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- The socioeconomics of the Mediterranean diet : prices, inequalities, and policiesPublication . Alves, Ricardo; Perelman, Julian; Lopes, CarlaABSTRACT - Healthy food promotion policies should consider how the food environment interacts with the population's socioeconomic inequalities. We seek to understand how (1) Mediterranean Diet adherence changes over time along economic cycles; (2) the role of food prices and household income in dietary patterns inequalities; (3) and if the household structure and family support influence individual diets. We found that the economic downturn was associated with a decrease in diet quality in Portugal, particularly among younger people. The economic recovery was accompanied by a generalized rise in Mediterranean Diet adherence in the European elderly, with a more pronounced increase in higher socioeconomic groups. We conclude that improving populations' welfare condition and reducing inequalities is a requisite for an equitable shift to healthier eating habits. Then, we observed that higher adherence to Mediterranean Diet in Portugal was associated with an overall higher dietary cost, highlighting the need to make healthy eating less regressive and affordable. Our findings suggested that while healthy food consumption is positively related to income, unhealthy food was mostly unrelated. Hence, fiscal policies can be effective and socially just policy tools for improving diets. Finally, our study on the influence of household structure on individual diets showed that people living alone or in single-parent families might be at a higher risk of following unhealthy diets. Not benefiting from economies of scale for purchasing and cooking at home may make eating healthier more difficult. We suggest that community-based health promotion services could mitigate the negative health effects on these families. RESUMO - As políticas para a promoção de uma alimentação saudável devem ter em conta o modo como os ambientes alimentares interagem com as desigualdades socioeconômicas na população. Procuramos compreender (1) como a adesão à Dieta Mediterrânica muda ao longo dos ciclos económicos; (2) o papel do preço dos alimentos e do rendimento familiar nas desigualdades encontradas nos padrões alimentares; (3) e se a estrutura e suporte familiar influenciam a dieta. A recessão económica esteve associada a uma diminuição da qualidade da dieta em Portugal, particularmente entre os mais jovens. A recuperação económica foi acompanhada por um aumento da adesão à Dieta Mediterrânica nos idosos europeus, particularmente em grupos socioeconómicos mais elevados. Concluímos que reduzir as desigualdades é um requisito necessário para uma mudança equitativa nos hábitos alimentares. Observou-se que uma maior adesão à Dieta Mediterrânica em Portugal esteve associada a um custo global mais elevado. Embora o consumo de alimentos saudáveis esteja positivamente relacionado com rendimento familiar, não se encontrou um claro gradiente entre os alimentos menos saudáveis e rendimento. Assim, políticas fiscais podem ser ferramentas políticas eficazes e socialmente justas para melhorar os padrões alimentares. Finalmente, as pessoas que vivem sozinhas ou estão em famílias monoparentais podem estar em maior risco de seguir dietas menos saudáveis. Este tipo de agregado familiar poderá não beneficiar de economias de escala para comprar e cozinhar em casa, representado assim um obstáculo para dieta saudável. Sugerimos que os serviços comunitários de promoção da saúde podem mitigar os efeitos negativos para a saúde destas famílias.
- Literacia em Saúde e a Compensação da Diabetes: qual a relação?Publication . Ó, Dulce Nascimento do; Loureiro, Isabel; Goes, Ana RitaRESUMO - As pessoas com diabetes desempenham um papel relevante nos resultados do tratamento, através das escolhas e decisões que tomam diariamente. Sequencialmente, a literacia em saúde tem grande peso no quotidiano das pessoas com diabetes, uma vez que abrange as competências necessárias para gerir a doença e a saúde. Com a presente investigação pretendeu-se compreender o papel da literacia em saúde na compensação da diabetes, considerando as suas diferentes dimensões e o papel de variáveis individuais, interpessoais, comportamentais e ambientais. A fim de dar resposta a esta finalidade realizaram-se três estudos. No primeiro estudo, realizou-se a adaptação do questionário de Literacia em Saúde (Health Literacy Questionnaire) ao contexto português e foram analisadas as suas propriedades psicométricas com uma população com diabetes, por considerarmos que poderá contribuir para a compreensão das necessidades das pessoas em literacia em saúde. O segundo estudo, pretendeu-se identificar o valor explicativo das dimensões de literacia em saúde (HLQ) para a compensação da diabetes, sem ajustamento e quando ajustada pelas variáveis sociodemográficas, clínica e autocuidados na diabetes. No terceiro estudo, foi explorado o papel da autoeficácia e do ambiente de cuidados de saúde na relação entre a literacia em saúde e a compensação da diabetes. Para o primeiro estudo, a tradução e adaptação teve por base um rigoroso protocolo, enviado pela equipa responsável pelo HLQ. Os procedimentos sugeridos no protocolo, relativamente à tradução, retroversão, reunião de consensos com a equipa nacional e autores principais do HLQ, foram mantidos nas várias adaptações culturais do HLQ de forma a contribuir para obtenção de dados sólidos sobre a validade dos resultados obtidos. A versão portuguesa do HLQ e um questionário de caracterização clínica e sociodemográfica foram aplicados a pessoas com diabetes, seguidas numa unidade de cuidados especializados em diabetes. Participaram, 453 pessoas com diabetes, das quais 52,2% eram homens, 84,1% viviam acompanhadas, 47% eram reformadas e 51.7% tinha mais que o 9ºano de escolaridade. A versão portuguesa do HLQ mostrou propriedades psicométricas satisfatórias e está agora disponível para avaliar a literacia em saúde nas pessoas com diabetes. Nos dois estudos seguintes, os dados foram recolhidos através de um questionário eletrónico, enviado para pessoas com diabetes, acompanhadas na mesma unidade cuidados especializados em diabetes. Participaram 706 pessoas com diabetes, das quais 60,2% eram do sexo masculino, 83,9% viviam acompanhadas, 52,4% estavam empregadas e 84,7% tinha mais de 9 anos de escolaridade. No segundo estudo, focado na relação entre as dimensões de literacia em saúde e a compensação, foi realizada a regressão linear múltipla, tendo-se verificado valores mais elevados de literacia em saúde estão significativamente associados a níveis mais baixos de HbA1c. Este resultado verificou-se em todas as dimensões com exceção da dimensão 5 – Apreciação sobre a informação de saúde. Nos modelos ajustados para condições sociodemográficas e clínica observou-se para as dimensões 2 e 3, um aumento do efeito da literacia em saúde nos níveis de HbA1c e para as dimensões 1, 4, 6, 7, 8, 9 uma diminuição desse efeito. Ao incluir os comportamentos de autocuidados, em todas as situações observou se uma redução do efeito bruto da literacia em saúde na compensação da diabetes. No terceiro estudo, focado na análise do impacto da autoeficácia e o ambiente dos cuidados de saúde na relação entre a literacia em saúde e a compensação da diabetes. Quando realizada a analise de mediação com a variável autoeficácia, verificou-se que a literacia em saúde prediz significativamente a autoeficácia e a autoeficácia prevê os níveis de HbA1c. As dimensões de literacia em saúde deixam de ser preditoras dos níveis de HbA1c após controlar para o mediador autoeficácia, pelo que os resultados suportam a hipótese de existência de mediação. Em relação à análise de mediação com a variável ambiente dos cuidados de saúde (perceção que as pessoas têm relativamente ao grau em que os profissionais de saúde apoiam a sua autonomia), observou-se que literacia em saúde prediz significativamente o ambiente dos cuidados de saúde e a ambiente dos cuidados de saúde prevê os níveis de HbA1c. Verificou se que as dimensões de literacia em saúde deixam de ser preditoras dos níveis de HbA1c após controlar para o mediador ambiente dos cuidados de saúde, com exceção da dimensão 3 – Gerir ativamente minha saúde, em que a mediação foi parcial. Nos modelos com as dimensões 5, 6 e 8 não se verificou o primeiro pressuposto da mediação, ou seja, não predizem significativamente a HbA1c. A presente investigação vem reforçar a importância da literacia em saúde para a compensação da diabetes. Evidenciou o seu efeito preditor na compensação da diabetes e aprofundou o conhecimento sobre a relação entre as dimensões de literacia em saúde e a compensação da diabetes, dando a conhecer o papel mediador da autoeficácia e do ambiente dos cuidados de saúde nessa relação. Desta forma, com esta investigação ficou patente a importância de promover a literacia em saúde e a autoeficácia das pessoas com diabetes para a autogestão da sua doença, saúde e regime terapêutico. A autoeficácia envolve a noção sobre as próprias competências para conseguir os níveis de desempenho necessários para a gestão da diabetes. Para este efeito sugere-se que as pessoas com diabetes e os profissionais estabeleçam um relacionamento colaborativo, assente na relação de confiança, facilitador da comunicação e decisão informada, da participação ativa da pessoa com diabetes. Simultaneamente, considera-se relevante para a promoção da literacia em saúde, a qualidade e a clareza da informação sobre saúde que se encontra acessível à população. De notar o papel dos profissionais de saúde na transmissão dessa informação de uma forma clara e individualizada, sendo que a promoção da responsividade dos profissionais de saúde poderá ser determinante para que as pessoas com diabetes tenham níveis mais elevados de literacia em saúde, se sintam mais integradas nas equipas de saúde, naveguem com maior facilidade no sistema de saúde e que, desta forma, tenham resultados mais positivos e ganhos em saúde.
- Lung cancer in Portugal: an epidemiologic analysis of incidence, geographic variability, survival and associated factors as a basis for the implementation of public policiesPublication . Guerreiro, Maria Teresa Dias; Nunes, Carla; Aguiar, Pedro; Araújo, AntónioABSTRACT - Objective: To investigate lung cancer (LC) survival in Portugal and the key factors that can contribute to its improvement, and generate evidence to inform future health policies that can lead to better outcomes for patients and for the health system. Methods: Patient-level data from the regional oncologic registries allowed a nationwide coverage. Background context for LC burden, classification, risk factors, survival, treatment, early diagnosis and quality-of-life was provided. We characterized patients diagnosed with lung cancer, analyzed incidence rates (IR), spatial patterns, and conducted 5-year survival analysis addressing factors as sex, age, histology, stage, treatment and quality-of-care indicators. Finally, we carried-out an overview on current LC screening programs. Results: Male:female ratio 3:1. IR markedly increased with age. Most patients (>80%) had locally-advanced or metastatic disease. Highest IR found in Azores. Most relevant high incidence clusters in Oporto and Lisbon areas. Median overall survival (OS) in a 5-year follow-up study was 264 days and cumulative OS 13.6%. Male gender, increasing age>50, and stage identified as main predictors of decreased survival. Stage had the worst impact. Treatment rate decreased with increasing stage, particularly for surgery (75.2% stage I; 7.8% stage IV) highlighting early diagnosis importance for potentially curative treatment. Treatment showed protective effect on survival but timely treatment did not, likely due to confounding by severity. Evidence supports LC screening implementation targeting high-risk patients to improve outcomes. Conclusions: Our research contributed to identify critical incidence areas. LC survival is highly dependent on early diagnosis, adequate and timely treatment. A targeted LC screening program can potentially transform disease survival.
- Prevalence, burden and healthcare needs of people living with osteoarthritis in Portugal: contribution to the development of a Model of CarePublication . Costa, Daniela Sofia Albino; Dias, Sónia; Cruz, Eduardo; Rodrigues, AnaABSTRACT - Background: Hip and/or knee Osteoarthritis (HKOA) are a leading and rising cause of disability worldwide. Evidence-based guidelines recommend core non-pharmacological and pharmacological interventions to improve pain, disability and quality of life. However, literature has shown that the outcomes of current care are far from optimal. Current interventions are heterogeneous, centred on symptomatic control with pharmacological interventions and surgical procedures, with a lack of processes to tailor treatment selection according to patient characteristics and preferences. To overcome this reality several countries and regions have implemented Models of Care (MoCs) for OA. These are frameworks that outline what care should be offered and how care should be delivered that aim to decrease the evidence-practice gap and optimize patient-level outcomes, quality of care and sustainability of health systems. To successfully implement an HKOA MoC in a country it is necessary to identify and understand the unmet needs of people living with this disease, the healthcare delivery and the pattern of healthcare utilization of these populations. Furthermore, it is needed to map effective solutions based on literature and identify which of them can be successfully applied in a specific setting. The work presented in this thesis used Portugal as a case-based setting for the future development of an HKOA MoC, with the following specific objectives: 1) to estimate the prevalence of HKOA and factors associated with its clinical and radiographic severity in Portugal. 2) to estimate the prevalence and factors associated with unmanageable pain levels among people with HKOA in Portugal. 3) to determine the trajectories of physical function and HRQoL and the factors associated with different trajectories in a 10-year longitudinal follow-up. 4) to analyse the healthcare services utilization of people with knee OA in Portugal, focusing on behavioral determinants for healthcare utilization. 5) to map and synthesize the literature of MoCs developed and implemented for people with knee OA. Methods: This thesis has two different phases. In the first phase, we analysed data from the nationwide population-based cohort – EpiDoC study (2011-2021) that included a representative sample of the Portuguese population randomly selected. In the first wave of EpiDoC study, after a structured interview where sociodemographic, lifestyle and health-related data were collected, participants were invited to an appointment with a rheumatologist, that validated the diagnosis of rheumatic diseases. These participants were then invited to participate in the subsequent waves (EpiDoC 2, 3 and 4) where structured interviews were again implemented. In the studies of the first phase of this thesis, we included participants that were diagnosed with HKOA by a rheumatologist in EpiDoC 1. In the second phase – potential solutions – we systematically analysed the published evidence published in peer-review and grey data sources, to perform a scoping review that mapped and synthesized the literature of MoCs developed and implemented for people with HKOA in primary care. Results: Across the 4 studies of the EpiDoC cohort we concluded that 14.1% (95%CI 12.6-15.7) of the Portuguese population have HKOA, and two-thirds self-report unmanageable pain levels. Age, female sex, multimorbidity, overweight/obesity, no regular exercise and education level were identified as factors associated with clinical severity. More than half of the population maintains moderate/low stable trajectories of physical function and HRQoL for 10 years. High users of healthcare services represent approximately 35% of people with HKOA. But, approximately 80% of participants with HKOA do not exercise regularly or are overweight/obese, which suggests a low uptake of evidence-based core interventions. The utilization of healthcare services seems not to be based just on clinical needs, revealing inequities in access to healthcare. The scoping review included 13 MoCs, that were implemented worldwide, delivering the core interventions in stepped care pathways at the primary care level. Despite the promising results at the patient-, organization- and implementation level, the heterogeneity in the report and the implementation strategies may difficult the transferability to other contexts and demand further high-quality research. Notwithstanding, it was possible to identify care pathways, evidence-based interventions and implementation strategies that could fit into the Portuguese healthcare system Conclusions: This thesis contributes to understanding the prevalence, characteristics and health-related status of people with HKOA in Portugal, as well as the suggested evidence-practice gap and inequities in the access to care regarding healthcare utilization. These results raise hypotheses about the uptake of core interventions and the access to healthcare by people with HKOA that should concern health authorities and call for future research in this area. Also, our results suggest the need to implement national strategies to optimize outcomes of care, and decrease and prevent future healthcare demands and rising costs related to HKOA, like MoCs. The implementation of a MoC in Portugal may be challenged by external, local and individual health context features that should be considered in the implementation process.
- Nutrient profile models to promote healthier food choices for childrenPublication . Santos, Mariana Ramos Sousa Coelho dos; Isabel, Loureiro; Rito, Ana IsabelABSTRACT - Introduction Noncommunicable diseases (NCDs) are the leading cause of death worldwide, constituting one of the greatest global public health challenges of the 21st century. According to the World Health Organisation (WHO), the incidence and prevalence of NCDs are conditioned by individual and social risk factors, namely smoking, sedentary lifestyle, overweight, inadequate eating habits and alcoholism, all of which are avoidable risk factors. In Portugal, according to data estimated by the 2019 Global Burden of Diseases (GBD) study, inadequate eating habits are one of the top five factors contributing to the loss of healthy life years. Factors influencing consumers' eating behaviours range from environmental factors, personal and individual differences, to economic and political ones, such as the cost or availability of food. Information provided by food labelling, food marketing and policies that impact on food prices also influences food choice. In this context, the implementation of measures to create healthy eating environments have been identified as actions that can influence food choices and the nutritional status of individuals, contributing to the promotion of healthy eating. These measures include the development of nutrient profile (NP) models that serve as a basis for the implementation of actions to promote healthy eating environments. Several NP models have been developed with the specific aim of defining the nutritional quality of individual foods or groups of foods by classifying them according to their specific nutrient content or ingredients of interest. NP models can be applied to guide the reformulation of food products, the establishment of specific compositional standards, the regulation of the marketing of foods for children, the establishment of nutrition and health claims and the creation of food labelling logos. This thesis aimed to investigate the application of NP models, in the domains of food labelling, food composition/reformulation and food marketing/promotion, to produce evidence to support policymakers and researchers in creating healthy food environments. The research consisted of four studies that used a combination of different research methods to address the overall aims and objectives initially established. Study 1 presented an overview of the guiding principles for implementing NP models, providing a better understanding of their importance as a tool for establishing public health interventions regarding consumers' food choices. The topics revisited in the state-of-the-art were intended to support policymakers in setting food and nutrition policies based on objective, transparent and reproducible methods for assessing the nutritional quality of food and non-alcoholic beverages. Study 2 applied the NP models in the domains of food composition/reformulation and food promotion, to assess and compare the World Health Organisation Regional Office for Europe (WHO-EURO), the EU food industry's commitment to advertising and marketing toward children (EU-Pledge), and the national model developed by the Directorate-General for Health (NPM-PT) performance in the classification of ready-to-eat cereals (RTECs) for children, available in Portuguese supermarkets according to their nutritional composition; analysed the potential for reformulation of RTECs identified as inadequate and assessed the impact of reformulating RTEC, on the quality of children's food in Portugal. Study 3 assessed the application of NP models in the domain of food labelling and aimed to evaluate the nutritional quality of foods consumed by the Portuguese population according to the Nutri-Score algorithm and investigated consistency with the dietary recommendations for the Portuguese population. Study 4 characterised the applicability of NP models in the food marketing/promotion domain, assessing the performance of the NP model developed by the WHO Regional Office for Europe for the evaluation of commercially available complementary foods for infants and young children up to 36 months of age and classified the degree of processing, according to the NOVA classification system. Results The NP models have a wide range of applications including front-of-pack (FoP) food labelling, regulation of food marketing to children, regulation of health and nutrition claims and school food standards. In response to the set of measures and agreements established between the food industry and policymakers, NP models have been developed, to modify the food environment by promoting healthier food choices. Regarding the application of the NP models in the reformulation of food products, the results of the second study showed statistically significant differences between the scenarios without and with reformulation, for the estimated sugar and dietary fibre content in infant cereals. The reformulation scenario, based on the nutritional criteria of the DGS Nutrient Profile Model (NPM-PT) showed a reduction of 43% in sugar content and an increase of 34% in fibre content, for the RTECs analysed. Concerning the application of NP models in the food labelling domain, the third study showed that the Nutri-Score had a good performance to discriminate differences in nutritional quality between different food groups, between foods of the same group and between different subgroups. At least three categories were observed for 75% of foods and distribution by at least two Nutri-Score categories was identified. The classifications were consistent with the Portuguese nutritional and dietary recommendations (93.0% of Vegetables included in category A and 57.1% of Bakery Products included in category E). The application of NP models in the food marketing/promotion domain, to evaluate the commercially available complementary foods for infants and young children up to 36 months of age, revealed the total sugar content of several categories was higher than recommended and in contradiction with the recommendations to restrict sugar intake in infants and young children. In addition, our study suggested that an early introduction of ultra-processed in infants and young children diet was probable. Conclusions This work has presented empirical evidence aimed to support policymakers to implement food and nutrition policies based on the application of NP models. Nutrient Profile Model is a tool that in the field of food composition/food labelling allows the identification of food products and beverages that are high in energy, salt, sugar, saturated fatty acids and trans-fatty acids, providing evidence for the reformulation of various food categories, intending to promote healthy eating habits. The implementation of measures aimed at modifying food environments, such as the restriction of food marketing and advertising to children, based on the NP model, represents a key area of intervention, to support a healthy diet for children and contribute to the fulfilment of the fundamental right to healthy food and adequate nutrition, to which all children are entitled. The NP models enable food and nutrition policymakers to identify unhealthy products and implement measures to achieve healthier food environments.
- Comportamentos suicidas: estudo longitudinal a vinte e quatro meses, numa urgência de psiquiatriaPublication . Taron, Marisa Cavaleiro Real Correia; Maia, Teresa; Nunes, CarlaRESUMO - Este estudo pretende identificar os fatores de risco para a ocorrência de tentativas de suicídio (TS) e de suicídios consumados ao longo de vinte e quatro meses, numa população adulta (18-65 anos) em risco suicida, na urgência de psiquiatria de um hospital geral. Definiram-se seis objetivos, três baseados numa componente transversal e três numa componente longitudinal. A componente transversal incluiu: Objetivo 1- Caraterizar a amostra em termos sociodemográficos, clínicos, de tratamento e das características das TS prévias; Objetivo 2- Caraterizar os subgrupos de “não repetidores” de TS (0-1) e de “repetidores” de TS (≥ 2); Objetivo 3- Comparar o grau de risco suicida avaliado pela percepção clínica do psiquiatra (gold standard), e por um instrumento quantitativo do risco de suicídio- escala SadPersons Modificada. A componente longitudinal incluiu: Objetivo 4- Observar as ocorrências de suicídios consumados, de TS, de urgências e de internamentos psiquiátricos, ao longo do período do estudo; Objetivo 5- Identificar os fatores de risco individuais com capacidade preditiva dos indicadores de resultados (suicídios e TS nos primeiros seis meses e no final dos 24 meses); Objetivo 6- Comparar a capacidade preditiva da avaliação clínica do risco suicida com a sua complementação pela escala, face aos indicadores de resultados. Após análises descritivas, foram utilizados testes de independência do qui-quadrado (p< 0,05), calculados os coeficientes de concordância Kappa e aplicados modelos de regressão logística binária (Odds bruta e ajustada para faixa etária e género, métodos enter e forward, p= 0,10-0,20, e determinadas as respetivas curvas ROC). A amostra (n= 147) de idade média de 41,9 anos (±11,9) foi maioritariamente do sexo feminino (61,9%), com patologia psiquiátrica na sua quase totalidade (94,6%), sobretudo do tipo afetivo (61,2%) e perturbações da personalidade (59,2%). Teve como fatores de risco associados ao subgrupo de “repetidores” de TS (47,6% vs. “não repetidores”: 52,4%): sexo feminino, antecedentes de comportamentos autolesivos, existência de maior número de internamentos psiquiátricos prévios, e uma TS recente como motivo da urgência de recrutamento. A avaliação do risco suicida revelou uma concordância maioritária entre os dois modos de avaliação, apenas com 27,2% (n= 40) de discrepância, com uma predominância de grau "moderado" (54,4%) pelo psiquiatra, e “leve” (55,1%) pela escala. Ao longo do estudo observaram-se 69 episódios de TS (n= 24; 16,6%), ocorrendo maioritariamente nos primeiros seis meses, ao inverso dos sete suicídios consumados (4,8% da amostra), que ocorreram predominantemente nos últimos 18-24 meses do estudo. As características individuais preditivas de futuras TS (regressão logística binária, p= 0,10-0,20) foram a patologia somática e o maior número de internamentos psiquiátricos prévios. A complementação da avaliação clínica do risco suicida pela escala, aumentou a capacidade preditiva de TS quer aos seis quer aos 24 meses. Em conclusão, confirmou-se a existência de um perfil de risco sociodemográfico, clínico, de antecedentes de tratamento e de TS prévias distinto para o subgrupo de “repetidores” de TS. Verificou-se um padrão de evolução temporal distinto para a ocorrência de TS e de suicídios consumados, bem como a existência de fatores preditivos de TS (patologia somática e maior número de internamentos psiquiátricos prévios) e de um acréscimo da capacidade preditiva de TS através da complementação da observação psiquiátrica pela aplicação da escala. As limitações centram-se na subjetividade do investigador, na ausência de uma validação da escala para a população portuguesa, nos viéses de memória dos utentes e nas lacunas de informação dos processos clínicos informatizados. Os pontos fortes incluem a considerável dimensão da amostra, a quase total ausência de “drop-outs” e a abrangência integrada, clínica e epidemiológica, a nível do próprio local de prestação de cuidados clínicos de urgência. A originalidade do estudo, inédito a nível nacional, consiste na sua metodologia longitudinal e na aplicação de uma escala quantitativa do risco suicida, enquanto ferramenta de apoio à avaliação do risco suicida. Como principal recomendação realça-se a necessidade de seguimento no período pós-crítico destes utentes que procuram os serviços de saúde, mas para os quais não parece haver uma capacidade de resposta adequada. Como perspetivas futuras consideram-se a ampliação da amostra num estudo durante um mais alargado período temporal e incorporando outros níveis de cuidados de saúde. As implicações práticas deste estudo centram-se na melhoria do conhecimento epidemiológico acerca dos fatores de risco associados aos comportamentos suicidas a nível das urgências de psiquiatria, e da respetiva contribuição para a otimização do planeamento da saúde com vista à prevenção do suicídio.
- Association between ambient air pollution exposure and biomarkers of cardiovascular risk: link between the first Portuguese Health Examination Survey and the air quality dataPublication . Gaio, Vânia Isabel da Silva; Dias, Carlos MatiasABSTRACT - The once-surprising observation that ambient air pollution (AAP) adversely affects the cardiovascular system is now well recognized but there are yet many gaps in understanding the pathophysiologic mechanisms linking AAP and cardiovascular diseases (CVD). In this sense, epidemiological studies on the association between AAP and health conditions that increase the risk to develop CVD may shed some light on the mechanisms mediating the AAP deleterious effect on the cardiovascular system. The overall aim of this thesis is to improve our knowledge on the relationship between exposure to particulate matter and biomarkers of cardiovascular risk. Specifically, this thesis addresses the association between exposure to ambient particulate matter (PM10) and biomarkers of dyslipidaemia, diabetes, hypertension and inflammatory response in the adult Portuguese mainland population, in 2015. A systematic review and meta-analysis was firstly conducted (Article 1) to summarise the current state of knowledge about the association between AAP and biomarkers of dyslipidaemia prior to design the plan of analysis on this topic. Despite the few studies included, it suggested some epidemiologic evidence supporting the association between PM10 and increased triglycerides levels (3.14%, 95%CI: 1.36-4.95, increase per 10µg/m3 PM10 increment). Subsequently, associations between PM10 exposure and each biomarker group was assessed through the linkage between air quality data collected through air quality monitoring network of the Environmental Portuguese Agency and individual data from the First Portuguese Health Examination Survey (Articles 2, 3 and 4). Globally, the results of this thesis supports the existence of a positive association between PM10 exposure and some biomarkers of cardiovascular risk, namely those related to dyslipidaemia (Triglycerides, in people with abdominal obesity: 1.84%, 95%CI: 0.02-3.69, increase per 1µg/m3 PM10 increment) and inflammatory response (White blood cells in females: 2.76%, 95%CI: 0.65-4.87, increase per 10 µg/m3 PM10 increment and Red cell distribution width in males: 2.96%, 95%CI: 0.80-5.12, increase per 10 µg/m3 PM10 increment). Consequently, it suggests that reduction of PM10 below current air quality standards would result in additional cardiovascular health benefits for the population. Additionally, results of this thesis contribute to provide more knowledge to establish the biologic plausibility to the previous epidemiologic studies reporting an association between air pollution and increased cardiovascular mortality and hospital admissions due to cardiovascular diseases. In future experimental studies, performed in animal models or in vitro, it would be important to explore deeply the hypothetical biological mechanisms presented in this thesis to explain the identified associations. In conclusion, exposure to AAP is largely beyond the control of persons and requires action by public authorities at the national and international levels. Results obtained within this thesis provide more scientific arguments for taking actions to improve air quality, even when the standard air quality limits are target. Finally, this thesis describe a methodological approach, that to my knowledge, was never performed in Portugal, linking air quality and health data, that could be used to study other environmental factors and other health outcomes in a perspective to improve the usage of data already collected and available to all the scientific community.
- Aposentação em Portugal: vivências por género e conjugalidade heterossexualPublication . Pedreiro, Ana Teresa Martins; Loureiro, Maria Isabel Guedes; Loureiro, Helena Maria Almeida Macedo
- A contribution to the economic evaluation of pharmacy-based public health interventions in a collaborative care model with primary care in PortugalPublication . Duarte, Suzete Maria Pereira Costa; Mateus, Céu; Pereira, JoãoABSTRACT - Objective: The main research question was to understand whether a pharmacy-driven collaborative intervention in hypertension and hyperlipidemia under IT-driven pre-agreed ICPs with local primary care in Portugal can be effective, cost-effective, and valued by patients compared with usual (fragmented) care. Methods: Data sources included: primary care clinical software; pharmacy dispensing software; patient telephone surveys; and published literature. First, we reviewed the state-of-the-art of economic evaluation of pharmacy services in Portugal. Second, we performed an overview of systematic reviews of economic evaluations of pharmacy based public health interventions on methodological challenges and triangulated results. Third, we designed, conducted, and assessed the effectiveness of a pragmatic quasi experimental controlled trial of collaborative management between community pharmacies and primary care. Fourth, we experimented CEA and CUA in a “proof-of concept” study alongside this trial versus usual care. Fifth, we explored variation in patient preferences and estimated WTA annual cost to the NHS alongside this trial, using DCE and incorporating it into a cost-benefit analysis. Results: We found 5 studies on the economic evaluation of pharmacy services in Portugal until June 2016. Fourteen systematic reviews containing 75 index publications were included in the overview. We, then, proposed a 4-step methodological approach for the economic evaluation of pharmacy-based public health interventions. We were not able to demonstrate effectiveness, cost-effectiveness nor cost-utility for this intervention versus usual care. The probability for the intervention to be cost-effective at the threshold €20,000 per QALY is below 40% and below 20% at the threshold €500 per mmHg decrease. Intervention patients were willing to accept NHS annual cost of €877 for their preferred scenario. The annual net benefit per patient was €788.20 and represents the monetary value of patients’ welfare surplus for this model. Conclusions: To our best knowledge it was the first pharmacy-based trial in Portugal experimenting different methods of economic evaluation. The evidence and lessons learned may assist in improving trial design and conduct, and in applying methods in future economic evaluations of collaborative pharmacy-based public health interventions. We also hope that we advance the standards of care and raise questions on the role of complementary innovative payment models of primary healthcare providers and pharmacies towards Value-Based Health Care and Patient-Centered Care.
- Measurement error in self-reported risk factors for cardiovascular disease: results from the first Portuguese National Health Examination SurveyPublication . Kislaya, Irina; Nunes, Baltazar; Tolonen, HannaABSTRACT - Accurate data on cardiovascular disease risk factors are essential for the design and evaluation of public health policies. Currently, self-reported data on hypertension and hypercholesterolemia constitute a primary data source for population health monitoring at European and national level. This thesis aimed to evaluate accuracy of self-reported data on hypertension and hypercholesterolemia, to quantify, and to correct measurement error bias using data from the first Portuguese Health Examination Survey (INSEF). Measurements of blood pressure and total cholesterol concentrations were used as gold-standards to estimate measurement error bias, sensitivity and specificity of selfreports, investigate error impact on outcome-exposure associations and illustrate application of multiple imputation for bias correction. Despite all the efforts to limit the error through design and fieldwork procedures, self-reported data underestimated prevalence of hypertension and hypercholesterolemia in Portuguese population. Being unequally distributed among socioeconomic subgroups, measurement errors resulted in underestimation of socioeconomic inequalities in younger and overestimation in older age groups. The study results highlight the importance of measurement error bias analysis when using self-reported data. Results from multiple imputation show the approach feasibility for measurement error bias adjustment in prevalence estimates and outcome-exposure associations when individual-level validation data is available. Health statistics on cardiovascular disease risk factors derived from self-reports should be used with caution. Integration of objective measurements in large-scale health surveys will improve the accuracy of epidemiological information on hypertension and hypercholesterolemia.