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The incidence of cancer in Europe has been increasing in recent years. Despite this, cancer prevention has remained a low priority in health policies. Cancer is one of the main causes of mortality among people experiencing homelessness, who continue to have difficulties accessing prevention programs. A strategy that has been tested to favor cancer prevention is the health navigator figure. The objective of CANCERLESS project is to implement this model among populations experiencing homelessness in four European countries to foster the prevention and early detection of cancer. In this perspective, a presentation of CANCERLESS project is made, and its ethical aspects are discussed according to the ethics of public health, the ethics of care, solidarity, relational autonomy, and the social recognition of the virtue of just generosity. The ethical foundations of CANCERLESS project are rooted in social justice and in equity in access to health systems in general and cancer screening programs in particular. The ethics of public health guided by utilitarianism are insufficient in serving the interests of the most disadvantaged groups of the population. Hence, it is necessary to resort to relational bioethics that includes the ethics of care and solidarity and that recognizes the moral identity of socially excluded persons, reaffirming their position of equality in society. Relational autonomy therefore provides a broader conception by including the influence of living conditions in decisions. For this reason, the CANCERLESS project opts for a dialogue with those affected to incorporate their preferences and values into decisions about cancer prevention.

Abstract Background There is increasing attention paid to the arrival of migrants from outwith the EU region to the European countries. Healthcare that is universally and equably accessible needs to be provided for these migrants throughout the range of national contexts and in response to complex and evolving individual needs. It is important to look at the evidence available on provision and access to healthcare for migrants to identify barriers to accessing healthcare and better plan necessary changes. Methods This review scoped 77 papers from nine European countries (Austria, Cyprus, France, Germany, Greece, Italy, Malta, Spain, and Sweden) in English and in country-specific languages in order to provide an overview of migrants’ access to healthcare. The review aims at identifying what is known about access to healthcare as well as healthcare use of migrants and refugees in the EU member states. The evidence included documents from 2011 onwards. Results The literature reviewed confirms that despite the aspiration to ensure equality of access to healthcare, there is evidence of persistent inequalities between migrants and non-migrants in access to healthcare services. The evidence shows unmet healthcare needs, especially when it comes to mental and dental health as well as the existence of legal barriers in accessing healthcare. Language and communication barriers, overuse of emergency services and underuse of primary healthcare services as well as discrimination are described. Conclusions The European situation concerning migrants’ and refugees’ health status and access to healthcare is heterogeneous and it is difficult to compare and draw any firm conclusions due to the scant evidence. Different diseases are prioritised by different countries, although these priorities do not always correspond to the expressed needs or priorities of the migrants. Mental healthcare, preventive care (immunization) and long-term care in the presence of a growing migrant older population are identified as priorities that deserve greater attention. There is a need to improve the existing data on migrants’ health status, needs and access to healthcare to be able to tailor care to the needs of migrants. To conduct research that highlights migrants’ own views on their health and barriers to access to healthcare is key.

Dental and oral health are considered among the main health issues for migrants and refugees, as access to dental health care services is often expensive and difficult. The study investigates dental and oral health determinants among migrants and refugees in 10 European countries (Austria, Bulgaria, Cyprus, France, Germany, Greece, Italy, Malta, Spain, and Sweden), examining how mental health, legal status, discrimination issues and dental services’ use frequency affect dental health. Methods: A cross sectional study using a purpose-made questionnaire was carried out to assess health status and access, with a dedicated section to measure self-perceived dental health, prevalence of caries, last visit to dentist and anticipated access to dental health services. Multivariable logistic regression models were performed to investigate the impact of quality of life, discrimination, immigration status, and other demographic factors on dental health. Results: About half of the sample suffered from poor dental condition and 22% had never visited a dentist. Migrants with higher educational levels had higher odds of having good dental health (OR = 1.08; 95%CI (1.03, 1.12)) and brushing their teeth daily (OR = 1.1; 95%CI (1.04, 1.17)). Higher general and mental health scores were indicative of better dental condition (general health: OR = 1.02; 95%CI (1.01, 1.03); mental health: OR = 1.01; 95%CI (1.004, 1.02)) and higher probability of daily teeth brushing (general health: OR = 1.02; 95%CI (1.01, 1.03); mental health: OR = 1.02; 95%CI (1.01, 1.03)). The possession of any kind of legal immigration permission and not having any children showed similar results. Age and discrimination were correlated with decreased likelihood for good dental conditions. Gender was correlated with daily teeth brushing, as female migrants had higher odds of brushing their teeth daily. Conclusions: Many migrants report poor dental health. Nonetheless, migrants with higher education levels, legal immigration status, better general and mental health, no children, lower sense of discrimination, younger age, and regular dental visits were positively correlated to good dental health (perceived as no dental caries).

In response to the coronavirus disease 2019 (Covid-19) world pandemic, affected countries such as Spain enacted measures comprising compulsory confinement as well as restrictions regarding free movement. Such measures likely influence children's and adolescents' lifestyles. Our study aimed to investigate the impact that the Covid-19 confinement has on health-related behaviors (HRBs) among Spanish children and adolescents. An online survey was administered to 516 parents to collect data about 860 children and adolescents (49.2% girls) aged between 3 and 16 years in relation to physical activity, screen exposure, sleep time, and fruit and vegetable consumption during the Covid-19 confinement. Respectively, t-paired test and t-test between groups served to check differences between HRBs levels before and during the confinement as well as between strict and relaxed confinement. Significant differences were found for a reduction of weekly minutes of physical activity during the confinement (−102.5, SD 159.6) (p < 0.001), an increase of daily hours of screen exposure (2.9, SD 2.1) (p < 0.001), and a reduction of daily fruit and vegetable consumption (−0.2, SD 1.6) (p < 0.001). Sleep time showed a significant difference between strict and relaxed confinement (−0.3, SD 0.1) (p < 0.05), whereas binomial logistic regression adjusted for covariates (age, sex, education of the parents, siblings, current condition, exposure to Covid-19, and previous health risk behavior) showed significantly lower odds for screen exposure risk behavior with relaxed confinement (OR 0.60, 95%CI 0.40–0.91). The present study suggests that Covid-19 confinement reduced physical activity levels, increased both screen exposure and sleep time, and reduced fruit and vegetable consumption. Therefore, most HRBs worsened among this sample of Spanish children and adolescents. Closure of schools, online education, and the lack of policies addressing the conciliation between labor and family life could have played an important role in HRBs worsening among pupils, which might be mitigated with adequate conciliation policies, parental guidance, and community support.

Freely available healthcare, universally accessible to the population of citizens, is a key ideal for European welfare systems. As labor migration of the twentieth century gave way to the globalized streams of the twenty-first century, new challenges to fulfilling these ideals have emerged. The principle of freedom of movement, together with large-scale forced migration have led to large scale movements of people, making new demands on European healthcare systems which had previously been largely focused on meeting sedentary local populations' needs. Drawing on interviews with service providers working for NGOs and public healthcare systems and with policy makers across 10 European countries, this paper considers how forced migrants' healthcare needs are addressed by national health systems, with factors hindering access at organizational and individual level in particular focus. The ways in which refugees' and migrants' healthcare access is prevented are considered in terms of claims based on citizenship and on the human right to health and healthcare. Where claims based on citizenship are denied and there is no means of asserting the human right to health, migrants are caught in a new form of inequality.

Access to healthcare impacts in health, and for its importance it has been conceptualized by different theoretical models. Theories tackling social barriers have been established too. Nevertheless, a lack of theorization about healthcare access of immigrants exists, and there is no theory able to integrate all the scientific literature on this and its impact on the health of immigrants. In order to study the factors relating to the access of immigrants and to guide the development and evaluation of public health interventions, an integrative approach is needed. In this regard, from an ecological perspective healthcare access of immigrants would be shaped by interrelated factors in different layers in a hierarchical system. This study is not aimed to re-invent the wheel, this is a proposal to re-organize the factors playing a role in the access to healthcare for immigrants and modelling them to propose an integrative framework to guide future research and policies. A qualitative design based on four focus groups were being carried out in Valencia (Spain). In the focus groups, 28 agents involved in healthcare provision participated. Based on the ecological model five-levels have guided a heuristic analysis: 1) Patient-level, 2) The relationship between patient-health professionals level, 3) Institutions influencing the healthcare access level, 4) Connectedness between services, community organisations and social networks level, 5) Socio-political Level. The results are presented by level: 1) Patient-level: the factors determining a role in healthcare access are gender inequities, country of origin, language proficiency, health literacy and acculturation process. 2) The relationship between patient-health professionals level: The cultural competence, racist attitudes and willingness to provide care of health professionals are determinants of healthcare access. 3) Institutions influencing the healthcare access level: The availability of resources as public culturally adapted information and interpreters and cultural mediators facilitate access to care. 4) Connectedness between services, community organisations and social networks level: how the service is integrated into the community, developing and providing services plays a key role to guarantee the accessibility. 5) Socio-political Level: Racism are cultural elements that promote the inclusion or exclusion of immigrants, influencing the rest of levels presented. The legislation establishes definitions of who is beneficiary of the healthcare, giving rights or not. Also, policies define the kind of service that is provided to whom and the co-payment. This study brings to light the harmony among the different scientific literature that would have been focused on comparing factors from one single level without taking into consideration the differences among all the rest of levels. The ecological framework also suggests that to guarantee access to health services, it is necessary to act through multiple levels of the model at the same time. Further research is needed to explore the relationship between different factors to design more integrative policies and interventions to guarantee equality in healthcare access. Also, the relationship among both origin and host health systems should be explored in order to recognise the factors influencing fully healthcare access of immigrants such as sharing personal medical records.

In Spain, shelters are the main public resource to provide housing to homeless people. The shelters provide housing to two target groups: local people who have been in an exclusion process that led them to homelessness, and an immigrant population consisting of mostly newcomers to the country and have no place to stay. In this regard, homelessness has been associated with poor health, morbidity and earlier mortality, but there is a lack of studies conducted comparing local and immigrant homeless populations. The “healthy immigrant effect” explains that immigrants arriving in the host country are, on average, healthier than comparable natives and that the length of time since immigration reduces this advantage. In this regard, the evidence shows that homeless newcomers are generally healthier than homeless locals and may have different service needs. This study aims to examine the relationship between immigrant status and the health status of homeless people in Valencia (Spain). Recruitment took place from August to September 2018 (ongoing). The sample consists of 80 homeless individuals recruited at shelters. Chi-square analyses were performed to examine the relationship between immigrant status and health status (assessed by whether they have no, one or more than one chronic conditions). The preliminary results show a relationship between immigration status and the number of chronic conditions they report. Specifically, the occurrence of comorbid conditions (more than one chronic condition) was more prevalent in the local homeless population compared to the immigrant homeless population. Although the impact of homelessness on health has been studied previously, the results of this study highlight the importance of continuing to evaluate the specific needs of the different homeless populations. In this regard, the results also support the “healthy immigrant effect”; comorbid health conditions were more prevalent in the local homeless population compared to the recent immigrant homeless population. These findings also may have implications for services organisation, highlighting the need to develop health and social care programmes tailored to newcomers, in order to avoid further risk factors associated with homelessness and its future deterioration in health.

Abstract Background People experiencing homelessness (PEH) are known to be at higher risk of adverse health outcomes and premature mortality when compared to the housed population and often face significant barriers when attempting to access health services. This study aimed to better understand the specific health care needs of PEH and the barriers and facilitators associated with their timely and equitable access to health services in the European context. Methods We conducted an exploratory cross-national qualitative study involving people with lived experience of homelessness and health and social care professionals in Austria, Greece, Spain, and the UK. A total of 69 semi-structured interviews comprising 15 social care professionals, 19 health care professionals, and 35 PEH were completed, transcribed, and analysed thematically. Results Findings were organised into three overarching themes relating to the research question: (a) Health care needs of PEH, (b) Barriers to health care access, and (c) Facilitators to health care access. Overall, the general health of PEH was depicted as extremely poor, and mainstream health services were portrayed as ill-equipped to respond to the needs of this population. Adopting tailored approaches to care, especially involving trusted professionals in the delivery of care, was identified as a key strategy for overcoming existing barriers. Conclusions The results of this study indicate there to be a high degree of consistency in the health care needs of PEH and the barriers and facilitators associated with their access to health care across the various European settings. Homelessness in itself is recognized to represent an essential social determinant of health, with PEH at risk of unequal access to health services. Changes are thus required to facilitate PEH’s access to mainstream primary care. This can also be further complemented by investment in ‘in-reach’ services and other tailored and person-centred forms of health care. Trial registration This study was registered retrospectively on June 6, 2022, in the registry of ClinicalTrials.gov under the number NCT05406687.

Summary: Background: People experiencing homelessness (PEH) have a higher prevalence of adverse health outcomes and premature mortality compared to the non-homeless population. These include a higher burden of cancer and cancer-specific morbidity and mortality—outcomes that may be a consequence of significant barriers to accessing primary and secondary prevention and community health services. This study aimed to better comprehend the health needs and barriers to accessing preventive cancer care for PEH across four European countries as well as necessary considerations for developing interventions around cancer prevention for this population. Methods: In this exploratory qualitative study, 69 semi-structured interviews were conducted across Austria, Greece, Spain, and the UK, with a sample comprising 15 professionals working in homelessness support services, 19 health professionals, and 35 PEH. Interviews took place between August 1 and October 31, 2021, and data were analysed inductively and iteratively following a thematic approach. Findings: Findings were organised into two overarching themes: (1) Experiences and understanding of cancer prevention and treatment and (2) Considerations for program interventions. While cancer was a significant worry among PEH across all settings, they generally had minimal knowledge and understanding of cancer symptoms and prevention. Specific programs for cancer prevention for PEH were described as almost non-existent. Health professionals in some settings indicated that cancer in PEH was often missed in the early stages and instead diagnosed when the severity of symptoms intensified. Interpretation: Overall, our findings indicate many commonalities in the health needs of PEH and the barriers they face when they seek access to cancer-specific healthcare services in the European context. Funding: This study received funding from the European Union’s Horizon 2020 Research and Innovation Programme under GA 965351.

Introduction Homelessness is a complex social issue that significantly impairs the health of those affected. People experiencing homelessness (PEH) have a higher prevalence of adverse health outcomes, including premature mortality, compared with the general population, with cancer being the second-leading cause of death. The objective of this scoping review is to map the evidence to assess the exposure of PEH to known cancer risk factors and identify barriers and facilitators PEH experience in accessing cancer prevention services.Methods and analysis This scoping review will be conducted in line with the Joanna Briggs Institute guidelines for scoping reviews. For a time window from the date of database establishment until 20 February 2023, the research team will create a detailed search strategy and apply it to the following databases: CINAHL, Embase, Global Index Medicus, PubMed, Scopus and Web of Science. In addition, we will search OpenGrey and Google for grey literature and contact non-governmental organisations to request relevant reports. In the first stage, eligibility criteria will be assessed through a blinded title/abstract assessment, and following this assessment, a full-text screening will be performed. Subsequently, the research team will perform the data extraction and synthesise all relevant information in relation to the scoping review question.Ethics and dissemination As this protocol does not involve gathering primary data, ethical approval is not necessary. The results of this review will be published in a peer-reviewed journal and on institutional websites.