Bruno Heleno

Background: Person-centeredness is a widely recognized key dimension of quality of care, but its implementation in primary care varies substantially. Understanding attitudes and challenges that support or hinder adoption is essential for effective integration. This paper explores general practitioners’/family physicians’ (GPs’) attitudes toward person-centered care (PCC) across 24 European countries and examines socio-demographic, professional, and work-related factors associated with these attitudes. Methods: An online self-reported survey was conducted among GPs across Europe. Attitudes were assessed with the Patient-Practitioner Orientation Scale (PPOS), a validated instrument scored from 1 to 6 where higher scores reflect a more patient-centered orientation, including the Caring and Sharing sub-scales. Because GPs were nested within countries, linear mixed-effects (multilevel) models were used with country as a random effect and practitioner- and practice-level characteristics as fixed effects. The intraclass correlation coefficient (ICC) quantified between-country variation. Analyses used cleaned data from the 24 countries available as of December 12, 2024. Results: In total, 3,691 GPs participated, and the mixed-model analysis of the PPOS total score included 3,370 respondents across 24 countries. Approximately 31% of the variance in PPOS total scores lay between countries (ICC = 0.31), indicating substantial cross-national variation. Regional grouping captured this variation better than EU integration status in descriptive comparisons; however, between-group variance was estimated from very few clusters and was therefore statistically unstable, thus exploratory. After adjustment, teaching involvement, specialist training in General Practice/Family Medicine, urban practice, an above-average share of psychiatrically vulnerable patients, and lower daily patient-contact volume were associated with higher (more patient-centered) scores, whereas higher perceived work-related stress, older age, and the least experience were associated with lower scores. Broadly similar patterns emerged for the Caring and Sharing sub-scales, with some dimensional differences. Conclusions: In this pan-European study, individual, professional, and practice-level factors were associated with GPs’ attitudes toward PCC, and a substantial share of the variation was attributable to differences between countries. Given the cross-sectional design and that PPOS measures attitudes rather than delivered care, results should be interpreted as associations at the attitudinal level. Identifying these factors may support strategies to foster person-centered attitudes across diverse European primary care settings. Trial registration: Not applicable.

Background: Cervical cancer is a public health concern. Although it is preventable through regular screening, participation in screening programmes remains suboptimal among women living in socially vulnerable situations and migrants due to barriers to conventional screening programmes. Consequently, these women experience disproportionately higher incidence and mortality rates, underscoring inequities in cervical cancer outcomes. Human Papillomavirus (HPV) self-sampling has emerged as a promising strategy to mitigate these barriers and enhance access to preventive reproductive health services. However, evidence of its acceptability in community settings is limited. Drawing on a culturally adapted HPV self-sampling intervention, this study aimed to explore the acceptability of HPV self-sampling among socially vulnerable migrant women in community settings in Lisbon. Methods: We conducted a sequential mixed-methods study among 111 socially vulnerable migrant women aged 30–65 years who participated in an HPV self-sampling intervention delivered through community-based organisations in Lisbon. The quantitative component consisted of a pre–post questionnaire assessing anticipated and experienced acceptability of HPV self-sampling. The qualitative component involved mini–focus group discussions with eight intervention participants to explore experiences in greater depth. Quantitative data were analysed using the Wilcoxon signed-rank test in R, and qualitative data were analysed thematically informed by the Theoretical Framework of Acceptability. Results: Our findings indicate high perceived acceptability of HPV self-sampling. Pre–post comparisons showed statistically significant changes (p < 0.05) in trust in test results, perceived ease and comfort, confidence in self-sampling, and the speed of the process, alongside reductions in pain, nervousness, embarrassment, and the need for help. Qualitative data contextualised these findings: women valued the privacy, simplicity, and trust. However, concerns regarding correct test performance and positive results were identified. Clear instructions and community settings emerged as perceived enablers. Conclusion: HPV self-sampling was perceived as acceptable among socially vulnerable migrant women. These findings may inform considerations for cervical cancer screening implementation aimed at expanding access to cervical cancer prevention with respect to how HPV self-sampling is introduced, facilitated, and supported within trusted community settings. Further research is needed to assess whether perceived acceptability translates into sustained screening uptake and equitable screening participation across diverse implementation settings.

Objective: The aim of this scoping review was to systematically identify and map the literature on statistical and mathematical approaches used to estimate weight growth curves in children under 24 months of age. This review traces the evolution of these models and identifies knowledge gaps in these approaches. Introduction: Growth monitoring through standardized growth curves, such as those from the World Health Organization, is essential for identifying growth faltering and emerging risks such as childhood obesity. Early growth models estimated individuals’ growth trajectories, followed by fixed effects models estimating mean population growth curves. More advanced mixed effects regression models were later introduced to account for individual variations, followed by even more flexible models that allowed for the estimation of additional parameters (eg, Generalized Additive Models for Location, Scale, and Shape; SuperImposition by Translation and Rotation). Eligibility criteria: This review included studies using statistical or mathematical methodologies to estimate weight growth curves for children under 24 months of age. Studies using cohort or cross-sectional designs were included, while case series, reviews, short letters, books, and abstract-only publications were excluded. Only studies published in English, Portuguese, or Spanish were included. Methods: This review followed the JBI methodology for scoping reviews. Searches was conducted in 7 databases: PubMed, Scopus, Web of Science Core Collection, SciELO, and LILACS, with theses and dissertations retrieved from ProQuest Dissertations and Theses Citation Index and RCAAP. The search was conducted on July 25, 2024. Two reviewers independently screened titles, abstracts, and full texts, with additional studies identified through the reference lists of included articles. Two reviewers extracted data using a customized data extraction tool. The findings are summarized in tables and in a narrative synthesis. Results: A total of 4274 records was screened, resulting in the inclusion of 29 studies, published between 1987 and 2023, most employing a cohort study design. Seven studies used mathematical approaches, while 22 used statistical approaches. Based on their structural/non-structural classification, the Berkey-Reed first-order model was the most often applied (n=7), followed by the Count model (n=6). Both the Jenss-Bayley model and mixed effects regression models with fractional polynomials appeared in 4 studies each. All mathematical studies applied structural models, with the Count model being the most frequent, followed by the Berkey-Reed first-order. Among statistical studies, 13 applied non-structural models, 5 used structural models, and 4 used both types. For structural models, the mixed effects Berkey-Reed first-order was the most used (n=4), while for non-structural models, mixed effects fractional polynomials models were the most applied (n=4). Conclusions: Both structural and non-structural models incorporate random effects, with the Berkey-Reed first-order and the Jenss-Bayley being the most used structural models, and fractional polynomials and SuperImposition by Translation and Rotation (SITAR) the most used non-structural models. Machine learning techniques, namely, artificial neural networks adapted for longitudinal data while providing interpretable results, may contribute to the development of more robust growth models. Review registration: OSF https://osf.io/95udq

Background: Since 2008, Portugal’s primary healthcare (PHC) units have been evaluated and partially funded based on an extensive set of quality indicators. This study aimed to explore the process of quality indicator selection, and the criteria used to choose among indicators. Methods: We conducted a qualitative study from 2022 to 2023, combining documentary analysis of 38 meeting minutes and 19 appendices from the National Technical Committee (NTC) with semi-structured interviews of 10 NTC members responsible for selecting these indicators. Data were analysed using computer-assisted thematic analysis with an interpretive approach in MAXQDA, and findings were triangulated across sources. The study followed the Standards for Reporting Qualitative Research (SRQR) guideline. Results: Key findings highlighted the importance of indicator validity, emphasizing the need for indicators to accurately reflect clinical performance unaffected by available resources or patients’ characteristics. Relevance was also viewed as a major attribute, requiring alignment with National Health Service goals, the potential to reduce performance gaps, and scientific robustness. Feasibility (e.g. availability of data) and usability (capacity to enhance quality in practice) were also frequently mentioned. Participants raised concerns about their roles within the Committee, noting ambiguity between providing technical input and acting as political representatives, compounded by professional tensions. Many also reported a lack of clarity regarding how indicators were developed, prioritised, and supported by evidence, with limited transparency and communication throughout the process. This contrasts with best practices identified in the literature, which emphasize transparency, pilot testing, and clearly defined roles to ensure effective stakeholder engagement. Conclusions: Our findings contribute to the understanding of quality indicator selection in primary healthcare, highlighting the need for clear stakeholder roles, greater transparency, structured consensus-building, and inclusion of patient and public perspectives. Future research should be embedded within the indicator development process to support continuous learning and improvement.

The COVID-19 pandemic has significantly impacted global healthcare systems, leading to challenges in managing Long COVID. Variations in definitions and diagnostic criteria across Europe hinder recognition and treatment efforts. This study aims to analyse and compare the definitions of Long COVID used in 34 European countries. A retrospective descriptive study was conducted involving key informants from 34 European countries, utilising an online questionnaire to gather data on Long COVID definitions. Quantitative and qualitative analyses were employed to assess the variability of definitions and challenges in managing Long COVID. The study found significant variation in Long COVID definitions among the participating countries; the most frequent definition was the other definition (n: 17, 50.0%), followed by the World Health Organisation's definition (n: 16, 47.0%) and the CDC definition (n: 11, 32.3%). Half of the countries reported using multiple definitions simultaneously, indicating a lack of standardisation. Qualitative analyses highlighted challenges such as difficulties in standardising terminology, variability in clinical criteria, and issues with implementing diagnostic codes. The findings underscore the need for a unified, yet adaptable, definition of Long COVID. Such a definition would support general practitioners (GPs) by simplifying diagnostic processes, improving continuity of care, and facilitating equitable patient access to multidisciplinary resources. The current lack of consensus complicates patient care, data collection, and resource allocation, impacting health policy development. Future efforts should focus on achieving agreement on definitions to ensure equitable treatment and effective healthcare responses to Long COVID.

Decision aids (DA) are evidence-based tools that support health-related decisions. Despite their recognised value, the use of DAs in primary care remains modest. In Portugal, clinical guidelines focus on clinical decision-making with minimal patient engagement. Adapting international DAs to the Portuguese context could be an efficient way to support the transition to shared decision-making. Understanding general practitioners’ (GPs) awareness and perceptions of DAs is essential before evaluating their willingness to adopt these tools for specific clinical problems. To explore Portuguese GPs’ perceptions of DAs and their implementation in primary care. Qualitative study with GPs and GP trainees in Portugal. Seven online focus groups were conducted with 33 GPs and GP trainees selected through purposive sampling. Data were analysed using deductive content analysis. Most participants initially confused DAs with clinical decision support tools; only one recognised them as aids for shared decision-making. After clarification, GPs expressed favourable attitudes and believed that patients were willing to use DAs. Key barriers to adoption included limited funding, time constraints, and the lack of Portuguese translations. Facilitators involved system integration and localisation. Priority topics centred on prevention (screening, statin use, vaccines, contraception, lifestyle changes) and specific medications (antibiotics, hormone replacement, psychotropics). Although unfamiliar to most participants, integrating DAs in primary care was well received, and these tools may provide added value in improving the quality of health decisions. Not applicable.

Person-centred care (PCC) is a fundamental principle in general practice, emphasising practices tailored to individual patient preferences, needs, and values. Despite the importance of PCC, general practitioners (GPs) face obstacles in effectively implementing it, with associated factors remaining unclear. The PACE GP/FP study aims to explore GPs' attitudes towards PCC and the factors facilitating or hindering its implementation in daily practice across European countries. This paper outlines the PACE GP/FP study protocol. The cross-sectional design with data collection via an online survey distribution to GPs in 24 European countries. Study instruments include two validated questionnaires (Perceived Stress Scale (PSS) and Patient Physician Orientation Scale (PPOS)) and additional items covering general information about the doctor and their practice, as well as facilitators and barriers to PCC. These additional items were specifically developed for the study, translated using the forward-backward method, evaluated through cognitive debriefing, and integrated into the REDCap platform to create language and country-specific survey links. The STROBE checklist guides the reporting of the manuscript. The PACE GP/FP study will provide a comprehensive exploration of GPs' attitudes towards PCC and the factors shaping its practice in Europe. The findings from the PACE GP/FP study will provide evidence for designing future implementation strategies and guide targeted interventions to promote PCC in primary care across Europe.

Clinical reasoning significantly impacts physicians’ performance and patient care quality. Research into learning transfer within clinical reasoning education, especially in managing multimorbidity in Family Medicine, is crucial. This study evaluates the impact of concept maps (CMs) on promoting clinical reasoning skills among undergraduate students, compared to traditional teaching methods (TM). A mixed methods approach was used in a controlled, non-randomized study with fifth-year Family Medicine undergraduates allocated to sessions using either CMs or TM. Quantitative data included a feedback questionnaire and evaluation of an individual task. Qualitative data comprised responses to an open-ended question and analysis of problem representation in the individual task. Among 313 eligible students, 112 participated (CM: 60, TM: 52). Both groups reported high satisfaction with their teaching methods. The CM group valued the holistic view and organization for managing multimorbidity cases, showing higher odds of positive scores on individual tasks (differences not statistically significant). Additionally, the CM group had a more homogeneous code matrix for problem representation in two clinical vignettes. While no definitive evidence supports the superiority of CMs over traditional methods, promising trends were noted. The CM group showed improved performance in individual tasks and better organization in managing multimorbidity cases. Further investigation is recommended to explore varying levels of CM usage and modifications to pre-class workloads. Not applicable.

The COVID-19 vaccination campaign in several European countries involved collaboration between public health and Primary Health Care (PHC). To highlight the role of PHC professionals in the COVID-19 vaccination rollout, specifically in terms of vaccine administration, communication and contributing to vaccination population coverage. A descriptive retrospective study of the COVID-19 vaccination campaign across 28 European countries was conducted, covering data from December 2020 to November 2021. Data were collected by key informants recruited from each country, who were health professionals involved in their national vaccination campaigns. Utilising an ad-hoc semi-structured questionnaire, information was gathered on organisation, communication strategies, priority groups, vaccine types, and vaccination pathways in PHC. PHC participated in communication strategies in 10 out of 28 countries, and vaccination was voluntary in most of them. The priority groups for vaccination varied across Europe, and the availability of vaccines in PHC differed between countries within the European Union (EU) and non-EU countries. The BioNTech Pfizer vaccine was the most widely available vaccine in most countries, followed by Moderna and AstraZeneca. PHC administered COVID-19 vaccines to the population, being the nurses the most involved, followed by general practitioners. Vaccination appointments were available online in 18/28 or by phone in 15/28, direct appointments at health centres were available in 8/28. In several countries, healthcare professionals who administered vaccines were given extra compensation for their role. PHC professionals played a crucial role in the successful distribution and administration of COVID-19 vaccines in European countries.

Objective: This scoping review aims to provide a systematic overview of the literature on statistical models to estimate weight growth curves among infants, examining key features such as study design, sample size, and statistical approaches. Introduction: Growth models were first developed to estimate individuals’ growth curves by modeling each individual separately. Later, with the aim of estimating mean trajectories, approaches using mixed effects regression models were proposed. More flexible models were also applied in this context, enabling the estimation of more parameters (eg, Generalized Additive Models for Location, Scale, and Shape; SuperImposition by Translation and Rotation models). Inclusion criteria: Studies of statistical/mathematical methodologies for estimating weight growth curves of infants under 24 months of age, based on prospective/retrospective cohorts, or cross-sectional studies will be included. Only studies published in English, Portuguese, or Spanish will be considered. Case series reports, reviews, short letter publications, books, and abstract-only papers, such as conference proceedings, will be excluded. Methods: This review will be conducted in accordance with the JBI methodology for scoping reviews. PubMed, Scopus, Web of Science Core Collection, SciELO, and LILACS will be searched for published studies, while ProQuest and RCAAP will be searched for unpublished studies. Search results will be imported into Rayyan to remove duplicates. Two reviewers will independently screen titles, abstracts, and full-text articles. Any disagreements will be resolved through discussion or with a third reviewer. The resulting data, namely mathematical/statistical approaches and models, will be summarized in tabular format, accompanied by a narrative summary. Review registration: Open Science Framework https://osf.io/95udq