http://hdl.handle.net/10362/2066 ENSP 2013-06-19T13:36:50Z http://hdl.handle.net/10362/9898 Title: Web-assisted tobacco intervention in Portuguese : intentions to make behavioural changes and behavioural changes Authors: Nunes, Luís Saboga Abstract: ABSTRACT - The problem of how to support “intentions to make behavioural changes” (IBC) and “behaviour changes” (BC) in smoking cessation when there is a scarcity of resources is a pressing issue in public health terms. The present research focuses on the use of information and communications technologies and their role in smoking cessation. It is developed in Portugal after the ratification of WHO Framework Convention on Tobacco Control (on 8 November 2005). The prevalence of smokers over fifteen years of age within the population stood at 20.9% (30.9% for men and 11.8% for women). While the strategy of helping people to quit smoking has been emphasised at National Health Service (NHS) level, the uptake of cessation assistance has exceeded the capacity of the service. This induced the search of new theoretical and practical venues to offer alternative options to people willing to stop smoking. Among these, the National Health Plan (NHP) of Portugal (2004-2010), identifies the use of information technologies in smoking cessation. eHealth and the importance of health literacy as a means of empowering people to make behavioural changes is recurrently considered an option worth investigating. The overall objective of this research is to understand, in the Portuguese context, the use of the Internet to help people to stop smoking. Research questions consider factors that may contribute to “intentions to make behavioural changes” (IBC) and “behavioural changes” (BC) while using a Web-Assisted Tobacco Intervention Probe (WATIP). Also consideration is given to the trade-off on the use of the Web as a tool for smoking cessation: can it reach a vast number of people for a small cost (efficiency) demonstrating to work in the domain of smoking cessation (efficacy)”? In addition to the introduction, there is a second chapter in which the use of tobacco is discussed as a public health menace. The health gains achieved by stopping smoking and the means of quitting are also examined, as is the use of the Internet in smoking cessation. Then, several research issues are introduced. These include background theory and the theoretical framework for the Sense of Coherence. The research model is also discussed. A presentation of the methods, materials and of the Web-Assisted Tobacco Intervention Probe (WATIP) follows. In chapter four the results of the use of the Web-Assisted Tobacco Intervention Probe (WATIP) are presented. This study is divided into two sections. The first describes results related to quality control in relation to the Web-Assisted Tobacco Intervention Probe (WATIP) and gives an overview of its users. Of these, 3,150 answered initial eligibility questions. In the end, 1,463 met all eligibility requirements, completed intake, decided on a day to quit smoking (Dday) and declared their “intentions to make behavioural changes” (IBC) while a second targeted group of 650 did not decide on a Dday. With two quit attempts made before joining the platform, most of the participants had experienced past failures while wanting to stop. The smoking rate averaged 21 cigarettes per day. With a mean age of 35, of the participants 55% were males. Among several other considerations, gender and the Sense of Coherence (SOC) influenced the success of participants in their IBC and endeavour to set quit dates. The results of comparing males and females showed that, for current smokers, establishing a Dday was related to gender differences, not favouring males (OR=0.76, p<0.005). Belonging to higher Socio-economic strata (SES) was associated with the intention to consider IBC (when compared to lower SES condition) (OR=1.57, p<0.001) and higher number of school years (OR=0.70, p<0.005) favoured the decision to smoking cessation. Those who demonstrated higher confidence in their likelihood of success in stopping in the shortest time had a higher rate of setting a Dday (OR=0.51, p<0.001). There were differences between groups in IBC reflecting the high and low levels of the SOC score (OR=1.43, p=0.006), as those who considered setting a Dday had higher levels of SOC. After adjusting for all variables, stages of readiness to change and SOC were kept in the model. This is the first Arm of this research where the focus is a discussion of the system’s implications for the participants’ “intentions to make behavioural changes” (IBC). Moreover, a second section of this study (second Arm) offers input collected from 77 in-depth interviews with the Web-Assisted Tobacco Intervention Probe (WATIP) users. Here, “Behaviour Change” (BC) and the usability of the platform are explored a year after IBC was declared. A percentage of 32.9% of self-reported, 12-month quitters in continuous abstinence from smoking from Dday to the 12-month follow- up point of the use of the Web-Assisted Tobacco Intervention Probe (WATIP) has been assessed. Comparing the Sense of Coherence (SOC) scores of participants by their respective means, according to the two groups, there was a significant difference in these scores of non smokers (BC) (M=144,66, SD=22,52) and Sense of Coherence (SOC) of smokers (noBC) (M=131,51, SD=21,43) p=0.014. This WATIP strategy and its contents benefit from the strengthening of the smoker’s sense of coherence (SOC), so that the person’s progress towards a life without tobacco may be experienced as comprehensible, manageable and meaningful. In this sample the sense of coherence (SOC) effect is moderate although it is associated with the day to quit smoking (Dday). Some of the limitations of this research have to do with self-selection bias, sample size (power) and self-reporting (no biochemical validation). The enrolment of participants was therefore not representative of the smoking population. It is not possible to verify the Web-Assisted Tobacco Intervention Probe (WATIP) evaluation of external validity; consequently, the results obtained cannot be applied generalized. No participation bias is provided. Another limitation of this study is the associated limitations of interviews. Interviewees’ perception that fabricating answers could benefit them more than telling the simple truth in response to questions is a risk that is not evaluated (with no external validation like measuring participants’ carbon monoxide levels). What emerges in this analysis is the relevance of the process that leads to the establishment of the quit day (Dday) to stop using tobacco. In addition, technological issues, when tailoring is the focus, are key elements for scrutiny. The high number of dropouts of users of the web platform mandates future research that should concentrate on the matters of the user-centred design of portals. The focus on gains in health through patient-centred care needs more research, so that technology usability be considered within the context of best practices in smoking cessation. 2012-01-01T00:00:00Z http://hdl.handle.net/10362/9795 Title: HPV : devem os rapazes ser vacinados? Authors: Coloma, Joana Isabel Ferreira Abstract: RESUMO - A infecção por Vírus do Papiloma Humano (Human Papillomavirus - HPV) é uma das doenças de transmissão sexual mais frequentes em todo o mundo. A descoberta de que esta infecção é responsável pelo carcinoma do colo do útero impulsionou o desenvolvimento de vacinas contra o HPV. Em Portugal, a vacina tetravalente contra o HPV faz parte do Plano Nacional de Vacinação, sendo administrada apenas a raparigas aos 13 anos de idade como medida profiláctica do carcinoma do colo do útero. Nos Estados Unidos da América, em Dezembro de 2010, a Food and Drugs Administration (FDA) aprovou o uso da vacina tetravalente na prevenção de lesões pré-cancerígenas e cancerígenas do ânus, tanto em rapazes como em raparigas, dos 9 aos 26 anos. A 25 de Outubro de 2011, o Advisory Committee on Immunization Practices (ACIP) recomendou que todos os rapazes de 11 e 12 anos sejam vacinados contra o HPV com a vacina tetravalente. Partindo desta realidade, o que se pretende com o presente trabalho é compilar evidência científica suficiente que permita ponderar mais aprofundadamente acerca das implicações, a partir de dados epidemiológicos e económicos, de se vacinar ou não os rapazes contra o HPV em Portugal. Em primeiro lugar recolheu-se evidência científica acerca da relação entre a infecção por HPV e o desenvolvimento de carcinomas de diversas regiões anatómicas. Em segundo lugar compilaram-se dados epidemiológicos sobre a incidência e sobrevivência associada aos diferentes tipos de tumores potencialmente associados à infecção por HPV, dando especial ênfase à realidade portuguesa. Em terceiro lugar enquadrou-se sucintamente a história da vacinação contra o HPV em Portugal e as vacinas existentes para prevenir esta infecção. Em quarto lugar foram revistos estudos de avaliação económica da vacinação contra o HPV quer em mulheres quer em homens, após uma introdução ao conceito de avaliação económica do medicamento. Em quinto lugar, foi feita uma estimativa dos custos com a vacinação dos rapazes contra o HPV durante os próximos 20 anos. Por último, procurou-se reflectir acerca das implicações de se alargar ou não a vacinação contra o HPV aos rapazes em Portugal.; ABSTRACT - The infection with Human Papilloma Virus (HPV) is a sexually transmitted infection very frequent throughout the world. The discovery that this infection is responsible for cervical carcinoma spurred the development of vaccines against HPV. In Portugal, the quadrivalent vaccine against HPV is part of the National Vaccination Plan, and it is administered only to 13 years old girls as a prophylactic measure of cervical carcinoma. In the United States of America, in December 2010, the Food and Drug Administration (FDA) approved the use of the quadrivalent vaccine for the prevention of pre-cancerous and cancerous lesions of the anus in both boys and girls from 9 to 26 years. On October 25th 2011, the Advisory Committee on Immunization Practices (ACIP) recommended that all boys 11 and 12 years old should be vaccinated against HPV with the quadrivalent vaccine. Given this context, what is intended with this study is to compile enough evidence that allows further consideration of the implications of whether or not to vaccinate boys against HPV in Portugal. Firstly, one collected scientific evidence about the relationship between HPV infection and the development of carcinomas of different anatomical regions. Secondly, epidemiological data on incidence and survival associated with different types of malignant tumors potentially associated with HPV infection was compiled, with special emphasis on the Portuguese reality. Thirdly, the history of HPV vaccination in Portugal and existing vaccines to prevent this infection were framed up succinctly. In fourth place, economic evaluation studies of HPV vaccination both in women as in men were reviewed, following an introduction to the subject of economic evaluation of pharmaceuticals. In fifth place, one estimated the costs of vaccinating boys against HPV over the next 20 years. Finally, one tried to reflect upon the implications of extending or not the HPV vaccination to boys in Portugal. 2012-01-01T00:00:00Z http://hdl.handle.net/10362/9759 Title: Caracterização da população diabética e impacto da diabetes mellitus na região do norte alentejano Authors: Graça, Helena Isabel Ricardo da Abstract: RESUMO - Actualmente, a diabetes mellitus é a doença crónica que representa o maior desafio aos sistemas de saúde, e é um importante problema de saúde pública, tanto no que concerne ao crescente aumento do número de pessoas afectadas pela doença, incapacidade, morbilidade e mortalidade prematura, como nos custos envolvidos no controlo e tratamento das suas complicações. Nesse sentido, e consciente do grande peso económico e epidemiológico que a diabetes mellitus acarreta, este trabalho versa sobre: (1) identificar a prevalência da diabetes mellitus, em 2010, na região do Alto Alentejo; (2) conhecer as evidências sobre as intervenções e cuidados prestados aos diabéticos desta região; e (3) analisar os custos directos com o internamento hospitalar, cujo diagnóstico principal foi a diabetes, no ano 2010, nesta região. Através deste estudo, constatamos que a diabetes, na região do Alto Alentejo, no universo dos diabéticos identificados (n=8.767), representou uma prevalência de 7,7 diabéticos por 100 habitantes. Quanto ao género, a prevalência é superior no sexo feminino (8,1%), em relação ao sexo masculino (7,2%). A média da idade foi de 67,5 anos, e verificou-se que a diabetes aumenta em grande escala com a idade, encontrando-se uma taxa de prevalência superior em idades acima dos 60 anos. Referente ao seguimento dos cuidados de saúde prestados pela ULS aos doentes com diabetes mellitus, fica muito aquém do que as Guidelines definem, para os cuidados prestados a estes doentes, tanto em termos de seguimento da própria doença, como na prevenção das suas complicações. Em relação ao internamento hospitalar, em 2010, registaram-se 255 episódios cujo diagnóstico principal foi a diabetes mellitus (250.xx), correspondendo estes casos a um total de 761.990€. A demora média de internamento foi de 10 dias (11,5 para o sexo masculino e 8,5 para o sexo feminino) e, a média das idades situa-se nos 65,5 anos.; ABSTRACT - Nowadays, diabetes mellitus is the chronicle disease that represents the biggest challenge health systems have to face. It is also a public health problem, not only because of the growing number of people affected by the disease, incapacity, morbidity and premature death, but also because of the costs of controlling it and its complications. Accordingly, and being aware of the great economical and epidemiological weight that diabetes mellitus has, this work aims to: (1) identify the prevalence of diabetes mellitus in 2010 in the region of Alto Alentejo; (2) know the evidence about the surgical interventions and health care done to diabetic patients in this region; and (3) analyse direct costs of hospital admissions in which the main diagnosis was diabetes, in 2010, in this region. Through this study, was found out that diabetes in Alto Alentejo, represented a prevalence of 7.7 diabetic per 100 inhabitants in the universe of the identified diabetic patients (n=8.767). When looking at gender, the prevalence is higher in females (8.1%) than in males (7.2%). The average age was 67.5 years old and it was detected that diabetes increases a lot with ageing by finding a higher prevalence in ages above 60. In what health care follow up by ULS to diabetes mellitus patients is concerned , both disease follow up and its complications prevention are far behind the Guidelines. When accounting for hospital admissions, in 2010 there were 255 cases in which the main diagnosis was diabetes mellitus (255.xx) and this corresponded to a total cost of 761.990€. The average hospital admission time was 10 days (11.5 male and 8.5 female) and the average age was 65.5 years old. 2012-01-01T00:00:00Z http://hdl.handle.net/10362/9709 Title: Demora desde o aparecimento dos primeiros sintomas até ao diagnóstico da tuberculose pulmonar em Portugal : análise de sobrevivência Authors: Silva, Marília Bettencourt Abstract: RESUMO - O presente estudo tem como objetivo contribuir para a Saúde Pública no controlo da tuberculose pulmonar (TBP), estudando a demora desde o aparecimento dos primeiros sintomas até ao diagnóstico da doença. As consequências da demora no diagnóstico podem ser fatais para os doentes e intensificar a proliferação do bacilo, influenciando a incidência da doença. Este estudo analisou os casos notificados com TBP pelo SVIG-TB, em Portugal Continental, no período de 2000 a 2009, com demora no diagnóstico de 1 a 365 dias. Foram utilizadas técnicas de estatística clássica para caracterização da base de dados e de análise de sobrevivência para caracterizar a demora até ao diagnóstico e modelar o risco de diagnóstico. As variáveis incluídas no estudo foram: género, idade, grupo etário, distrito de residência, área crítica de incidência da tuberculose, presença ou ausência da infeção pelo VIH, caso novo e reincidência, número de tratamentos anteriores, presença ou ausência de fatores de risco (álcool, tabaco, outras drogas, reclusão e sem-abrigo) e número de fatores de risco. Verificou-se que nos 35 711 casos notificados a mediana da demora até ao diagnóstico foi de 55 dias. Todas as variáveis referidas anteriormente demostraram estar correlacionadas com a demora, exceto no que diz respeito às áreas críticas ou não críticas e aos sem-abrigo. No modelo de Cox as variáveis que se mostraram relevantes ao diagnóstico foram o género em 10,2%, grupos etários, distritos, presença ou ausência de VIH em 12%, dependência alcoólica em 6,3% e dependência de tabaco em 8,8%. Estes resultados apontam para a efetividade de medidas de controlo da tuberculose, principalmente no caso de a pessoa apresentar alguns fatores de risco.; ABSTRACT - The aim of this study is to contribute to public health on pulmonary tuberculosis control, studying the delay from onset of the first symptoms and the diagnosis of pulmonary tuberculosis. The consequences of delay in diagnosis can be fatal to patients and spread the proliferation of bacillus, influencing the disease incidence. This study analyzes the reported cases by SVIG-TB in Portugal in the period between 2000 and 2009, with delay in diagnosis of 1 to 365 days. There were used classical statistical analysis techniques to database characterization and survival analysis to characterize the delay in diagnosis of pulmonary tuberculosis and to modeling diagnosis risk. The variables included in the study are: gender, age, age group, residence district, critical area of tuberculosis incidence, presence or absence of HIV infection, new case and recurrence, number of previous treatments, presence or absence of risk factors (alcohol, tobacco, other drugs, incarceration and homelessness) and number of risk factors. In 35 711 cases it was found that the median of delay in diagnosis was 55 days. All variables mentioned above have shown to be correlated with the delay, except for critical or not critical areas and in the case of the homelessness. In the Cox model, the variables that were relevant to the diagnosis were gender in 10,2%, age groups, districts, presence or absence of HIV in 12%, alcohol in 6,3% and tobacco dependence in 8,8%. These results indicate the effectiveness of some measures of TB control, especially if the person has some risk factors. 2012-01-01T00:00:00Z