Problemas ligados ao álcool em centros de emergência (PLACE)-People experiencing homelessness with alcohol-related problems in Lisbon's emergency shelters during the COVID-19 pandemic: a description and analysis of a harm reduction intervention.

Introduction: Alcohol-related problems disproportionally affect people experiencing homelessness. As the first wave of the COVID-2019 pandemic spread in 2020, a number of emergency shelters were opened in Lisbon. Increased difficulties in obtaining alcohol could have led to an increased incidence of alcohol withdrawal. Therefore, a low-threshold harm reduction intervention was introduced to these emergency shelters. This consisted of a fixed medication treatment, made available immediately for those with specific conditions, without the need for a medical evaluation or abstinence from alcohol, together with an offer of subsequent access to specialized addiction centers. The Problemas Ligados ao Álcool em Centros de Emergência (PLACE) study (alcohol-related problems in emergency shelters) is a retrospective mixed-methods observational study. It describes the demographic, health, and social characteristics of shelter users participating in the program and aims to evaluate the intervention as well as the experience of the patients, professionals, and decision-makers involved. Results: A total of 69 people using shelters self-reported alcohol-related problems. Among them, 36.2% of the people accepted a pharmacological intervention, and 23.2% selected an addiction appointment. The take-up of the intervention was associated with better housing outcomes. A description of an individual's trajectory after leaving the shelter is provided. Discussion: This study suggests that non-abstinence-focused interventions can be useful and well-tolerated in treating addiction in this population.

The Association Between Chronic Disease and Serious COVID-19 Outcomes and Its Influence on Risk Perception: Survey Study and Database Analysis.

BACKGROUND: COVID-19, a viral respiratory disease first reported in December 2019, quickly became a threat to global public health. Further understanding of the epidemiology of the SARS-CoV-2 virus and the risk perception of the community may better inform targeted interventions to reduce the impact and spread of COVID-19. OBJECTIVE: In this study, we aimed to examine the association between chronic diseases and serious outcomes following COVID-19 infection, and to explore its influence on people's self-perception of risk for worse COVID-19 outcomes. METHODS: This study draws data from two databases: (1) the nationwide database of all confirmed COVID-19 cases in Portugal, extracted on April 28, 2020 (n=20,293); and (2) the community-based COVID-19 Barometer survey, which contains data on health status, perceptions, and behaviors during the first wave of COVID-19 (n=171,087). We assessed the association between relevant chronic diseases (ie, respiratory, cardiovascular, and renal diseases; diabetes; and cancer) and death and intensive care unit (ICU) admission following COVID-19 infection. We identified determinants of self-perception of risk for severe COVID-19 outcomes using logistic regression models. RESULTS: Respiratory, cardiovascular, and renal diseases were associated with mortality and ICU admission among patients hospitalized due to COVID-19 infection (odds ratio [OR] 1.48, 95% CI 1.11-1.98; OR 3.39, 95% CI 1.80-6.40; and OR 2.25, 95% CI 1.66-3.06, respectively). Diabetes and cancer were associated with serious outcomes only when considering the full sample of COVID-19-infected cases in the country (OR 1.30, 95% CI 1.03-1.64; and OR 1.40, 95% CI 1.03-1.89, respectively). Older age and male sex were both associated with mortality and ICU admission. The perception of risk for severe COVID-19 disease in the study population was 23.9% (n=40,890). This was markedly higher for older adults (n=5235, 46.4%), those with at least one chronic disease (n=17,647, 51.6%), or those in both of these categories (n=3212, 67.7%). All included diseases were associated with self-perceptions of high risk in this population. CONCLUSIONS: Our results demonstrate the association between some prevalent chronic diseases and increased risk of worse COVID-19 outcomes. It also brings forth a greater understanding of the community's risk perceptions of serious COVID-19 disease. Hence, this study may aid health authorities to better adapt measures to the real needs of the population and to identify vulnerable individuals requiring further education and awareness of preventive measures.

'I Didn't Know Where to Go': A Mixed-Methods Approach to Explore Migrants' Perspectives of Access and Use of Health Services during the COVID-19 Pandemic.

The COVID-19 pandemic put pressure on health systems, affecting populations' use of health services, especially those experiencing increased difficulties in healthcare access, as some migrant groups. This study aimed to investigate access and use of health services during the COVID-19 pandemic among migrants in Portugal. A mixed-methods approach was used. A community-based cross-sectional survey was conducted involving migrant communities residing in the Lisbon Metropolitan Area. Analyses of a subsample of participants (n = 929) examined factors associated with perceived worsening of access to health services during the pandemic. Semi-structured interviews with 14 migrants were conducted and thematically analyzed to further understand experiences and difficulties in health services' use. Around 44% of surveyed participants reported worsening of access to health services since the pandemic, more frequently women, those with lower income, and those who perceived being at moderate or high risk for COVID-19 infection. Digital change in services and lack of formal and informal support during lockdowns were highlighted by interviewers as main barriers in access to healthcare for migrants. The pandemic renewed concerns about inequalities in healthcare access among migrants. It is key that in following years health systems are able to address the potential accumulated burden of disease.

The Copenhagen Neck Functional Disability Scale: an analysis of singers with dysphonia and without vocal complaints. / Escala Funcional de Incapacidade do Pescoço de Copenhagen: análise em cantoras disfônicas e em cantoras sem queixas vocais.

PURPOSE: To analyze and compare the degree of cervical disability in singers with dysphonia and in singers without self-reported vocal complaints. METHODS: A cross-sectional observational analysis. Sixty-two singers participated in the study: Thirty-two singers without vocal complaints and 30 singers with a speech-language pathology and otorhinolaryngological diagnosis of dysphonia. For singers without vocal complaints, two questionnaires were applied via Google Forms: A three-question questionnaire regarding vocal complaints and how each singer perceived their speaking and singing voice, and the Copenhagen Neck Functional Disability Scale (CNFDS). Data on singers with dysphonia were extracted from a database previously collected by a team of researchers at the speech-language pathology department of the Federal University of Minas Gerais. The difference in data collection methodology between the two groups was due to restrictions presented by the coronavirus pandemic. The Mann-Whitney test was used to compare the two groups, at a significance level of 5%. RESULTS: There was a significant difference between the groups (p=0.0001), demonstrating that singers with dysphonia suffered more from cervical pain and discomfort than singers without vocal complaints. CONCLUSION: Singers with dysphonia have more cervical pain and discomfort than singers without vocal complaints, thus presenting with greater cervical disability.

OBJETIVO: analisar e comparar o grau de incapacidade cervical em cantoras disfônicas e em cantoras sem queixas vocais autorreferidas. MÉTODO: estudo observacional analítico transversal. Participaram do estudo 32 cantoras sem queixas vocais e 30 cantoras com diagnóstico fonoaudiológico e otorrinolaringológico de disfonia. Para as cantoras sem queixas vocais foram utilizados dois questionários aplicados virtualmente via GoogleForms, sendo um questionário composto por três perguntas referentes às queixas vocais e como cada cantora percebia sua voz de falada e de forma cantada e a Escala Funcional de Incapacidade do Pescoço de Copenhagen (EFIPC). Os dados referentes às cantoras disfônicas foram extraídos de um banco de dados previamente coletado por uma equipe de pesquisadores no Observatório de Saúde Funcional em Fonoaudiologia da Universidade Federal de Minas Gerais e a diferença na metodologia de coleta de dados entre os dois grupos deu-se devido às restrições apresentadas pela pandemia causada pelo coronavírus. Para a comparação entre os dois grupos, foi utilizado o teste Mann-Whitney e foi considerado um nível de significância de 5%. RESULTADOS: Houve diferença significativa entre os grupos (p=0,0001), demonstrando que as cantoras disfônicas sofrem mais com dores e desconfortos cervicais do que as cantoras sem queixas vocais. CONCLUSÃO: cantoras disfônicas apresentam mais dor e desconforto cervical do que as cantoras sem queixas vocais, caracterizando uma maior incapacidade cervical.

Association between perception of COVID-19 risk, confidence in health services and avoidance of emergency department visits: results from a community-based survey in Portugal.

OBJECTIVES: To examine the association between the perception of COVID-19 risk, confidence in health services and avoidance of emergency department (ED) visits in Portugal during the COVID-19 pandemic. DESIGN: Community-based, cross-sectional survey. SETTING: Volunteer sample that completed the online survey between April 2020 and May 2021. PARTICIPANTS: 987 participants who perceived needing ED care. Of those, 242 reported avoiding ED visits. OUTCOME MEASURES: Logistic regression models for ED avoidance were conducted to estimate the effect of risk perception and confidence in health services, adjusted for sociodemographics, health status and time. RESULTS: The adjusted odds for ED avoidance were higher for participants lacking confidence in health service response to non-COVID-19 conditions (adjusted OR: 6.39; 95% CI 3.19 to 12.82) and COVID-19 (1.81; 1.19 to 2.77) and lower for those perceiving a low risk of being infected at a health provider (0.16; 0.07 to 0.38). CONCLUSION: In our sample, confidence in health services and risk perception of infection at a health provider were associated with the decision to avoid the ED. These results suggest that policymakers and care providers need to mitigate the negative consequences of delayed healthcare; be aware of the implications of distrust and fear from those in need of healthcare and provide equally distributed safe alternatives to ED care.

The Implication of the First Wave of COVID-19 on Mental Health: Results from a Portuguese Sample.

The social conditions created by the COVID-19 pandemic had a great potential to affect the mental health of individuals. Meta-analyses indicate a rise in these problems in these periods among general populations, patients and health professionals, even with substantial heterogeneous results. This paper examines mental health impacts specifically during the first wave of COVID-19. An online survey was conducted with a Portuguese convenience sample (N = 1.062) comprising questions about substance use, perceived stress, post-traumatic stress disorder and self-damage behaviors. The results concerning substance use show an extensive use of medication to sleep or calm down, especially among women and older respondents, a small percentage of alcohol consumers with a high pattern of use and less frequent cannabis consumption, even with a quarter of users who began only in the COVID-19 period. The rates of perceived stress and PTSD were higher compared with international prevalence estimations during the pandemic conditions. Both correlated measures were worse for women and young people. Another problematic issue was the rate of suicidal ideation, with a relevant proportion of starters during this period. These data reinforce the need to promote access to mental health services.

The links of stress, substance use and socio-demographic factors with domestic violence during the Covid-19 pandemic in Portugal.

BACKGROUND: Lockdown, as a measure implemented to combat the coronavirus disease 2019 (COVID-19) pandemic, left many domestic violence (DV) victims trapped with their abusers. This study intends to explore the links between perceived stress, substance use and socio-demographic factors with DV experiences during COVID-19 pandemic in Portugal. METHODS: A cross-sectional study was carried out on a sample of 1062 participants over 16 years old, residing in Portugal. Data were collected through an online survey conducted between April and October 2020. The associations between potential factors and DV were investigated using bivariable analysis and multivariable logistic regression. RESULTS: The prevalence of DV reported was 13.75% (n = 146), disaggregated into psychological violence (13%, n = 138), sexual violence (1.0%, n = 11) and physical violence (0.9%, n = 10). Multivariable analyses confirmed that perceived financial difficulties (OR = 1.608; P = 0.019), use of medications to sleep or calm down (OR = 1.851; P = 0.002) and perceived stress (OR = 2.443; P = 0.003) were responsible for DV exposure during COVID-19 pandemic. Younger age (<25 years old) and consumption of alcohol were associated with a higher risk of DV victimization. CONCLUSIONS: Interventions aimed at preventing and confronting DV are necessary within the strategies to combat COVID-19 in Portugal, especially aimed at groups in vulnerable situations, during and after the pandemic.

Involving Older Adults During COVID-19 Restrictions in Developing an Ecosystem Supporting Active Aging: Overview of Alternative Elicitation Methods and Common Requirements From Five European Countries

Background Information and communication technology solutions have the potential to support active and healthy aging and improve monitoring and treatment outcomes. To make such solutions acceptable, all stakeholders must be involved in the requirements elicitation process. Due to the COVID-19 situation, alternative approaches to commonly used face-to-face methods must often be used. One aim of the current article is to share a unique experience from the Pharaon project where due to the COVID-19 outbreak alternative elicitation methods were used. In addition, an overview of common functional, quality, and emotional goals identified by six pilot sites is presented to complement the knowledge about the needs of older adults. Methods Originally planned face-to-face co-creation seminars were impossible to carry out, and all pilot sites chose alternative requirements elicitation methods that were most suitable in their situation. The elicited requirements were presented in the form of goal models. In one summary goal model, we provide an overview of common functional, quality, and emotional goals. Results Different elicitation methods were combined based on the digital literacy of the target group and their access to digital tools. Methods applied without digital technologies were phone interviews, reviews of literature and previous projects, while by means of digital technologies online interviews, online questionnaires, and (semi-)virtual co-creation seminars were conducted. The combination of the methods allowed to involve all planned stakeholders. Virtual and semi-virtual co-creation seminars created collaborative environment comparable to face-to-face situations, while online participation helped to save the time of the participants. The most prevalent functional goals elicited were “Monitor health,” “Receive advice,” “Receive information.” “Easy to use/comfortable,” “personalized/tailored,” “automatic/smart” were identified as most prevalent quality goals. Most frequently occurring emotional goals were “involved,” “empowered,” and “informed.” Conclusion There are alternative methods to face-to-face co-creation seminars, which effectively involve older adults and other stakeholders in the requirements elicitation process. Despite the used elicitation method, the requirements can be easily transformed into goal models to present the results in a uniform way. The common requirements across different pilots provided a strong foundation for representing detailed requirements and input for further software development processes.

Factors Associated with COVID-19 Vaccine Hesitancy after Implementation of a Mass Vaccination Campaign.

An online cross-sectional study on COVID-19 vaccination adhesion was conducted in Portugal nine months after vaccination rollout (September-November 2021). Logistic regression was used to identify factors associated with hesitancy to take the COVID-19 vaccine in the community-based survey, "COVID-19 Barometer: Social Opinion". Hesitancy was 11%; however, of those, 60.5% stated that they intended to take the vaccine. Hesitancy was associated with factors such as lower monthly household income; no intention of taking the flu vaccine this year; perceived reasonable health status; having two or more diseases; low confidence in the health service response; worse perception of the adequacy of anti-COVID-19 government measures; low or no perceived risk of getting COVID-19; feeling agitated, anxious or sad some days; and lack of trust in the safety and efficacy of the vaccines. Confidence in vaccines, namely against COVID-19, is paramount for public health and should be monitored during vaccination rollout. Clear communication of the risks and benefits of vaccination needs improvement to increase adherence and public confidence.

How Did the COVID-19 Pandemic Affect Migrant Populations in Lisbon, Portugal? A Study on Perceived Effects on Health and Economic Condition.

Increasing evidence on the effects of the COVID-19 pandemic suggests that its social and health impacts are being disproportionately shouldered by socioeconomically disadvantaged populations, including migrants. Knowledge of how these populations are experiencing the COVID-19 crisis is scarce. We examined the effects of the pandemic on the perceived individual financial situation and health condition of migrants in Lisbon, Portugal, and described the most affected subgroups. A cross-sectional survey was conducted with a diverse community-based sample of 1126 migrants. A worsening of their financial situation since the pandemic was reported by 55.6% of the participants and a worsening of their health condition by 19.9%. A worsened financial situation was most often reported by those ≥45 years old and with a lower income (

Factors Associated with the Patient's Decision to Avoid Healthcare during the COVID-19 Pandemic.

The COVID-19 pandemic has resulted in changes in healthcare use. This study aimed to identify factors associated with a patient's decision to avoid and/or delay healthcare during the COVID-19 pandemic. We used data from a community-based survey in Portugal from July 2020 to August 2021, "COVID-19 Barometer: Social Opinion", which included data regarding health services use, risk perception and confidence in health services. We framed our analysis under Andersen's Behavioural Model of Health Services Use and utilised Poisson regression to identify healthcare avoidance associated factors. Healthcare avoidance was high (44%). Higher prevalence of healthcare avoidance was found among women; participants who reported lower confidence in the healthcare system response to COVID-19 and non-COVID-19; lost income during the pandemic; experienced negative emotions due to physical distancing measures; answered the questionnaire before middle June 2021; and perceived having worse health, the measures implemented by the Government as inadequate, the information conveyed as unclear and confusing, a higher risk of getting COVID-19, a higher risk of complications and a higher risk of getting infected in a health institution. It is crucial to reassure the population that health services are safe. Health services should plan their recovery since delays in healthcare delivery can lead to increased or worsening morbidity, yielding economic and societal costs.

Assessing health literacy among migrants and associated socioeconomic factors

Health literacy, the ability to understand, access, appraise, remember and use health information and health services, has great potential to reduce health inequalities and improve access to and quality of health care, particularly among groups that experience vulnerability, including migrant groups. Across Europe, including in Portugal, little is known about the health literacy strengths, needs and preferences among migrants. We aimed to assess the health literacy of diverse migrants living in Portugal and identify if health literacy needs differ across sociodemographic subgroups. A cross-sectional survey was administered to migrants living in Portugal. Data were collected using the Health Literacy Questionnaire (HLQ), an internationally tested and robust multi-dimensional measurement tool with nine scales, and a demographic and socioeconomic questionnaire. Associations were tested using Welch's ANOVA. In total, 1126 adult migrants were surveyed: 53.4% female, mean age of 35.8 years (range 18-77), 48.9% from African countries, 29.5% from Middle East/Asian countries, 21.6% from Brazil. Low scores on most HLQ scales were clearly associated with sociodemographic characteristics such as lower levels of education: 1. Feeling understood and supported by healthcare providers (p = 0.045);2. Having sufficient information to manage health (p < 0.001);3. Actively managing health (p = 0.036);4. Social support for health (p = 0.001);5. Appraisal of health information (p < 0.001);7. Navigating the health system (p = 0.031);8. Finding health information (p = 0.007). Similar patterns were found for participants who were unemployed and with lower income (<650€). Health literacy needs of migrant communities should be taken into account when designing interventions aiming to mitigate health inequalities and to promote health literacy. This is even more pertinent in the current context of the COVID-19, where its adverse social and economic impacts are likely to aggravate health inequalities. Key messages Lower health literacy is related to lower socioeconomic status. Mapping health literacy needs can inform interventions to mitigate health inequalities among vulnerable migrant groups.

Double jeopardy from the COVID-19 pandemic: risk of exposure and income loss in Portugal.

BACKGROUND: Increasing evidence indicates that the first wave of the COVID-19 pandemic had immediate health and social impact, disproportionately affecting certain socioeconomic groups. Assessing inequalities in risk of exposure and in adversities faced during the pandemic is critical to inform targeted actions that effectively prevent disproportionate spread and reduce social and health inequities. This study examines i) the socioeconomic and mental health characteristics of individuals working in the workplace, thus at increased risk of COVID-19 exposure, and ii) individual income losses resulting from the pandemic across socioeconomic subgroups of a working population, during the first confinement in Portugal. METHODS: This study uses data from 'COVID-19 Barometer: Social Opinion', a community-based online survey in Portugal. The sample for analysis comprised n = 129,078 workers. Logistic regressions were performed to estimate the adjusted odds ratios (AOR) of factors associated with working in the workplace during the confinement period and with having lost income due to the pandemic. RESULTS: Over a third of the participants reported working in the workplace during the first confinement. This was more likely among those with lower income [AOR = 2.93 (2.64-3.25)], lower education [AOR = 3.17 (3.04-3.30)] and working as employee [AOR = 1.09 (1.04-1.15)]. Working in the workplace was positively associated with frequent feelings of agitation, anxiety or sadness [AOR = 1.14 (1.09-1.20)] and perception of high risk of infection [AOR = 11.06 (10.53-11.61)]. About 43% of the respondents reported having lost income due to the pandemic. The economic consequences affected greatly the groups at increased risk of COVID-19 exposure, namely those with lower education [AOR = 1.36 (1.19-1.56)] and lower income [AOR = 3.13 (2.47-3.96)]. CONCLUSIONS: The social gradient in risk of exposure and in economic impact of the pandemic can result in an accumulated vulnerability for socioeconomic deprived populations. The COVID-19 pandemic seems to have a double effect in these groups, contributing to heightened disparities and poor health outcomes, including in mental health. Protecting the most vulnerable populations is key to prevent the spread of the disease and mitigate the deepening of social and health disparities. Action is needed to develop policies and more extensive measures for reducing disproportionate experiences of adversity from the COVID-19 pandemic among most vulnerable populations.

Understanding Cervical Cancer Screening Barriers among Migrant Women: A Qualitative Study with Healthcare and Community Workers in Portugal.

Cervical cancer screening (CCS) has been proven to reducing mortality of cervical cancer; yet migrant women show a lower participation in screening compared to non-migrants. This study explores the perspectives of healthcare workers and community workers on the factors influencing the CCS participation of migrant women living in Portugal. A qualitative study with online focus groups was conducted. Healthcare workers experienced in CCS and community workers working with migrant communities were purposively sampled. A semi-structured guide was used covering the participation of migrant women in CCS, barriers, and strategies to overcome them. Data were analyzed using content analysis. Participants considered that migrant women have low participation in CCS related to insufficient knowledge, low risk perception, and lack of interest on preventive care. Other barriers such as difficulties in accessing the healthcare services, relationship with healthcare workers, language, and cultural differences were highlighted. Promoting continuity of care, disseminating culturally tailored information, and use of self-sampling methods were suggested to improve participation in CCS. Inequalities in access to CCS among migrant women are mostly caused by information gaps and healthcare system-related barriers. Building a migrant-friendly healthcare system that creates opportunities for healthcare workers to establish relationships with their patients and delivering culturally and linguistically adapted information may contribute to overcoming those barriers and increasing the participation of migrant women in screening.

Migrant Communities at the Center in Co-design of Health Literacy-Based Innovative Solutions for Non-communicable Diseases Prevention and Risk Reduction: Application of the OPtimising HEalth LIteracy and Access (Ophelia) Process.

The drivers of high prevalence of non-communicable diseases (NCD) among migrants are well-documented. Health literacy is regarded as a potential tool to reduce health inequalities and improve migrant's access to and quality of health care. Yet, little is known about the health literacy needs among these groups and how to address them. This paper outlines the protocol for a migrant community-based co-design project that seeks to optimize health literacy, health promotion, and social cohesion in support of prevention of NCDs among migrants in Lisbon using the OPtismizing HEalth LIteracy and Access (Ophelia) process. This participatory implementation research project starts with a mixed-methods needs assessment covering health literacy strengths, weaknesses and needs of migrants, and local data about determinants of health behaviors, service engagement, and organizational responsiveness. Diverse migrant groups will be engaged and surveyed using the Health Literacy Questionnaire and questions on sociodemographic and economic characteristics, health status, use of health services, and perceived impact of the COVID-19 pandemic. Semi-structured interviews with migrants will also be conducted. Based on data collected, vignettes will be developed representing typical persons with diverse health literacy profiles. Migrants and stakeholders will participate in ideas generation workshops for depth co-creation discussions in simulated real-world situations based on the vignettes, to design health literacy-based multisectoral interventions. Selected interventions will be piloted through quality improvement cycles to ensure ongoing local refinements and ownership development. Through a genuine engagement, the project will evaluate the uptake, effectiveness and sustainability of the interventions. This protocol takes a grounded approach to produce evidence on real health literacy needs from the perspective of key stakeholders, especially migrants, and embodies strong potential for effective knowledge translation into innovative, locally relevant, culturally and context congruent solutions for prevention of NCDs among migrants. Given the diverse communities engaged, this protocol will likely be adaptable to other migrant groups in a wide range of contexts, particularly in European countries. The scale-up of interventions to similar contexts and populations will provide much needed evidence on how health literacy interventions can be developed and applied to reduce health inequality and improve health in diverse communities.

Factors Associated with COVID-19 Vaccine Hesitancy.

It is critical to develop tailored strategies to increase acceptability of the COVID-19 vaccine and decrease hesitancy. Hence, this study aims to assess and identify factors associated with COVID-19 vaccine hesitancy in Portugal. We used data from a community-based survey, "COVID-19 Barometer: Social Opinion", which includes data regarding intention to take COVID-19 vaccines, health status, and risk perception in Portugal from September 2020 to January 2021. We used multinomial regression to identify factors associated with intention to delay or refuse to take COVID-19 vaccines. COVID-19 vaccine hesitancy in Portugal was high: 56% would wait and 9% refuse. Several factors were associated with both refusal and delay: being younger, loss of income during the pandemic, no intention of taking the flu vaccine, low confidence in the COVID-19 vaccine and the health service response during the pandemic, worse perception of government measures, perception of the information provided as inconsistent and contradictory, and answering the questionnaire before the release of information regarding the safety and efficacy of COVID-19 vaccines. It is crucial to build confidence in the COVID-19 vaccine as its perceived safety and efficacy were strongly associated with intention to take the vaccine. Governments and health authorities should improve communication and increase trust.