Joana Alves

Depressive disorders represent the second leading cause of disability globally, and Portugal reports the second highest prevalence in Europe. Nevertheless, the role of socioeconomic factors, behavioural determinants, and potential differences in treatment remain underexplored. This study assessed socioeconomic inequalities in depression and inequity in mental healthcare utilization among Portuguese adults aged 25–65 years, and evaluated whether health behaviours mediate the socioeconomic status (SES) and depression association. We used microdata from the 2019 Portuguese National Health Interview Survey. Depression was measured through self-report and PHQ-8 (≥10, moderate and moderately-severe; ≥20, severe). Concentration curves and indices, standardized by sex and age, assessed SES-related inequality in depression; horizontal inequity in mental healthcare utilization was estimated by adjusting for morbidity. Logistic regression models estimated the SES-depression association, and mediation by health behaviours (smoking, alcohol, sedentary lifestyle, diet, BMI) was evaluated using attenuation analysis. Overall, 13.0% reported depression in the previous year and 6.8% met PHQ-8 criteria. Both were disproportionately concentrated among lower-income groups, with the strongest inequality observed for severe depression. Horizontal inequity was also observed: specialist consultations were disproportionately used by higher-income groups when adjusting for self-reported depression, whereas medication was more concentrated among lower-income individuals meeting PHQ-8 criteria. Sedentarism, BMI, and alcohol drinking partially mediated SES-depression association, reducing effect estimates by up to 23.9%. Marked socioeconomic inequalities exist in depression and mental healthcare utilization in Portugal. Strengthening equitable access to evidence-based mental healthcare and addressing upstream behavioural and socioeconomic determinants are critical to reducing the national mental health burden.

Background and objectives Herpes zoster (HZ) and associated complications comprise a considerable public health burden in older adults. This study aimed to evaluate the cost-effectiveness of recombinant zoster vaccine (RZV) versus no vaccine for the prevention of HZ in older adults in Portugal. Methods A static multicohort Markov model (ZONA) was adapted to the Portuguese context. The base-case compared RZV with no vaccination in a hypothetical cohort of 1 million adults aged ≥65 years. Real-world data were used for first-dose coverage (56.1%) and second-dose completion (67.2%), with vaccine efficacy and waning based on 11-year follow-up data. Outcomes were calculated over a lifetime horizon from the societal perspective, with a 4% discount applied to costs and quality-adjusted life years (QALYs). In the base-case, HZ incidence was based on previously reported European data. Sensitivity analyses were performed, and a scenario analysis explored the impact of alternative HZ incidence rates based on recent Portuguese data. Results Over a lifetime horizon, RZV was estimated to prevent 45,551 HZ cases, 9056 post-herpetic neuralgia (PHN) cases, 5580 cases with other non-PHN complications, and 6 HZ deaths. The incremental cost-effectiveness ratio (ICER) from the societal perspective was €48,707 per QALY gained, below a hypothetical willingness-to-pay threshold of two times the gross domestic product per capita per QALY gained (equivalent to €62,200). This base-case ICER was most sensitive to the annual incidence of initial HZ. In the scenario analysis, exploring higher HZ incidence based on Portuguese data, the estimated ICER was €41,877 per QALY gained. In both the base-case and the scenario analyses, ICERs were lowest in individuals aged 65–69 years, with ICERs ranging from €36,207 to €42,700 per QALY gained, in the scenario analysis and base case, respectively. Conclusions RZV presents a cost-effective option for the prevention of HZ and its complications in Portuguese adults aged ≥ 65 years, with greater cost effectiveness in those aged 65–69 years.

By March 2020, the first COVID-19 cases were detected in Portugal. Anecdotal evidence showed that the National Health Service absenteeism rate rose. The present study aimed to quantify and characterize the absenteeism rate among these healthcare workers during the COVID-19 pandemic in Portugal. This study used data from the Portuguese National Health Service Transparency Portal for the number of National Health Service workers and absence days (2015 - 2021). Absenteeism was compared, before and after the pandemic onset, in absolute terms, and as absenteeism rates. Additionally, we performed an interrupted time series analysis, by fitting a Poisson regression model with level change. We controlled for data seasonality using Fourier terms. The results showed that, between 2015 and March 2020, the average monthly absenteeism rate was of 12.2%, rising to 14.5% in the subsequent period. This represented an increase of 19% in the absenteeism rate. The interrupted time series analysis showed an increase of 10.8% in the National Health Service absenteeism rate after the pandemic onset [relative risk = 1.10; 95% CI 1.10 - 1.11; p < 0.01]. When accounting for seasonality in the data, the interrupted time series analysis showed an increase of 11.0% in the National Health Service absenteeism rate [relative risk = 1.11; 95% CI 1.00 - 1.23; p < 0.05]. These results suggest an increased number of days of absence rate among the National Health Service healthcare workers during the COVID-19 pandemic.

Introduction: Diabetes, particularly type 2 diabetes (T2D), stands as one of the leading noncommunicable diseases worldwide. In Portugal, the prevalence of diabetes has surged, with T2D affecting 14% of adults in 2021. Its repercussions extend beyond individual health, deeply impacting familial, social, and community dynamics, presenting a significant public health challenge globally. Objectives: The VA|PREVENTION project (https://doi.org/10.54499/2022.02969.PTDC) aims to assess the (cost-) effectiveness and implementation of an innovative person-centered digital intervention to prevent T2D among high-risk adults. Methodology: A comprehensive approach encompasses the Behavior Change Wheel for intervention design, scalability principles, the WHO guidelines for digital health interventions, co-design, and the ISO framework for usability assessment. Evaluation will be pursued through a type 1 hybrid effectiveness-implementation study (randomized controlled trial), supplemented by qualitative and economic studies. Results: The web application prototype features Ema, an automated virtual human coach (VHC), educational menus and a dashboard (version 1.0). Co-design included 2 workshops with 11 representatives of end-users and health professionals. Ema uses standardized techniques from an ontology to support behavior change, based on an initial assessment of low-level target behaviors (e.g. walking, fruit consumption, and reducing red meat intake), and barriers to performing these behaviors. Ema communicates in a helpful-cooperative style using a synthetic voice in European Portuguese, with its speech also appearing as subtitles on the interface. Users interact with Ema by pressing buttons or entering data, such as the daily number of steps. Ethics approval was granted for usability assessment with end-users. Conclusions: The project is expected to yield health, scientific, technological, and policy impacts, powered by an exploitation and sustainability roadmap. Key messages: • Innovative type 2 diabetes prevention through a scalable web app with a virtual human coach. • Comprehensive and robust approach for developing and evaluating the digital behavior change intervention.

Background: Incentivizing healthcare professionals through pay-for-performance (P4P) schemes has become an essential strategy to enhance healthcare quality and efficiency. In Portugal, a P4P framework was put in place in Primary Health Care (PHC). Understanding how these incentives influence healthcare delivery is crucial for optimizing P4P effectiveness. Objectives: This scoping review aims to compare the impacts of intrinsic and extrinsic incentives of P4P schemes within PHC teams. Methods: We are conducting a comprehensive scoping review following the PRISMA-ScR guidelines. The databases PubMed/MEDLINE, Scopus, Web of Science, and PsycINFO are being searched to identify experimental and quasi-experimental studies. Eligible studies focused on PHC providers organized in teams, examining the role of intrinsic and extrinsic incentives under both public and private healthcare settings. Results: Preliminary findings include a Dutch study demonstrating significant improvements in adherence to prescribing guidelines through electronic health records based P4P indicator. In Ethiopia, performance-based non-financial incentives led to enhanced data quality and evidence utilization among health workers. Conversely, a study from Burkina Faso highlighted mixed results in antenatal care quality improvement despite incentive implementation. In Scotland, studies on the removal of financial incentives indicated potential declines in certain quality care metrics, suggesting the complexities involved in the direct and indirect effects of incentive withdrawal. Conclusions: The preliminary evidence indicates that both intrinsic and extrinsic incentives can significantly impact the effectiveness of P4P schemes, though the nature and magnitude of these impacts vary considerably. The findings underscore the necessity of a nuanced approach to designing and implementing incentive mechanisms in PHC to foster sustainable improvements in healthcare quality. Key messages: • Intrinsic and extrinsic incentives significantly influence P4P scheme effectiveness in PHC. • Designing P4P incentives requires nuanced consideration of varying impacts on healthcare quality.

Background: While it is known that educational inequalities in smoking start during early and middle adolescence, it is unknown how they further develop until adulthood. The aim of this article is to map, in the Portuguese context, how educational inequalities in smoking emerge from pre-adolescence until young adulthood. Methods: This study used longitudinal data from the EPITeen Cohort, which recruited adolescents enrolled in schools in Porto, Portugal. We included the 1,038 participants followed at ages 13 (2003/2004), 17, 21, and 24 years. We computed the odds ratio (OR) for the prevalence of smoking states (never smoking, experimenter, less-than-daily, daily and former smoker) and the incidence of transitions between these states, as function of age and education, stratified by sex. We also added interaction terms between age and education. Results: Educational inequalities in daily smoking prevalence, with higher prevalence among those with lower educational level, emerged at 17 years old and persisted until higher ages. They were formed in a cumulative way by the increased risk of experimenting between 13 and 17 years, and increased risk of becoming daily smoker between 17 and 21 years. The incidence of smoking cessation was higher among the higher educated. Inequalities were formed similarly for women and men, but with lower level and showed no significance among women. Conclusions: These results highlight that actions to prevent smoking should also take in account the potential impact in smoking inequalities, and should focus not only on middle adolescence but also on late adolescence and early adulthood.

Background While it is known that educational inequalities in smoking start during early and middle adolescence, it is unknown how they further develop until adulthood. The aim of this article is to map, in the Portuguese context, how educational inequalities in smoking emerge from pre-adolescence until young adulthood. Methods This study used longitudinal data from the EPITeen Cohort, which recruited adolescents enrolled in schools in Porto, Portugal. We included the 1,038 participants followed at ages 13 (2003/2004), 17, 21, and 24 years. We computed the odds ratio (OR) for the prevalence of smoking states (never smoking, experimenter, less-than-daily, daily and former smoker) and the incidence of transitions between these states, as function of age and education, stratified by sex. We also added interaction terms between age and education. Results Educational inequalities in daily smoking prevalence, with higher prevalence among those with lower educational level, emerged at 17 years old and persisted until higher ages. They were formed in a cumulative way by the increased risk of experimenting between 13 and 17 years, and increased risk of becoming daily smoker between 17 and 21 years. The incidence of smoking cessation was higher among the higher educated. Inequalities were formed similarly for women and men, but with lower level and showed no significance among women. Conclusions These results highlight that actions to prevent smoking should also take in account the potential impact in smoking inequalities, and should focus not only on middle adolescence but also on late adolescence and early adulthood.

Background: By March 2020, the first Covid-19 cases were detected in Portugal. While the National Health Service (NHS) faced an increased demand for health care, anecdotal evidence showed that the NHS absenteeism rose. This might be explained by outbreaks in healthcare units, COVID-19 infection due to close contact with patients, self-isolation and quarantines, and family challenges originated by lockdowns. The present work aimed to quantify the absenteeism among NHS workers during the COVID-19 pandemic in Portugal. Methods: This study used data for the number of NHS workers and absence days (2015-2021), from the Portuguese NHS Transparency Portal and the Strategy and Planning Office. Absenteeism was compared, before and after the pandemic onset, in absolute terms, and as absence rates (number of absent days as a percentage of potential workforce days). Additionally, we performed an interrupted time series analysis, by fitting a Poisson regression model with level change. We controlled for data seasonality using Fourier terms (pairs of sine and cosine functions). Results: From 2015 until March 2020, the average monthly absence rate was of 12.2, rising to 14.4 in the remaining period. This represented an increase of 18% in the absence rate. The interrupted time series showed an increase of 10.8% in the NHS absenteeism after the pandemic onset [Relative risk =1.10; 95% confidence interval (CI) 1.10-1.11; p < 0.01]. When accounting for seasonality in the data, the model showed an increase of 11.0% in the NHS absenteeism [Relative risk =1.11; 95% CI 1.01-1.22; p < 0.05]. Conclusions: These results highlight the excess of absence days among the NHS workers during the COVID-19 pandemic. In future healthcare crises, health professionals should be protected, by assuring a safe workplace and making protective equipment available. Only then will be possible to reduce constraints in healthcare assistance, guarantee the adequate response, and contain the absence costs. Key messages:

Previous literature has showed that the likelihood of smoking is higher among offspring with smoking parents. The aim of this cohort study is to investigate during which smoking initiation stages and at what ages adolescents are more likely to be influenced by parental smoking. This study used the EPITeen Cohort, which recruited 13-year-old adolescents born in 1990, enrolled at schools in Porto, Portugal. Participants (n = 996) were followed across four waves at 13, 17, 21 and 24 years old. We computed the odds ratio (OR) and 95% confidence intervals for the prevalence of the different smoking states (never smoking, experimenter, less than daily smoker, daily smoker and former smoker), and incidence transitions between these states (to smoking experimenter; to less than daily smoker, to daily smoker; to former smoker) as function of age, parental smoking status and their interaction. Compared with other participants, those with two smoking parents had an increased prevalence of experimentation at 13 years (OR for the interaction at 13 years compared with 24 years = 2.13 [1.50–3.01]) and daily smoking at all ages (OR for parental smoking =1.91 [1.52–2.40]). The latter increase is related to a significantly increased risk to transit from early smoking stages to daily smoking at all ages (OR for parental smoking = 1.83 [1.43–2.34]). Parental smoking influences offspring’s daily smoking prevalence especially by increasing the risk to transit to daily smoking up to early adulthood. Prevention should focus on parents and parental influences especially among offspring who may transition to daily smokers.