania | 64 (54–74) | 7698 | 1.4 (1.1–1.8) | 58% (50–69) | 84% |
Ukraine | 73 (49–102) | 19,521 | 16 (11–22) | 55% (39–82) | 79% |
UK | 6.9 (6.3–7.6) | 4458 | 0.24 (0.09–0.46) | 89% (81–98) | 78% |
China | 59 (50–68) | 633,156 | 0.84 (0.71–0.98) | 74% (64–87) | 94% |
France | 8.2 (7.2–9.2) | 4606 | 0.42 (0.32–0.52) | 83% (73–94) | 12% |
Italy | 6.6 (5.7–7.6) | 2287 | 0.34 (0.19–0.54) | 54% (47–63) | - |
Angola | 350 (225–503) | 66,058 | 41 (26–59) | 55% (38–85) | 69% |
Guinea-Bissau | 361 (234–516) | 2561 | 114 (74–164) | 36% (25–55) | 89% |
2008 | 2009 | 2010 | 2011 | 2012 | 2013 | 2014 | 2015 | 2016 | 2017 | 2018 | TOTAL | |
---|---|---|---|---|---|---|---|---|---|---|---|---|
Portugal | 87 | 94 | 113 | 82 | 100 | 76 | 115 | 112 | 111 | 76 | 65 | 1031 |
Guinea-Bissau | 21 | 19 | 22 | 28 | 27 | 15 | 21 | 30 | 25 | 27 | 18 | 253 |
Cabo Verde | 19 | 23 | 24 | 26 | 23 | 24 | 17 | 19 | 16 | 24 | 11 | 226 |
Angola | 13 | 15 | 17 | 18 | 24 | 14 | 16 | 19 | 27 | 31 | 20 | 214 |
S. Tomé | 2 | 4 | 5 | 0 | 4 | 1 | 7 | 3 | 2 | 3 | 3 | 34 |
Brazil | 2 | 6 | 6 | 3 | 2 | 2 | 4 | 1 | 1 | 6 | 1 | 34 |
Mozambique | 2 | 2 | 3 | 4 | 5 | 1 | 4 | 2 | 1 | 1 | 3 | 28 |
Others | 3 | 2 | 6 | 7 | 12 | 9 | 11 | 10 | 5 | 5 | 8 | 78 |
TOTAL | 149 | 165 | 196 | 168 | 197 | 142 | 195 | 196 | 188 | 173 | 129 | 1898 |
Country of Origin | TB Type | Risk Factor | Legal Status | Reason to Come | Entry Point | |
---|---|---|---|---|---|---|
P1 | Angola | P | - | SDD | Health | PHC |
P2 | Angola | Pleural | - | SDD | Live | Screening |
P3 | Guinea-B | Ganglionar | HIV | SDD | Health | PHC |
P4 | Guinea-B | Bone/miliar | HIV | SDD | Health | Private clinic |
P5 | Angola | Pleural | - | User number | Live/Study | ER |
P6 | Guinea-B | P | - | User number | Live | ER |
P7 | Angola | Peritoneal | HIV | User number | Health/Live | PHC |
P8 | Guinea-B | Disseminated | - | User number | Tourism | Ambulance |
P9 | Angola | Bone | - | SDD | Health | ER |
P10 * | Angola | P | HIV | SDD | Health | PHC |
P11 | Angola | P | Health p | SDD | Health | Private clinic |
P12 * | Angola | Pleural | - | User number | Tourism | PHC |
P13 | Angola | Pleural | - | User number | Health | Private clinic |
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Ribeiro, R.M.; Gonçalves, L.; Havik, P.J.; Craveiro, I. Tuberculosis and Migrant Pathways in an Urban Setting: A Mixed-Method Case Study on a Treatment Centre in the Lisbon Metropolitan Area, Portugal. Int. J. Environ. Res. Public Health 2022, 19, 3834. https://doi.org/10.3390/ijerph19073834
Ribeiro RM, Gonçalves L, Havik PJ, Craveiro I. Tuberculosis and Migrant Pathways in an Urban Setting: A Mixed-Method Case Study on a Treatment Centre in the Lisbon Metropolitan Area, Portugal. International Journal of Environmental Research and Public Health. 2022; 19(7):3834. https://doi.org/10.3390/ijerph19073834
Chicago/Turabian StyleRibeiro, Rafaela M., Luzia Gonçalves, Philip J. Havik, and Isabel Craveiro. 2022. "Tuberculosis and Migrant Pathways in an Urban Setting: A Mixed-Method Case Study on a Treatment Centre in the Lisbon Metropolitan Area, Portugal" International Journal of Environmental Research and Public Health 19, no. 7: 3834. https://doi.org/10.3390/ijerph19073834