Implementation gaps of the Portuguese National Health Plan: a stakeholders’ perception analysis

Background

The Portuguese National Health Plan (PNS) 2012-2016, extended to 2020, was the strategic health document shaping the direction of intervention within the Health System. The National Institute of Health Doutor Ricardo Jorge (INSA) is the institution responsible for carrying out its final evaluation. To underpin PNS final evaluation a multistep process was designed.

Methods

A mixed methods study using a convenience sample was implemented to assess stakeholders’ perception about five PNS dimensions: dissemination, communication, implementation, impact, and evaluation. For this purpose, two different tools were used. Semi-structured interviews with former health policy managers were conducted. In addition, an online survey was designed and widely distributed to additional stakeholders. From October 2019 to February 2020, data was collected using two separate instruments. Integral transcriptions of the interviews were made. Qualitative content analysis and quantitative descriptive analysis were used.

Results

A total of 12 interviews and 179 valid surveys were obtained. Regarding stakeholders’ perception about PNS implementation process, there was an overall positive recognition about the strategic and operational relevance of the PNS, as a common dialogue platform and a tool for health improvements both for health status and health system function in Portugal. Among pointed implementation barriers, management was mentioned as the major constraint, mainly due to shortage of human and financial resources to carry out the recommended interventions within the PNS timeline.

Conclusions

As part of the evaluation process the research team found relevant gain knowledge of the wider context in which PNS was developed and implemented, based on stakeholders’ perception. Their considerations are important not only to support the definition of the questions and criteria for PNS final evaluation, but also to highlight key issues for the future policy cycle.

Key messages

Low levels of TiO2-nanoparticles interact antagonistically with Al and Pb alleviating their toxicity

The contamination and bioavailability of deleterious metals in arable soils significantly limits crop development and yield. Aiming at mitigating Pb- and Al-induced phytotoxicity, this work explores the use of P25 titanium dioxide nanoparticles (nTiO₂) in soil amendments. For that, Lactuca sativa L. plants were germinated and grown in the presence of 10 ppm Pb or 50 ppm Al, combined or not with 5 ppm nTiO₂. Growth parameters, as well as endpoints of the redox state [cell relative membrane permeability (RMP), thiobarbituric acid reactive substances content, total phenolic content and photosynthesis (sugars and pigments levels, chlorophyll a fluorescence and gas exchange), were evaluated. Concerning Al, nTiO₂ treatment alleviated the impairments induced in germination rate, seedling length, water content, RMP, stomatal conductance (g_s), intercellular CO₂ (C_i), and net CO₂ assimilation rate (P_N). It increased anthocyanins contents and effective efficiency of photosystem II (Φ_PSII). In Pb-exposed plants, nTiO₂ amendment mitigated the effects in RMP, P_N, g_s, and C_i. It also increased the pigment contents and the transpiration rate (E) comparatively to the control without nTiO₂. These results clearly highlight the high potential of low doses of nTiO₂ in alleviating metal phytotoxicity, particularly the one of Pb. Additionally, further research should explore the use of these nanoparticles in agricultural soil amendments.

Trends in breastfeeding rates in Portugal: results from five National Health Interview Surveys

Background

The World Health Organization advice breast milk as the perfect food for the newborn starting immediately after birth and exclusively up to at least 6 months of age. However, there are considerable differences in breastfeeding rates between countries related to their policies on breastfeeding promotion and duration of maternity leave. This study aims to describe changes in breastfeeding rates over time in Portugal as a way to inform social policies and public health initiatives on breastfeeding.

Methods

To examine the breastfeeding rates evolution we used data from five National Health Surveys. Breastfeeding was assessed based on information provided by the mothers of children born between 1982 and 2014. Birth cohorts were grouped in block of 3-year period. We estimated 3 and 6-months exclusive breastfeeding rates and 95% confidence intervals. Trends in breastfeeding rates for each outcome were assessed by linear regression weighting each cohort-specific estimate by the inverse of variance in the logit scale.

Results

We analyzed data on 9172 children; sample size by birth cohort ranged from 213 in 2012/14 to 1651 in 1994/96. Proportion of infants ever breastfed during the study period varied between 71.7% and 86.7%. The 3 months exclusive breastfeeding rate increased by 9.5% (CI95%:7.8-11.3%) per 3-year period, from 41.3% (CI95%:38.7-43.9%) in 1982/84 to 62.4% (CI95%:55.7-68.7%) in 2012/14. The 6 months exclusive breastfeeding rate raised up from 23.5% (CI 95%:21.2-25.7%) in 1982/84 to 31.9% (CI95%:26.0-38.5%) in 2012/14, corresponding to 5.6% increase per 3-year period.

Conclusions

This study shows a positive evolution in breastfeeding practices, with an increased in the prevalence of women who reported exclusively breastfeeding until the 3rd and 6th month after birth. Our results may be explained by changes in maternity leave duration. Furthermore, the results emphasize the need for further investment in breastfeeding support services and professionalś training.

Key messages

Positive evolution in breastfeeding practices in Portugal. Maternity leave duration could have a positive role.

Descriptive analyse of a case control study in Portugal: identify to prevent

Background

Prenatal exposure to environmental risk factors are one of the known causes of congenital anomalies (CA). In 2015, a cluster of anorectal anomalies, a rare malformation, in Setúbal district raised interest in researchers. The aim of study was to assess the impact of prenatal exposure of the mothers on the occurrence of CA in the offspring.

Methods

A Case-control study (1:2) was implemented between 2016-2019. Newborns with CA (cases) and newborns without CA (controls) are identified and recruited. Parents were personally interviewed by a health professional using a standardized questionnaire. A descriptive analyses was performed and cases and controls were described based on maternal residence during pregnancy. Chi-square test was used to compare cases and controls.

Results

97 cases and 194 controls were identified. There was a male predominance in the case group (60 vs. 34) and no difference in gestational age between case and control groups. The mean birth weight was similar (3115g in cases vs. 3221g in controls). There was no difference related to mean mother's age nor the presence of maternal chronic disease. Smoking had more expression in the case group (21,2% vs. 16,3%). Moita (37,8%) is the municipality with higher frequency of cases. Musculoskeletal anomalies were the most frequent (35.4%), followed by genital (22.2%) and other anomalies (11%). During the study period, five cases with anorectal anomalies were reported, 4 of them born at 2016 and in 3 the mothers residence place was Moita.

Conclusions

In this study, the high proportion of cases from Moita suggests a possible environmental exposure to a teratogenic agent. Also smoking during pregnancy could be a high risk to anorectal anomalies, as suggested in other studies. More investment in public health measures could protect population from harmful environments.

Key messages

Pprenatal exposure to environemental risk factors increase the risk of congenital anomalies. Mothers residence and place of work could be a risk factor to pregnancy.

Neural tube defects: how many cases could have been prevented in Portugal?

Neural tube defects (NTD) occurs when the neural tube does not close properly until the 28th day of foetal life. About 70% of NTD can be prevent if women start folic acid (FA) before pregnancy and until the end of 1st trimester. Portugal has this primary prevention since 1998, however the secondary prevention of NTD with TOPFA is still high (80%). The aim of this study is to describe when FA intake was started and estimate the number of cases that would have be prevented if FA intake started before pregnancy as recommended.

A cross-sectional study using data from the National Registry of Congenital Anomalies between 2004-2017 was performed. The temporal evolution of the beginning of FA intake was analysed with Cochran-Armitage test for proportions. The proportion of preventable cases was estimated considering the 70% prevention fraction and the number of NTD cases registered in RENAC that occurred in pregnancies without the recommended FA supplementation.

On average, 13.8% of all women started FA before pregnancy, 46.2% during 1st trimester and 6.1% did not take folic acid. A statistically significant trend (p < 0.001) was observed in the group that started before pregnancy with increase from 6.8% in 2004 to 17.9% in 2017. The prevalence of NTD was 4.2 cases / 10,000 births, ranging from 2 cases / 10,000 births (2007) to 7 cases / 10,000 births (2014). Between women who had a pregnancy with NTD, 16.8% started FA before pregnancy, 42.2% in the 1st trimester and 9.7% did not take the supplement. If all women had started FA before pregnancy, an estimated 202 NTD cases could have been prevented.

In Portugal, the proportion of women who adhere to this measure is very low, similarly to other European countries, compromising the primary prevention of NTD. Perhaps due to the high percentage of TOPFA, the idea that this anomalies continue to affect our children has been lost. Primary prevention of NTDs should be encouraged with measures that promote FA supplementation.

Key messages

Primary prevention of NTD is possible. Proportion of women who adhere to primary prevention is low.

Effect of lifestyle on blood pressure in Portuguese population under antihypertensive drugs

Background

Hypertension is one of the main risk factors for disability and death from cardiovascular diseases. Current guidelines include initiatives to control blood pressure values in hypertensive patients that focus on lifestyle changes. The main objective of this study was to estimate the association between lifestyle and blood pressure in patients under antihypertensive drugs.

Methods

An analysis of the data of Portuguese Health Examination Survey (INSEF) was performed. Individuals who met INSEF inclusion criteria and who referred to be under antihypertensive drugs in the two weeks prior to the questionnaire were studied. Lifestyle variables (alcohol consumption, smoking, additional salt intake, fruit and vegetables consumption, practice of physical activity) were measured by questionnaire, and blood pressure values were obtained by physical examination. Associations between lifestyle factors and blood pressure, stratified by sex and adjusted to sociodemographic variables and to obesity, were estimated through a multiple linear regression model.

Results

Alcohol consumption (ß=6.31, p = 0.007) and smoking (ß=4.72, p = 0.018) were associated with systolic blood pressure in men. Additional salt intake, fruit and vegetable consumption, and practice of physical activity were not associated with blood pressure in men. In women, no association was observed for any behavioural variable.

Conclusions

These conclusions reinforce the need, also in the population under antihypertensive drugs, particularly in the male sex, to focus the fight against high systolic blood pressure in these two modifiable and preventable behaviours: smoking and alcoholic consumption.

Key messages

Alcohol consumption and smoking are the behavioral determinants associated with high systolic blood pressure values in men under antihypertensive drugs. These conclusions reinforce the need to focus the fight against high systolic blood pressure in the preventable and modifiable behavioural determinants.

A long-term pulmonary rehabilitation program progressively improves exercise tolerance, quality of life and cardiovascular risk factors in patients with COPD

BACKGROUND

Support and treatment options have been widely discussed in recent decades with the aim of improving morbidity, mortality and quality of life of chronic respiratory disease (COPD) patients. Although it is believed that longer pulmonary rehabilitation programs can provide better results, most of the evidence comes from short-term programs.

AIM

To determine the effects of an outpatient pulmonary rehabilitation program on exercise tolerance, dyspnoea, hemodynamic variables and quality of life.

DESIGN

Case series study.

SETTING

Rehabilitation Centre.

POPULATION AND METHODS

A convenience sample of COPD patients was enrolled in this study. The intervention consisted of a 96-wk exercise training program, including aerobic training, upper-limb exercises and inspiratory muscle training. Pulmonary function tests, blood biochemistry, six-minute walking distance test and health-related quality of life were recorded at baseline and after completion of the 6th, 12th, 18th, 24th months.

RESULTS

Forty one consecutive COPD patients were recruited and thirty six completed the study. There was a significant improvement in hemodynamics, demonstrated by the gradual reduction in heart rate, blood pressure and MvO2 (double product) starting from the 12th month. Lipid profile showed a reduction of low density lipids and an increase of the high density lipids levels starting from the 6th month. Exercise tolerance, dyspnoea, respiratory muscle strength and quality of life also improved starting from the 6th month.

CONCLUSION

A 24-month pulmonary rehabilitation program leads to a progressive improvement in quality of life, dyspnoea and exercise tolerance, and reduces cardiovascular risk factors in patients with chronic obstructive pulmonary disease.

IMPACT

Our study suggests that long-term pulmonary rehabilitation programs can result in further improvements in the aforementioned cardiorespiratory variables.

Anorectal malformations and pregnancy-related disorders: a registry-based case-control study in 17 European regions

OBJECTIVE

To identify pregnancy-related risk factors for different manifestations of congenital anorectal malformations (ARMs).

DESIGN

A population-based case-control study.

SETTING

Seventeen EUROCAT (European Surveillance of Congenital Anomalies) registries, 1980-2008.

POPULATION

The study population consisted of 1417 cases with ARM, including 648 cases of isolated ARM, 601 cases of ARM with additional congenital anomalies, and 168 cases of ARM-VACTERL (vertebral, anal, cardiac, tracheo-esophageal, renal, and limb defects), along with 13 371 controls with recognised syndromes or chromosomal abnormalities.

METHODS

Multiple logistic regression analyses were used to calculate adjusted odds ratios (ORs) for potential risk factors for ARM, such as fertility treatment, multiple pregnancy, primiparity, maternal illnesses during pregnancy, and pregnancy-related complications.

MAIN OUTCOME MEASURES

Adjusted ORs for pregnancy-related risk factors for ARM.

RESULTS

The ARM cases were more likely to be firstborn than the controls (OR 1.6, 95% CI 1.4-1.8). Fertility treatment and being one of twins or triplets seemed to increase the risk of ARM in cases with additional congenital anomalies or VACTERL (ORs ranging from 1.6 to 2.5). Maternal fever during pregnancy and pre-eclampsia were only associated with ARM when additional congenital anomalies were present (OR 3.9, 95% CI 1.3-11.6; OR 3.4, 95% CI 1.6-7.1, respectively), whereas maternal epilepsy during pregnancy resulted in a five-fold elevated risk of all manifestations of ARM (OR 5.1, 95% CI 1.7-15.6).

CONCLUSIONS

This large European study identified maternal epilepsy, fertility treatment, multiple pregnancy, primiparity, pre-eclampsia, and maternal fever during pregnancy as potential risk factors primarily for complex manifestations of ARM with additional congenital anomalies and VACTERL.

Cardiopulmonary exercise testing variables as predictors of long-term outcome in thoracic sarcoidosis

Cardiopulmonary exercise testing (CPET) plays an important role in the assessment of functional capacity in patients with interstitial lung disease. The aim of this study was to identify CPET measures that might be helpful in predicting the vital capacity and diffusion capacity outcomes of patients with thoracic sarcoidosis. A longitudinal study was conducted on 42 nonsmoking patients with thoracic sarcoidosis (median age = 46.5 years, 22 females). At the first evaluation, spirometry, the measurement of single-breath carbon monoxide diffusing capacity (D_LCOsb) and CPET were performed. Five years later, the patients underwent a second evaluation consisting of spirometry and D_LCOsb measurement. After 5 years, forced vital capacity (FVC)% and D_LCOsb% had decreased significantly [95.5 (82-105) vs 87.5 (58-103) and 93.5 (79-103) vs 84.5 (44-102), respectively; P < 0.0001 for both]. In CPET, the peak oxygen uptake, maximum respiratory rate, breathing reserve, alveolar-arterial oxygen pressure gradient at peak exercise (P(A-a)O₂), and Δ SpO₂ values showed a strong correlation with the relative differences for FVC% and D_LCOsb% (P < 0.0001 for all). P(A-a)O₂ ≥22 mmHg and breathing reserve ≤40% were identified as significant independent variables for the decline in pulmonary function. Patients with thoracic sarcoidosis showed a significant reduction in FVC% and D_LCOsb% after 5 years of follow-up. These data show that the outcome measures of CPET are predictors of the decline of pulmonary function.

Trends of food intake in Portugal, 1987–1999: results from the National Health Surveys

OBJECTIVE

To assess trends of food intake in Portugal.

DESIGN

Analysis of three cross-sectional studies: 1987, 1995-1996 and 1998-1999.

SETTING

Representative samples of free-living individuals.

SUBJECTS

64 734 men and 71 282 women.

INTERVENTIONS

Food intake was assessed by questionnaires inquiring the number of meals and which foodstuffs (fish, meat, milk, rice/pasta/potatoes, soup, vegetables and fruit) had been consumed the day before.

RESULTS

Age-adjusted average number of meals decreased from 3.3+/-0.1 in 1987 to 2.9+/-0.1 in 1998-1999 in both genders (P<0.001). In men, the percentage of subjects consuming meat, milk and potatoes/rice/pasta increased from 73, 66 and 91% in 1987 to 83, 74 and 95% in 1998-1999, respectively. The percentage of subjects consuming soup and fish decreased from 70 and 56% in 1987 to 62 and 53% in 1998-1999, respectively. In women, the percentage of subjects consuming meat, milk, potatoes/rice/pasta and vegetable increased from 70, 66, 89 and 71% in 1987 to 78, 77, 93 and 83% in 1998-1999, respectively. The percentage of subjects consuming soup and fish decreased from 70 and 55% in 1987 to 64 and 53% in 1998-1999, respectively. These trends were more pronounced in the younger age, which also displayed a higher frequency of snacking. Multivariate analysis adjusting for age group, region and educational level showed that the consumption of meat, milk and vegetables increased and the consumption of soup, fish and fruit decreased in 1998-1999 relative to 1995-1996.

CONCLUSIONS

Within a decade, the Portuguese dietary pattern has changed considerably, shifting from a traditional, south European to a more Westernized, protein-rich diet.

SPONSORSHIP

The Unidade de Nutrição e Metabolismo of the Instituto de Medicina Molecular is partially funded by a grant from the FCT (Fundação para a Ciência e a Tecnologia) ref. RUN 437.

Milk intake is inversely related to obesity in men and in young women: data from the Portuguese Health Interview Survey 1998–1999

OBJECTIVE

To assess the relationships between milk intake and body mass index (BMI) in a representative sample of the mainland Portuguese population.

DESIGN

Cross-sectional study.

SETTING

National Health Interview Survey 1998-1999. Average daily milk intake was calculated by a frequency questionnaire that also assessed the average volume of one serving. BMI was derived from the subject's reported height and weight.

SUBJECTS

A total of 17,771 men and 19 742 women aged > or =18 y.

RESULTS

In men, milk intake was inversely related to BMI (r = -0.10, P < 0.001), whereas the relationship in women was weaker (r = -0.06, P < 0.001). In men, prevalence of milk consumers was lower in obese (62%) and in overweight (68%) than in normal weight subjects (71%, P < 0.001). After adjusting for age, region, physical activity, smoking, number of meals and educational level, milk intake decreased with increasing BMI (adjusted mean +/- s.e.: 280 +/- 5, 266 +/- 5 and 246 +/- 7 ml/day for normal, overweight and obese subjects, respectively, P < 0.001), even after excluding subjects who did not consume milk (368 +/- 5, 353 +/- 6 and 346 +/- 8 ml/day, P < 0.02). In women, prevalence of milk consumers was lower in obese (71%) and in overweight (72%) than in normal weight subjects (76%, P < 0.001). In women younger than 55 y, milk intake decreased with increased BMI categories (291 +/- 9, 271 +/- 10 and 269 +/- 11 ml/day for normal, overweight and obese subjects, respectively, P < 0.001), whereas no relationship was found in the older group.

CONCLUSIONS

Increased calcium intake is slightly but significantly negatively related with BMI in men and premenopausal women. The lack of relationship in older women might be due to the hormonal status, but awaits further investigation.

Evaluation of cDNA libraries from different developmental stages of Schistosoma mansoni for production of expressed sequence tags (ESTs)

A comparative study of the gene expression profile in different developmental stages of Schistosoma mansoni has been initiated based on the expressed sequence tag (EST) approach. A total of 1401 ESTs were generated from seven different cDNA libraries constructed from four distinct stages of the parasite life cycle. The libraries were first evaluated for their quality for a large-scale cDNA sequencing program. Most of them were shown to have less than 20% useless clones and more than 50% new genes. The redundancy of each library was also analyzed, showing that one adult worm cDNA library was composed of a small number of highly frequent genes. When comparing ESTs from distinct libraries, we could detect that most genes were present only in a single library, but others were expressed in more than one developmental stage and may represent housekeeping genes in the parasite. When considering only once the genes present in more than one library, a total of 466 unique genes were obtained, corresponding to 427 new S. mansoni genes. From the total of unique genes, 20.2% were identified based on homology with genes from other organisms, 8.3% matched S. mansoni characterized genes and 71.5% represent unknown genes.

[Total cholesterol and high-density lipoprotein cholesterol in patients with non-insulin-dependent diabetes mellitus]

Non-insulin-dependent diabetics often have quantitative changes in plasma lipid profiles characterised by higher triglycerides and lower HDL-cholesterol than the average population. This paper summarises the cross-sectional data (reported by the general practitioners participating in Medicos-Sentinela) concerning total and HDL-cholesterol in a cohort of non-insulin-dependent diabetics treated at primary care settings in Portugal. Total cholesterol and High Density Lipoprotein (HDL) associated cholesterol were significantly higher in women. Total cholesterol increased significantly with age (in women), regular alcohol intake, body mass index, systolic blood pressure and diastolic blood pressure (in males). HDL-cholesterol showed significant increase with age (both sexes and males only), gender, and alcohol intake in males. The increase in total cholesterol found in patients with regular alcohol intake is an infrequently reported finding.

Joint inflammation provoked by a local synovial allergic reaction

Homocytotropic antibody was stimulated in animals by administering protein antigens in a vaccine with B. pertussis adjuvant. The titers of the allergic antibody responses were judged by passive cutaneous anaphylaxis reactions. Sera or globulin fractions containing high titers of antibody activity were injected into the knee joints of experimental animals. After sufficient delay for unfixed proteins to be cleared from the knee joints, animals were challenged intravenously with the corresponding antigen. The resultant local reaction of swelling and warmth (passive synovial anaphylaxis) was judged visually and by scanning procedures. Histological studies showed evidence of mast cell degranulation concurrent with synovial reaction.