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Mixed methods study protocol to explore acculturation, lifestyles and health of immigrants from the Community of Portuguese-Speaking Countries in two Iberian contexts: how to face uncertainties amidst the COVID-19 pandemic
  1. Daniela Alves1,2,
  2. Isabel Craveiro1,2,
  3. Nekane Basabe3,
  4. Luzia Gonçalves1,2,4
  1. 1Global Health and Tropical Medicine, Instituto de Higiene e Medicina Tropical, Universidade Nova de Lisboa, Lisboa, Portugal
  2. 2Unidade de Saúde Pública Internacional e Bioestatística, Instituto de Higiene e Medicina Tropical, Universidade Nova de Lisboa, Lisboa, Portugal
  3. 3Department of Social Psychology and Methodology of Behavioural Sciences, Faculty of Pharmacy, Universidad del País Vasco, Vitoria, Spain
  4. 4Centro de Estatística e Aplicações da Universidade de Lisboa, Lisboa, Portugal
  1. Correspondence to Luzia Gonçalves; LuziaG{at}


Introduction Studies which focus on the process of acculturation in the lifestyles, nutritional status and health of immigrants from the Community of Portuguese-Speaking Countries (CPLP) in the Iberian Peninsula are still scarce. This study aims to explore the influence of the acculturation process and dietary acculturation on the lifestyle and nutritional and health status of CPLP immigrants in Portugal and Spain, focusing on two Iberian contexts: Lisbon Metropolitan Area and the Basque Country.

Methods and analysis A mixed methods sequential explanatory design, combining cross-sectional studies and semistructured interviews. Official data will also be analysed. Primary data will be collected through a questionnaire and assessment of nutritional status and body composition. The estimated samples sizes are 1061 adults (≥18 years old) in the Lisbon Metropolitan Area and 573 in the Basque Country. Time-location sampling will be used for the quantitative component and non-probabilistic sampling for the qualitative component. If safety conditions are not guaranteed due to the COVID-19 pandemic, online studies will be conducted. The semistructured interviews will complement the questionnaire data and extend knowledge about the process of acculturation of CPLP immigrants and their relationship with eating habits and physical activity. Thematic analysis will be used for qualitative data. Triangulation of data derived from different methods will be carried out. An integrative approach will be used to address potential discrepancies in findings and limitations inherent to the study design. As inter-method discrepancies may occur, triangulation protocol will be used, elaborating a ‘convergence coding matrix’ to display findings emerging from each component of the study.

Ethics and dissemination Ethical approval was obtained through the IHMT Ethics Council (Doc No 20/2020), Portugal, and it was submitted to the Ethics Committee of the UPV/EHU (Doc No under revision), Spain.

  • public health
  • nutrition & dietetics
  • statistics & research methods

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Strengths and limitations of this study

  • This research will use mixed methods to obtain quality data to deepen the knowledge of the phenomenon of acculturation and its relationship with the lifestyles, nutritional and health status of Community of Portuguese-Speaking Countries (CPLP) immigrants in the two Iberian contexts, providing indicators for an adequate response to their health needs.

  • To better understand if the language of the host country can favour the process of acculturation and, consequently, the lifestyle and health of CPLP immigrants.

  • In current COVID-19 pandemic context, assessment of body composition by a nutritionist can be compromised.

  • Samples may not be representative of the entire migrant population from all CPLP countries in both contexts.


‘Good Health and Well-Being’ is one of the Agenda 2030 Sustainable Development Goals and migration is crucial for meeting this agenda.1–4 Migration is the movement of people from their usual residence to another place, within a country or state or across international borders to another country, region, or continent, according, according to the definition of International Organization to Migration.5 The same source defines an immigrant from the perspective of the country of arrival, a person who moves into a country other than that of his or her nationality or usual residence, so that the country of destination effectively becomes his or her new country of usual residence.5 Migration has increased in recent decades in Europe.6 7 According to the United Nations, roughly 82 million migrants lived in Europe in 2019.7

Migrants play an important role in population growth, counteracting population ageing and making an essential contribution to the sustainability and economic development of their arrival countries.8 9 On the other hand, they are considered a vulnerable population group in terms of physical, mental and social health.6 10–13 Thus, public health policies of the host countries must pay particular attention to the health of immigrants.3

The concept of acculturation, associated with migration, is a process by which a group, usually a minority, learns and/or adopts cultural patterns (values, norms, ideas, behaviours) from a dominant group,14–18 which may result in the genesis of a new culture that brings together elements from the two original cultures.14–19 Berry19 defined four acculturation strategies: (1) separation (high affiliation to the original culture, low affiliation to the new culture); (2) assimilation (high affiliation to the new culture, low affiliation to the original culture); (3) integration (high affiliation to both cultures); and (4) marginalisation (low affiliation to cultures).

Dietary acculturation is the process by which immigrants adopt the dietary practices of the host country.20 21 Satia20 21 mentions some factors that influence the process of dietary acculturation such as: age, gender, education, professional situation, language, the composition and size of the household, number of children, income, place of residence, access to foods, access to traditional supermarkets, beliefs regarding diet and health, social integration, exposure to the culture of the host country and level of nutritional transition in the country of origin.

Regarding the influence of sociodemographic and economic factors in the process of acculturation, in general, women reveal more difficulties in the adaptation process to the host country, especially when origin and destination cultures are very different.22–24 Adult or older people have greater difficulties in adapting to the host country.22–25 Immigrants with higher education and income have higher acculturation levels.22–25 Language proficiency and cultural proximity are also associated with higher acculturation levels.23–26 Acculturation process and dietary acculturation are associated with lifestyle and nutritional status, and consequently, with the health of migrants.10 11 15 Some findings in the literature on this topic are controversial, describing both positive and negative impacts on the health of immigrants.3 10 27–34

The Community of Portuguese-Speaking Countries (CPLP) includes nine countries: Angola, Brazil, Cabo Verde, Guinea-Bissau, Equatorial Guinea, Mozambique, Portugal, São Tomé and Príncipe, and Timor-Leste.35 Its population totals more than 291 million inhabitants36 37 and occupies a total area of 10 742 000 km² spread over the four continents (7.2% of the planet Earth).35 In addition to sharing the Portuguese language (in the majority of their countries), CPLP represents centuries of collective history, commercial, military, political and cultural exchanges, despite the enormous physical distance between geographical spaces and peoples. The Portuguese language is one of the most widespread languages in the world.38 It remains, today, a major language of international communication and has strong geographical projection, destined to increase.38 In terms of social integration, as mentioned above, the literature points out that cultural proximity and fluency in the language of the destination country, and the ability to learn it, increase the immigrant’s success in the host country.26 39–41 Thus, CPLP immigrants in Portugal may benefit from the process of acculturation.

Portugal and Spain are important destinations for CPLP immigrants. In Portugal in 2019, the foreign resident population totalled 590 348 citizens (an increase of 22.9% compared with 2018).42 Seven out of 10 municipalities with the largest number of foreign citizens registered in Portugal belong to the Lisbon Metropolitan Area (LMA) (236 113 citizens).42 In Spain, in the same year, the number of foreigners with a registration certificate or residence card was 5 663 348.43 In 2018, women of foreign nationality were responsible for 11% of births in Portugal44 and 20.8% in Spain.45 These percentages are important because in 2018 the foreign population represented only 4.7% and 10.7% of the total population resident in Portugal and Spain, respectively.44 46

Portugal, which is part of the CPLP, due to its historical connections, is the host country for many immigrants from this community.47 48 As regards Spain, including the Basque Country (BC), the majority of foreign immigration is essentially from other countries in Europe, Latin America (including Brazil) and North Africa (mostly of Moroccan origin).49 50

To our knowledge, research studies about the relationship between acculturation and lifestyle, nutritional status and health of migrants in this community are still scarce.51 In addition, no studies were found about this topic comparing the two Iberian countries (Portugal and Spain). Regarding health indicators and nutritional status, in both countries, cardiovascular diseases were the main cause of death.52 53

Approximately one-third of all deaths in Portugal and Spain are attributed to behavioural factors such as tobacco and alcohol consumption, dietary risks and low levels of physical activity.52 53 The prevalence of overweight and obesity in the Iberian Peninsula is over 60%.54 55 Goulão et al51 assessed the nutritional status of CPLP immigrants in Portugal with percentages of overweight and obesity ranging from 35.1% to 50.8%. Information about this immigrant community in Spain is even more scarce. A study carried out in Madrid with immigrants from Equatorial Guinea reports prevalence values of obesity of 11.0% in men and 23.2% in women.30 In the BC, overweight and obesity among immigrants from Latin America (including Brazilian participants) were over 34% and 6%, respectively.56

Understanding the process of acculturation and dietary acculturation may be a step towards promoting the health of immigrant communities in the two European countries.57–59


The main objective is to explore the influence of the acculturation process and dietary acculturation on the lifestyle and nutritional and health status of CPLP immigrants in Portugal and Spain, focusing on two Iberian contexts: LMA and the BC.

The specific objectives of the study are: (1) to understand the acculturation process and the dietary acculturation of the CPLP immigrants in LMA and BC; (2) to analyse the lifestyles (eating habits, physical activity and toxic habits) of CPLP immigrants in LMA and BC; (3) to characterise the health status and occurrence of chronic diseases among CPLP immigrants in LMA and BC; (4) to understand the influence of acculturation strategies on overweight and obesity (using reported and measured data) and self-report of non-communicable chronic diseases in LMA and BC; (5) to understand differences and similarities in lifestyles, nutritional and health status among immigrants from different countries of the CPLP, analysing differences by sex; (6) to compare acculturation strategies, lifestyles, nutritional and health status between CPLP immigrants who live and/or work in LMA and CPLP immigrants who do not live and/or work in LMA; (7) to explore potential changes in lifestyle and body weight reported by immigrants in the confinement period during the COVID-19 pandemic; and (8) to promote integrated results that enhance the knowledge of CPLP immigrants in the two Iberian contexts, with a focus on lifestyles, nutritional status and health according to the experienced acculturation process.



This research will use a quantitative-qualitative design through cross-sectional and semistructured interview studies using a mixed methodology approach.60 The global study will be carried out in three phases: (1) application of a questionnaire; (2) body composition measurements, assessment of nutritional status and counselling by a nutritionist; and (3) conducting semistructured interviews (figure 1). The study of body composition will only be carried out if all safety conditions are ensured due to the COVID-19 pandemic. However, reported weight and height data will be collected during the questionnaire.

Figure 1

Study design. CPLP, Community of Portuguese-Speaking Countries.

The data collection will be carried out in November and December 2020 in LMA and during 2021 in BC.

Study locations

The study will be carried out in LMA, Portugal and BC, Spain. LMA is located on the coast of Portugal that includes 18 municipalities in two districts (nine in the Lisbon district and nine in the Setúbal district) with more than 2.8 million inhabitants.61 The official language is Portuguese. BC is located in the northeast of Spain, with around 2.1 million inhabitants,62 composed of three provinces: Álava, Guipúzcoa and Bizkaia. BC has two official languages: Spanish and Euskera.


Adult immigrants from first and/or second generation whose country of origin is part of CPLP and who have currently been living in LMA or BC for at least 6 months. Regarding the foreign population, according to the Portuguese Foreigners and Borders Service, 112 850 and 30 420 immigrants from the CPLP countries, respectively, lived in the district of Lisbon and Setúbal in 2019.42 Brazil and Cabo Verde are the most represented countries. In 2019, official data from the Basque Immigration Observatory indicate 16 025 citizens from CPLP in BC.46 The Portuguese and Brazilian population residing in the BC was the most represented of the CPLP countries in the same year.50

Phase 1: quantitative methods/cross-sectional studies


The inclusion criteria for the participants in the cross-sectional studies are: adult (≥18 years) immigrants from first or second generation whose origin is a CPLP country, who can communicate in Portuguese or, in the case of the BC study, can communicate in Portuguese or Spanish and who have been living for at least 6 months in one of the two Iberian contexts. An immigrant is considered to be first generation if born in the country of origin and a second generation immigrant if born in the host country, but one or both parents were born in the country of origin.32

Sample size

The prevalence of overweight (preobesity and obesity) found in previous studies30 51 56 was considered to calculate the sample size in each context. Assuming that there will be no substantial differences between countries, and considering the estimate that provides a maximum size (p=0.50) for a 95% CI to a proportion with a margin error of 3%, the sample in LMA should have about 1061 participants (corrected for a population of 143 270 CPLP immigrants in the district of Lisbon and Setúbal). In BC, with a margin error of 4%, the estimated sample size is around 580 participants (for a population of 16 025 CPLP immigrants in BC).

Sampling frames will be sought from government and private entities to use random sampling methods.63–66 In case of failure of lists from institutions/organisations, time-location sampling (TLS) will be used.65–67 This sampling method has been developed for hard-to-reach populations such as migrants.65–70 In TLS, the assumption is that it is possible to access the target population in predefined venues and encounters through random sampling of these venues and at different time units (eg, Venue A: Monday, 09:00–18:00; Venue D: Friday, 14:00–17:00, etc).65–70 These venues may be public or private (recreational associations, public service centres, shopping centres, parks, bars, restaurants, cultural events, etc). In each context, a previous ethnographic mapping of the universe of these locations will be made.66 71 Some authorisations will be needed for data collection.

The first participant and the following are chosen randomly from the previously determined time intervals, considering the duration of the questionnaire, the body composition assessment and counselling on nutritional status.

Online study

If it is impossible to collect face-to-face data, due to the COVID-19 pandemic, online surveys will be conducted. Despite the limitations of prefilled online questionnaires,72 the literature described this strategy as valid and effective for the collection of public health data in the context of a pandemic.73–75 It will be possible to access the target population for data collection in a short time, with savings on costs72–75 and complying with the necessary security rules (social distancing).76 Associations of immigrants from CPLP or of another type but who work with this population in both contexts will be contacted to disseminate the questionnaire. They will be contacted by email and/or social media pages to present the project and requested to disclose the questionnaire. To increase the response rate, the principal investigator will disclose the study in groups and social media pages (Facebook, Instagram and LinkedIn) that have some connection and/or carry out work with the migrant population from CPLP. The questionnaire will be available for 2 months in each context.


The questionnaire will be based on existing health questionnaires such as the National Health Survey of Portugal,77 the Basque Country Health Survey78 and acculturation measures used in other studies.16 19 32 79 80 In LMA, the questionnaire will be done in Portuguese. In BC, the option of choosing the language (Spanish or Portuguese) will be given for the questionnaire and the interview.

Seven themes will be included in the questionnaire: (1) spoken and written Portuguese/Spanish language; (2) sociodemographic data; (3) migration (years in the host country and other countries previously); (4) cultural factors (attitude and behaviour acculturation scales79 80 and sociocultural adaptation scale80); (5) health status; (6) lifestyle variables that include issues related to eating habits, level of dietary acculturation,81 physical activity, consumption of alcohol and tobacco and changes resulting from the COVID-19 pandemic); and (7) self-reported anthropometric data (weight and height) and perception of nutritional status. The study phase 1 outcomes are summarised in table 1.

Table 1

Variables and outcomes

Acculturation measures

Accumulation will be measured considering two scales: (1) attitudes of acculturation and (2) behaviours of acculturation regarding the country of origin and the host county proposed by Basabe et al.79 Scales include six items with a Likert-type response ranging from 1 (Nothing) to 5 (Very). Combining these two scales, four acculturation strategies will be defined according to Basabe et al.79 A complementary approach to assess the acculturation level will be based on a score adapted from Alkerwi et al.32 The sum of the three indicators (generation, spoken language and years of immigration) results in an acculturation level, ranging from 1 (less acculturated) to 4 (more acculturated).

Dietary acculturation is based on a scale ranging from 1 to 10 considering the fowling question: ‘How similar are your eating habits here and those you had in your host country or the country of origin of your parents or closest family members?’ The value 1 indicates that the participant has eating habits completely different from his country of origin (first generation) or the country of origin of his parents (second generation). The value 10 indicates the same eating habits. A low change in eating habits is considered if the scores vary between 7 and 10, a moderate change in eating habits for scores of 5 or 6 and a high change in eating habits for scores between 1 and 4.81 In the qualitative component, these and other aspects of the acculturation process will be addressed through complementary and integrative ways, as described further.

Body composition

If the evolution of the COVID-19 pandemic is favourable, anthropometric measurements will be made by a nutritionist, after completing the questionnaire82: height (stadiometer Seca 20-205 cm range), waist circumference (using a measuring tape), weight (kg), fat mass (kg and %), fat-free mass (kg), muscle mass (kg), bone mass (kg) and body water (kg and %) (Tanita SC330S with impedance).83 Derived indices will be calculated from the measured data (eg, body mass index, cardiovascular risk from the waist-height ratio and the nutritional status, according to the definition of the WHO).84–86

The nutritionist will provide information to the participant regarding their nutritional status and brief personalised advice for healthy eating and physical activity. In the case of obesity, the participant will be advised to seek out a nutritionist at the health centre of his residence for detailed monitoring, according to the ethical code for the nutritionist profession in Portugal and Spain.87 88

Secondary data

In each Iberian context, access to official data related to the target population will be requested, with the aim of making a more detailed and comparative analysis within the scope of this study. In Portugal, data will be requested from the following sources: (1) Portuguese National Health Questionnaire, carried out in 2014 and 2019, from the National Statistics Institute, and (2) National Health Survey with Physical Examination, carried out in 2015, from the Instituto Nacional Ricardo Jorge. In BC, information from the Basque Country Health Survey carried out in 2018 will be requested from the health department of the Basque government. The data requested will be sociodemographic characteristics, health status (chronic diseases), health determinants (eating habits, physical activity, consumption of tobacco and alcoholic beverages) and reported nutritional status. In the Portuguese context, information from measured anthropometric data (weight, height and waist and hip circumference) will be requested.

Statistical analysis

The data will be analysed with SPSS V.25.0 and R package. In the first phase, an exploratory and descriptive analysis will be carried out. The second phase will include parametric and non-parametric tests and multivariate analysis with different approaches such as linear log models89–92 to study the interaction between qualitative variables and simple and multiple binary logistic regression models93–95 to identify variables that are associated with a binary outcome. Mediation analyses will be carried out to ascertain whether the relationship between an independent variable and a dependent variable is mediated by a third variable.96 In all analyses performed, statistical assumptions and possible confounding variables will be considered.97–99

Phase 2/3: qualitative studies

The qualitative component aims to complement the results of the cross-sectional studies and deepen knowledge about the process of acculturation and its relationship with lifestyle. It will also be an opportunity to understand how the COVID-19 pandemic affected eating habits and the practice of physical activity.


To participate in the qualitative study, a previous participation in cross-sectional studies is mandatory. In the cross-sectional studies, participants will declare their willingness (or not) to participate in later stages of this research, and will provide a contact (email and/or mobile phone). Other inclusion criteria will be defined after a preliminary analysis of the data obtained in cross-sectional studies such as the level/strategy of acculturation and nutritional status.

Sampling and data collection techniques

Non-probabilistic sampling (convenience sampling) will be adopted from the participants who gave their contact during the questionnaire. Three attempts will be made to contact each participant and formal consent will be requested for participation in this stage.100

Semistructured interviews will be carried out101 102 by video call (eg, Skype, Zoom, WhatsApp, Messenger), if the participant prefers this option. Theoretical saturation sampling will be used to close the final sample size.100

A preliminary semistructured interview guide will be prepared with questions on three major themes: country of origin, acculturation and language, and lifestyles. Regarding the country of origin, second-generation immigrants will be asked about their parents’ country of origin. Regarding acculturation and language, participants will be questioned about the influence (positive or negative) of the languages of the two contexts, as well as other facilitators or barriers encountered in the process of sociocultural adaptation. On the topic of lifestyles, questions will be asked about food preferences, influence of the country of origin and host country on eating habits, alterations of eating habits during the COVID-19 pandemic and barriers to the practice of physical activity (table 1). The interview topic guide will be finalised after the preliminary analysis of data from cross-sectional studies. All documents will be produced in Portuguese and translated into Spanish. In BC, the participant may choose the language in which the interview will be conducted.

Data analysis

The interviews will be transcribed, and the data will be analysed using the content analysis technique.103 104 Thematic analysis will be carried out using phrases or paragraphs as units of analysis.103 104 The units of analysis will be coded in alphanumeric form.100 101 Content analysis will be carried out using the ATLAS.ti software.103 105 106 This software will be used to identify the themes emerging from the data, and this will provide a rich, detailed account of the data set. Themes will be compared by different members of the analysis team until a consensus is reached.

Patient and public involvement

No patient was involved.

Ethics and dissemination

The proposal was submitted and approved by the IHMT Ethics Council (Doc No 20/2020) and by the Ethics Committee of the University of the Basque Country (Doc No under revision). The documents/instruments will be produced in Portuguese and translated into Spanish.

Participants will be previously informed about the objectives and procedures of the study. Participation does not involve risks and no remuneration is foreseen. The confidentiality and anonymity of the participants will be guaranteed.

Informed consent will be requested in the various phases of the study. In the case of conducting the face-to-face study, participants will give their written consent. In the online study, participants will give informed consent on the online platform of the survey.

Availability for participation in the qualitative study will be requested at the end of the survey and, in case of acceptance, there will be a survey field to collect a means of contact (email and/or phone number). This information will be unlinked and later deleted from the questionnaire database and inserted in a file protected with a password.

Regarding the informed consent of the qualitative component, the informed consent form will be previously sent to participants by email, allowing its contents to be read. Oral consent will be collected for all respondents, which will be recorded in the audio file.

The interviews will be transcribed by the doctoral student, providing for the omission or codification of elements that allow the identity of participants to be revealed. The ethical code of the profession of the nutritionist in Portugal and Spain will be fulfilled.87 88 All data and collected information will be saved with a password and will be destroyed after 5 years. We aim to disseminate the findings through national and international conferences, peer-reviewed journals and a doctoral thesis.


This study protocol uses a mixed methods approach to provide a better understanding about the process of acculturation and its relationship with lifestyles, nutritional and health status of CPLP immigrants in two Iberian contexts: the LMA—Portugal and the autonomous community of the BC—Spain. In both contexts, demographics and lifestyles are similar. However, the Portuguese language may help in the process of acculturation for CPLP immigrants in Portugal.

Based on a quantitative study, strategies and levels of acculturation and dietary acculturation will be defined using a questionnaire. The acculturation process will be deepened through a qualitative study in each context, exploring several themes of the interview guide, as how the language influenced (positively or negatively) the acculturation and other potential facilitators or barriers encountered in the sociocultural adaptation to host country. Regarding dietary acculturation, food preferences and the influence of the country of origin and host country on eating habits will be addressed in the qualitative studies. An integrative approach will be used to address several findings from quantitative and qualitative components, for a better understanding of the process of acculturation, including dietary acculturation, and the influence on health, nutritional status and lifestyle.

A possible risk of the study will be the impossibility of carrying out the assessment of body composition due to the pandemic situation. The analysis of the nutritional status measured as defined in the objectives may not be possible to maintain. However, reported weight and height data will be collected. Also reported data from secondary data sources that will be accessed, facilitating the discussion of the results of this study.

Limitations related to cross-sectional studies and the application of the questionnaire such as non-response, recall and social desirability bias will be considered. For the online study, several additional issues may amplify selection bias. Access to the internet may be a critical issue in some migrant communities. Even for those participants with good access to web platforms, the lack of a single internet registration, the possibility of a single internet user answering the questionnaire several times, opening date and closing date to the online survey, among others, bring difficulties to quantify the exact number of users reached, non-responses and also the characteristics of users who respond or do not respond.107 108 In general, this is a serious concern, but sometimes a bias due to non-response can be reduced by applying correction techniques such as adjustment weighting.109 On the other hand, immigrants are a hard-to-reach population, therefore an online study is a cheap and quick way to reach this population in safety conditions for COVID-19. TLS presents also well-established limitations.66 70 Thus, generalisation of the findings may be compromised because it is difficult to obtain representative samples of the CPLP immigrants in both contexts.

The limitations of the qualitative component include, among others, prejudice and bias of the researcher, effects of observers and potential constraints on the replication of the study. There may be difficulties in transferring results from qualitative methods

Limitations derived from mixed methods will be the long time required for data collection and possible difficulty to integrate all results.110 111 As intermethod discrepancies may occur, triangulation protocol will be used,112 elaborating a ‘convergence coding matrix’ to display findings emerging from each component of the study on the same page in order to assess eventual agreement, partial agreement, silence or dissonance between findings from different components. Silence means that a theme or finding arises from one data set and not another, and it might be expected because of the strengths of different methods to examine different aspects of the phenomenon. This might contribute to increase understanding or lead to further investigations.113

Despite the predicted limitations, sound scientific evidence will be produced that may contribute to the development of public health policies that promote a healthy lifestyle and better health results for these immigrants with specific characteristics and that still require further studies in the Iberian Peninsula.

Ethics statements



  • Contributors DA, IC, NB and LG designed the project. DA drafted the manuscript. IC, NB and LG drafted and revised the manuscript. All authors approved the final version.

  • Funding This study was funded by Fundação para a Ciência e Tecnologia (FCT) - Doctoral Grant SFRH/BD/115382/2016, UID/04413/2020, UIDB/0006/2020 and UIDP/0006/2020.

  • Competing interests None declared.

  • Patient and public involvement Patients and/or the public were involved in the design, or conduct, or reporting, or dissemination plans of this research. Refer to the Methods section for further details.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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