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Simões Cunha M, Amaral R, Pereira AM, Almeida R, Alves-Correia M, Loureiro CC, Lopes C, Carvalho J, Ribeiro C, Vidal C, Antolín-Amérigo D, Pinto D, Ferreira-Magalhães M, Vasconcelos MJ, Lozoya C, Santos N, Cardia F, Taborda-Barata L, Ferreira R, Morais Silva P, Ferreira TM, Câmara R, Silva E, Bordalo D, Guimarães C, Calix MJ, da Silva S, Marques ML, Morete A, Nunes C, Vieira C, Páscoa R, Alves A, Marques JV, Reis B, Monteiro L, Monteiro R, Cepa M, Valentim B, Coelho DS, Fernandes S, Meireles P, Aguiar MA, Mourão AR, Fonseca JA, Jácome C. Symptoms of anxiety and depression in patients with persistent asthma: a cross-sectional analysis of the INSPIRERS studies. BMJ Open 2023; 13:e068725. [PMID: 37147092 PMCID: PMC10163458 DOI: 10.1136/bmjopen-2022-068725] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/07/2023] Open
Abstract
OBJECTIVES Anxiety and depression are relevant comorbidities in asthma, but, in Portugal and Spain, data on this topic are scarce. We assessed, in patients with asthma, the frequency of anxiety and depression using the Hospital Anxiety and Depression Scale (HADS) and the European Quality of Life Five Dimension Questionnaire (EQ-5D); the level of agreement between these questionnaires, and the factors associated with these symptoms. METHODS This is a secondary analysis of the INSPIRERS studies. A total of 614 adolescents and adults with persistent asthma (32.6±16.9 years, 64.7% female) were recruited from 30 primary care centres and 32 allergy, pulmonology and paediatric clinics. Demographic and clinical characteristics, HADS and EQ-5D were collected. A score ≥8 on Hospital Anxiety and Depression Scale-Anxiety/Hospital Anxiety and Depression Scale-Depression or a positive answer to EQ-5D item 5 indicated the presence of these symptoms. Agreement was determined by Cohen's kappa. Two multivariable logistic regressions were built. RESULTS According to HADS, 36% of the participants had symptoms of anxiety and 12% of depression. According to EQ-5D, 36% of the participants had anxiety/depression. The agreement between questionnaires in identifying anxiety/depression was moderate (k=0.55, 95% CI 0.48 to 0.62). Late asthma diagnosis, comorbidities and female gender were predictors of anxiety/depression, while better asthma control, health-related quality of life and perception of health were associated with lower odds for anxiety/depression. CONCLUSION At least 1/3 of the patients with persistent asthma experience symptoms of anxiety/depression, showing the relevance of screening these disorders in patients with asthma. EQ-5D and HADS questionnaires showed a moderate agreement in the identification of anxiety/depression symptoms. The identified associated factors need to be further investigated in long-term studies.
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Affiliation(s)
- Mafalda Simões Cunha
- Center for Health Technology and Services Research (CINTESIS), Faculty of Medicine, University of Porto, Porto, Portugal
| | - Rita Amaral
- Allergy Unit, Instituto and Hospital CUF, Porto, Portugal
- CINTESIS@RISE, MEDCIDS, Faculty of Medicine of the University of Porto, Porto, Portugal
- Department of Cardiovascular and Respiratory Sciences, Porto Health School, Polytechnic Institute of Porto, Porto, Portugal
- Department of Women's and Children's Health, Paediatric Research, Uppsala University, Uppsala, Sweden
| | - Ana Margarida Pereira
- Center for Health Technology and Services Research (CINTESIS), Faculty of Medicine, University of Porto, Porto, Portugal
- Allergy Unit, Instituto and Hospital CUF, Porto, Portugal
- Department of Community Medicine, Information and Health Decision Sciences (MEDCIDS), Faculty of Medicine of the University of Porto, Porto, Portugal
| | - Rute Almeida
- CINTESIS@RISE, MEDCIDS, Faculty of Medicine of the University of Porto, Porto, Portugal
| | - Magna Alves-Correia
- Center for Health Technology and Services Research (CINTESIS), Faculty of Medicine, University of Porto, Porto, Portugal
- Allergy Unit, Instituto and Hospital CUF, Porto, Portugal
| | - Cláudia Chaves Loureiro
- Pulmonology Department, Hospitais da Universidade de Coimbra, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - Cristina Lopes
- Basic and Clinic Immunology, Faculty of Medicine of the University of Porto, Porto, Portugal
- Immuno-allergology, Hospital Pedro Hispano, Unidade Local de Saúde de Matosinhos, Matosinhos, Portugal
| | - Joana Carvalho
- Serviço de Pediatria, Hospital Pedro Hispano, Unidade Local de Saúde de Matosinhos, Matosinhos, Portugal
| | - Carmelita Ribeiro
- Serviço de Imunoalergologia, Hospital Universitário de Coimbra, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - Carmen Vidal
- Servicio de Alergia, Complejo Hospitalario Universitario de Santiago, Santiago de Compostella, Spain
| | - Dario Antolín-Amérigo
- Servicio de Alergia, Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria, Madrid, Spain
| | - Diana Pinto
- Serviço de Pediatria, Centro Materno Infantil do Norte, Centro Hospitalar Universitário do Porto, Porto, Portugal
| | - Manuel Ferreira-Magalhães
- CINTESIS@RISE, MEDCIDS, Faculty of Medicine of the University of Porto, Porto, Portugal
- Serviço de Pediatria, Centro Materno Infantil do Norte, Centro Hospitalar Universitário do Porto, Porto, Portugal
| | - Maria João Vasconcelos
- Serviço de Imunoalergologia, Centro Hospitalar Universitário de São João, Porto, Portugal
| | - Carlos Lozoya
- Allergy, Hospital Amato Lusitano, Unidade Local de Saúde de Castelo Branco, Castelo Branco, Portugal
| | - Natacha Santos
- Serviço de Imunoalergologia, Centro Hospitalar Universitário do Algarve, Portimão, Portugal
| | - Francisca Cardia
- Unidade de Saúde Familiar Terras de Azurara, Agrupamento de Centros de Saúde Dão Lafões, Mangualde, Portugal
| | - Luís Taborda-Barata
- CICS-UBI Centro de Investigação em Ciências da Saúde - Health Sciences Research Centre & UBIAir - Clinical & Experimental Lung Centre, University of Beira Interior, Covilha, Portugal
- Department of Allergy & Clinical Immunology, Cova da Beira University Hospital Centre, Covilhã, Portugal
| | - Rosário Ferreira
- Departamento de Pediatria, Hospital de Santa Maria, Centro Hospitalar de Lisboa Norte, Lisboa, Portugal
| | | | - Tania Monteiro Ferreira
- Unidade de Saúde Familiar Progresso e Saúde, Agrupamento de Centros de Saúde Baixo Mondego, Tocha, Portugal
| | - Raquel Câmara
- Serviço de Pneumologia, Hospital Nossa Senhora do Rosário, Centro Hospitalar Barreiro Montijo, Barreiro, Portugal
| | - Eurico Silva
- Unidade de Saúde Familiar João Semana, Agrupamento de Centros de Saúde de Baixo Vouga, Ovar, Portugal
| | - Diana Bordalo
- Serviço de Pediatria, Unidade Hospitalar de Famalicão, Centro Hospitalar do Médio Ave, Vila Nova de Famalicão, Portugal
| | - Cristina Guimarães
- Unidade de Cuidados de Saúde Personalizados Norte (Arnaldo Sampaio), Agrupamento de Centros de Saúde Pinhal Litoral, Monte Redondo, Portugal
| | - Maria José Calix
- Serviço de Pediatria, Hospital de São Teotónio, Centro Hospitalar Tondela Viseu, Viseu, Portugal
| | - Sofia da Silva
- Unidade de Saúde Familiar Cuidarte, Unidade Local de Saúde do Alto Minho, Portuzelo, Portugal
| | - Maria Luís Marques
- Serviço de Imunoalergologia, Hospital da Senhora da Oliveira, Guimarães, Guimaraes, Portugal
| | - Ana Morete
- Allergy Unit, Instituto and Hospital CUF, Porto, Portugal
- Serviço de Imunoalergologia, Hospital Infante D Pedro, Centro Hospitalar Baixo Vouga, Aveiro, Portugal
| | - Carlos Nunes
- Centro de Imunoalergologia do Algarve, Portimão, Portugal
| | - Cláudia Vieira
- Unidade de Saúde Familiar Corgo, Agrupamento de Centros de Saúde Douro I - Marão e Douro Norte, Vila Real, Portugal
| | - Rosália Páscoa
- Center for Health Technology and Services Research (CINTESIS), Faculty of Medicine, University of Porto, Porto, Portugal
- Department of Community Medicine, Information and Health Decision Sciences (MEDCIDS), Faculty of Medicine of the University of Porto, Porto, Portugal
- Unidade de Saúde Familiar Homem do Leme, ACeS Porto Ocidental, Porto, Portugal
| | - Adelaide Alves
- Serviço de Pneumologia, Centro Hospitalar Vila Nova de Gaia/Espinho, Vila Nova de Gaia, Portugal
| | - José Varanda Marques
- Unidade de Saúde Familiar Viseu-Cidade, Agrupamento de Centros de Saúde do Dão Lafões, Viseu, Portugal
| | - Bruno Reis
- Unidade de Cuidados Saúde Personalizados Sicó, Agrupamento de Centros de Saúde Pinhal Litoral, Leiria, Portugal
| | - Luís Monteiro
- Center for Health Technology and Services Research (CINTESIS), Faculty of Medicine, University of Porto, Porto, Portugal
- USF Esgueira +, ACES Baixo Vouga, Esgueira, Portugal
| | - Rosário Monteiro
- CINTESIS@RISE, MEDCIDS, Faculty of Medicine of the University of Porto, Porto, Portugal
- Unidade de Saúde Familiar Homem do Leme, ACeS Porto Ocidental, Porto, Portugal
| | - Margarida Cepa
- Unidade de Saúde Familiar Marquês, ACES Pinhal Litoral, Pombal, Portugal
| | - Bruno Valentim
- Unidade de Saúde Familiar Condeixa, ACES Baixo Mondego, Condeixa-a-Nova, Portugal
| | - Daniela Sousa Coelho
- Unidade de Cuidados de Saúde Personalizados de Amarante, ACES Tâmega I - Baixo Tâmega, Amarante, Portugal
| | - Sara Fernandes
- Unidade de Saúde Familiar Bracara Augusta, ACES Cávado I, Braga, Portugal
| | - Patrícia Meireles
- Unidade de Saúde Familiar Almedina, ACES Douro II - Douro Sul, Lamego, Portugal
| | - Margarida Abreu Aguiar
- Unidade de Saúde Familiar Valongo, ACES Grande Porto III - Maia / Valongo, Valongo, Portugal
| | - Ana Rita Mourão
- Unidade de Saúde Familiar Canelas, ACES Grande Porto VIII - Espinho / Gaia, Vila Nova de Gaia, Portugal
| | - Joao A Fonseca
- Allergy Unit, Instituto and Hospital CUF, Porto, Portugal
- CINTESIS@RISE, MEDCIDS, Faculty of Medicine of the University of Porto, Porto, Portugal
- MEDIDA - Medicina, Educação, Investigação, Desenvolvimento e Avaliação, Porto, Portugal
| | - Cristina Jácome
- CINTESIS@RISE, MEDCIDS, Faculty of Medicine of the University of Porto, Porto, Portugal
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Cachim A, Pereira AM, Almeida R, Amaral R, Alves‐Correia M, Vieira‐Marques P, Chaves‐Loureiro C, Ribeiro C, Cardia F, Gomes J, Vidal C, Silva E, Rocha S, Rocha D, Marques ML, Páscoa R, Morais D, Cruz AM, Santalha M, Simões JA, da Silva S, Silva D, Gerardo R, Todo Bom F, Morete A, Vieira I, Vieira P, Monteiro R, Raimundo MR, Monteiro L, Neves Â, Santos C, Penas AM, Regadas R, Marques JV, Rosendo I, Aguiar MA, Fernandes S, Cardoso CS, Pimenta F, Meireles P, Gonçalves M, Fonseca JA, Jácome C. Measuring adherence to inhaled control medication in patients with asthma: Comparison among an asthma app, patient self-report and physician assessment. Clin Transl Allergy 2023; 13:e12210. [PMID: 36825517 PMCID: PMC9930432 DOI: 10.1002/clt2.12210] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Revised: 08/27/2022] [Accepted: 09/30/2022] [Indexed: 02/17/2023] Open
Abstract
BACKGROUND Previous studies have demonstrated the feasibility of using an asthma app to support medication management and adherence but failed to compare with other measures currently used in clinical practice. However, in a clinical setting, any additional adherence measurement must be evaluated in the context of both the patient and physician perspectives so that it can also help improve the process of shared decision making. Thus, we aimed to compare different measures of adherence to asthma control inhalers in clinical practice, namely through an app, patient self-report and physician assessment. METHODS This study is a secondary analysis of three prospective multicentre observational studies with patients (≥13 years old) with persistent asthma recruited from 61 primary and secondary care centres in Portugal. Patients were invited to use the InspirerMundi app and register their inhaled medication. Adherence was measured by the app as the number of doses taken divided by the number of doses scheduled each day and two time points were considered for analysis: 1-week and 1-month. At baseline, patients and physicians independently assessed adherence to asthma control inhalers during the previous week using a Visual Analogue Scale (VAS 0-100). RESULTS A total of 193 patients (72% female; median [P25-P75] age 28 [19-41] years old) were included in the analysis. Adherence measured by the app was lower (1 week: 31 [0-71]%; 1 month: 18 [0-48]%) than patient self-report (80 [60-95]) and physician assessment (82 [51-94]) (p < 0.001). A negligible non-significant correlation was found between the app and subjective measurements (ρ 0.118-0.156, p > 0.05). There was a moderate correlation between patient self-report and physician assessment (ρ = 0.596, p < 0.001). CONCLUSIONS Adherence measured by the app was lower than that reported by the patient or the physician. This was expected as objective measurements are commonly lower than subjective evaluations, which tend to overestimate adherence. Nevertheless, the low adherence measured by the app may also be influenced by the use of the app itself and this needs to be considered in future studies.
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Affiliation(s)
| | - Ana Margarida Pereira
- Center for Health Technology and Services Research (CINTESIS)Faculty of MedicineUniversity of PortoPortoPortugal,Department of Community Medicine, Information and Health Decision Sciences (MEDCIDS)Faculty of MedicineUniversity of PortoPortoPortugal,Allergy UnitInstituto and Hospital CUF‐PortoPortoPortugal
| | - Rute Almeida
- Center for Health Technology and Services Research (CINTESIS)Faculty of MedicineUniversity of PortoPortoPortugal,Department of Community Medicine, Information and Health Decision Sciences (MEDCIDS)Faculty of MedicineUniversity of PortoPortoPortugal
| | - Rita Amaral
- Center for Health Technology and Services Research (CINTESIS)Faculty of MedicineUniversity of PortoPortoPortugal,Department of Community Medicine, Information and Health Decision Sciences (MEDCIDS)Faculty of MedicineUniversity of PortoPortoPortugal,Department of Cardiovascular and Respiratory SciencesPorto Health SchoolPolytechnic Institute of PortoPortoPortugal,Department of Women's and Children's HealthPediatric ResearchUppsala UniversityUppsalaSweden
| | - Magna Alves‐Correia
- Center for Health Technology and Services Research (CINTESIS)Faculty of MedicineUniversity of PortoPortoPortugal,Allergy UnitInstituto and Hospital CUF‐PortoPortoPortugal
| | - Pedro Vieira‐Marques
- Center for Health Technology and Services Research (CINTESIS)Faculty of MedicineUniversity of PortoPortoPortugal
| | - Claudia Chaves‐Loureiro
- Pulmonology DepartmentHospitais da Universidade de CoimbraCentro Hospitalar e Universitário de CoimbraCoimbraPortugal,Clinical Academic Center of CoimbraCoimbraPortugal
| | - Carmelita Ribeiro
- Serviço ImunoalergologiaCentro Hospitalar e Universitário de CoimbraCoimbraPortugal
| | - Francisca Cardia
- Unidade de Saúde Familiar (USF) Terras de AzuraraAgrupamento de Centros de Saúde Dão LafõesMangualdePortugal
| | - Joana Gomes
- Serviço de Imunoalergologia, Unidade ICentro Hospitalar Vila Nova de Gaia/EspinhoVila Nova de GaiaPortugal
| | - Carmen Vidal
- Servicio de AlergiaComplejo Hospitalario Universitario de SantiagoSantiago de CompostelaSpain
| | - Eurico Silva
- USF João SemanaAgrupamento de Centros de Saúde (ACES) Baixo VougaOvarPortugal
| | - Sara Rocha
- USF Arte NovaACES Baixo VougaOliveirinhaPortugal
| | - Diana Rocha
- USF Sá de MirandaACES Cávado II ‐ Gerês/CabreiraVila VerdePortugal
| | - Maria Luís Marques
- Serviço de ImunoalergologiaHospital da Senhora da OliveiraGuimarãesPortugal
| | - Rosália Páscoa
- Center for Health Technology and Services Research (CINTESIS)Faculty of MedicineUniversity of PortoPortoPortugal,Department of Community Medicine, Information and Health Decision Sciences (MEDCIDS)Faculty of MedicineUniversity of PortoPortoPortugal,USF Abel SalazarACES GaiaVila Nova de GaiaPortugal
| | - Daniela Morais
- USF CorgoACES Douro I ‐ Marão e Douro NorteVila RealPortugal
| | | | - Marta Santalha
- Serviço de PediatriaHospital da Senhora da OliveiraGuimarãesPortugal
| | - José Augusto Simões
- Center for Health Technology and Services Research (CINTESIS)Faculty of MedicineUniversity of PortoPortoPortugal,USF Caminhos do CértomaACES Baixo MondegoPampilhosaPortugal,Department of Medical SciencesUniversity of Beira InteriorCovilhãPortugal
| | - Sofia da Silva
- USF CuidarteUnidade Local de Saúde do Alto MinhoPortuzeloPortugal
| | - Diana Silva
- Faculty of MedicineUniversity of PortoPortoPortugal,Serviço de ImunoalergologiaCentro Hospitalar Universitário de São JoãoPortoPortugal
| | - Rita Gerardo
- Serviço de PneumologiaHospital Santa MartaCentro Hospitalar Universitário de Lisboa CentralLisboaPortugal
| | | | - Ana Morete
- Allergy UnitInstituto and Hospital CUF‐PortoPortoPortugal,Serviço de ImunoalergologiaHospital Infante D PedroCentro Hospitalar Baixo VougaAveiroPortugal
| | - Inês Vieira
- Unidade de Cuidados Saúde Personalizados Arnaldo SampaioACES Pinhal LitoralLeiriaPortugal
| | | | - Rosário Monteiro
- Center for Health Technology and Services Research (CINTESIS)Faculty of MedicineUniversity of PortoPortoPortugal,Department of Community Medicine, Information and Health Decision Sciences (MEDCIDS)Faculty of MedicineUniversity of PortoPortoPortugal,USF Homem do LemeACES Porto OcidentalPortoPortugal
| | | | - Luís Monteiro
- Center for Health Technology and Services Research (CINTESIS)Faculty of MedicineUniversity of PortoPortoPortugal,USF Esgueira+ACES Baixo VougaEsgueiraPortugal
| | | | - Carlos Santos
- USF Santo AntónioACES Cávado III ‐ Barcelos/EsposendeBarcelosPortugal
| | | | - Rita Regadas
- USF Aquilino RibeiroACES Douro II ‐ Douro SulMoimenta da BeiraPortugal
| | | | - Inês Rosendo
- Center for Health Technology and Services Research (CINTESIS)Faculty of MedicineUniversity of PortoPortoPortugal,USF Coimbra CentroACES Baixo MondegoCoimbraPortugal
| | | | - Sara Fernandes
- UCSP São João da PesqueiraACES Douro SulSão João da PesqueiraPortugal
| | - Carlos Seiça Cardoso
- Center for Health Technology and Services Research (CINTESIS)Faculty of MedicineUniversity of PortoPortoPortugal,USF CondeixaACES Baixo MondegoCondeixa‐a‐NovaPortugal
| | | | | | | | - João Almeida Fonseca
- Center for Health Technology and Services Research (CINTESIS)Faculty of MedicineUniversity of PortoPortoPortugal,Department of Community Medicine, Information and Health Decision Sciences (MEDCIDS)Faculty of MedicineUniversity of PortoPortoPortugal,Allergy UnitInstituto and Hospital CUF‐PortoPortoPortugal,MEDIDA – Medicina, Educação, Investigação, Desenvolvimento e AvaliaçãoPortoPortugal
| | - Cristina Jácome
- Center for Health Technology and Services Research (CINTESIS)Faculty of MedicineUniversity of PortoPortoPortugal,Department of Community Medicine, Information and Health Decision Sciences (MEDCIDS)Faculty of MedicineUniversity of PortoPortoPortugal
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3
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Neves AL, Jácome C, Taveira-Gomes T, Pereira AM, Almeida R, Amaral R, Alves-Correia M, Mendes S, Chaves-Loureiro C, Valério M, Lopes C, Carvalho J, Mendes A, Ribeiro C, Prates S, Ferreira JA, Teixeira MF, Branco J, Santalha M, Vasconcelos MJ, Lozoya C, Santos N, Cardia F, Moreira AS, Taborda-Barata L, Pinto CS, Ferreira R, Morais Silva P, Monteiro Ferreira T, Câmara R, Lobo R, Bordalo D, Guimarães C, Espírito Santo M, Ferraz de Oliveira J, Cálix Augusto MJ, Gomes R, Vieira I, da Silva S, Marques M, Cardoso J, Morete A, Aroso M, Cruz AM, Nunes C, Câmara R, Rodrigues N, Abreu C, Albuquerque AL, Vieira C, Santos C, Páscoa R, Chaves-Loureiro C, Alves A, Neves Â, Varanda Marques J, Reis B, Ferreira-Magalhães M, Almeida Fonseca J. Determinants of the Use of Health and Fitness Mobile Apps by Patients With Asthma: Secondary Analysis of Observational Studies. J Med Internet Res 2021; 23:e25472. [PMID: 34550077 PMCID: PMC8495570 DOI: 10.2196/25472] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Revised: 04/01/2021] [Accepted: 06/14/2021] [Indexed: 12/23/2022] Open
Abstract
Background Health and fitness apps have potential benefits to improve self-management and disease control among patients with asthma. However, inconsistent use rates have been reported across studies, regions, and health systems. A better understanding of the characteristics of users and nonusers is critical to design solutions that are effectively integrated in patients’ daily lives, and to ensure that these equitably reach out to different groups of patients, thus improving rather than entrenching health inequities. Objective This study aimed to evaluate the use of general health and fitness apps by patients with asthma and to identify determinants of usage. Methods A secondary analysis of the INSPIRERS observational studies was conducted using data from face-to-face visits. Patients with a diagnosis of asthma were included between November 2017 and August 2020. Individual-level data were collected, including age, gender, marital status, educational level, health status, presence of anxiety and depression, postcode, socioeconomic level, digital literacy, use of health services, and use of health and fitness apps. Multivariate logistic regression was used to model the probability of being a health and fitness app user. Statistical analysis was performed in R. Results A total of 526 patients attended a face-to-face visit in the 49 recruiting centers and 514 had complete data. Most participants were ≤40 years old (66.4%), had at least 10 years of education (57.4%), and were in the 3 higher quintiles of the socioeconomic deprivation index (70.1%). The majority reported an overall good health status (visual analogue scale [VAS] score>70 in 93.1%) and the prevalence of anxiety and depression was 34.3% and 11.9%, respectively. The proportion of participants who reported using health and fitness mobile apps was 41.1% (n=211). Multivariate models revealed that single individuals and those with more than 10 years of education are more likely to use health and fitness mobile apps (adjusted odds ratio [aOR] 2.22, 95%CI 1.05-4.75 and aOR 1.95, 95%CI 1.12-3.45, respectively). Higher digital literacy scores were also associated with higher odds of being a user of health and fitness apps, with participants in the second, third, and fourth quartiles reporting aORs of 6.74 (95%CI 2.90-17.40), 10.30 (95%CI 4.28-27.56), and 11.52 (95%CI 4.78-30.87), respectively. Participants with depression symptoms had lower odds of using health and fitness apps (aOR 0.32, 95%CI 0.12-0.83). Conclusions A better understanding of the barriers and enhancers of app use among patients with lower education, lower digital literacy, or depressive symptoms is key to design tailored interventions to ensure a sustained and equitable use of these technologies. Future studies should also assess users’ general health-seeking behavior and their interest and concerns specifically about digital tools. These factors may impact both initial engagement and sustained use.
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Affiliation(s)
- Ana Luísa Neves
- Department of Community Medicine, Information and Health Decision Sciences (MEDCIDS), Faculty of Medicine, University of Porto, Porto, Portugal.,Center for Health Technology and Services Research (CINTESIS), Faculty of Medicine, University of Porto, Porto, Portugal.,Imperial NIHR Patient Safety Translational Research Centre, Institute of Global Health Innovation, Imperial College London, London, United Kingdom
| | - Cristina Jácome
- Department of Community Medicine, Information and Health Decision Sciences (MEDCIDS), Faculty of Medicine, University of Porto, Porto, Portugal.,Center for Health Technology and Services Research (CINTESIS), Faculty of Medicine, University of Porto, Porto, Portugal
| | - Tiago Taveira-Gomes
- Department of Community Medicine, Information and Health Decision Sciences (MEDCIDS), Faculty of Medicine, University of Porto, Porto, Portugal.,Center for Health Technology and Services Research (CINTESIS), Faculty of Medicine, University of Porto, Porto, Portugal.,Instituto de Investigação e Formação Avançada em Ciências e Tecnologias da Saúde, Institute of Research and Advanced Training in Health Sciences and Technologies, University Institute of Health Sciences, Cooperativa de Ensino Superior Politécnico e Universitário, CRL, Gandra, Portugal.,Faculdade de Ciências da Saúde, Universidade Fernando Pessoa, Porto, Portugal
| | - Ana Margarida Pereira
- Department of Community Medicine, Information and Health Decision Sciences (MEDCIDS), Faculty of Medicine, University of Porto, Porto, Portugal.,Center for Health Technology and Services Research (CINTESIS), Faculty of Medicine, University of Porto, Porto, Portugal.,Allergy Unit, Instituto and Hospital CUF, Porto, Portugal
| | - Rute Almeida
- Department of Community Medicine, Information and Health Decision Sciences (MEDCIDS), Faculty of Medicine, University of Porto, Porto, Portugal.,Center for Health Technology and Services Research (CINTESIS), Faculty of Medicine, University of Porto, Porto, Portugal
| | - Rita Amaral
- Department of Community Medicine, Information and Health Decision Sciences (MEDCIDS), Faculty of Medicine, University of Porto, Porto, Portugal.,Center for Health Technology and Services Research (CINTESIS), Faculty of Medicine, University of Porto, Porto, Portugal.,Department of Cardiovascular and Respiratory Sciences, Porto Health School, Polytechnic Institute of Porto, Porto, Portugal.,Department of Women's and Children's Health, Paediatric Research, Uppsala University, Uppsala, Sweden
| | | | - Sandra Mendes
- Center for Health Technology and Services Research (CINTESIS), Faculty of Medicine, University of Porto, Porto, Portugal
| | | | - Margarida Valério
- Serviço Pneumologia, Hospitais da Universidade de Coimbra, Coimbra, Portugal
| | - Cristina Lopes
- Unidade de Imunoalergologia, Hospital Pedro Hispano, Unidade Local de Saúde de Matosinhos, Matosinhos, Portugal.,Imunologia Básica e Clínica, Faculdade de Medicina, Universidade do Porto, Porto, Portugal
| | - Joana Carvalho
- Serviço de Pediatria, Hospital Pedro Hispano, Unidade Local de Saúde de Matosinhos, Matosinhos, Portugal
| | - Ana Mendes
- Serviço de Imunoalergologia, Hospital de Santa Maria, Centro Hospitalar Lisboa Norte, Lisboa, Portugal
| | - Carmelita Ribeiro
- Serviço de Imunoalergologia, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - Sara Prates
- Serviço de Imunoalergologia, Hospital de Dona Estefânia, Centro Hospitalar Universitário de Lisboa Central, Lisboa, Portugal
| | - José Alberto Ferreira
- Serviço de Imunoalergologia, Unidade I, Centro Hospitalar Vila Nova de Gaia/Espinho, Vila Nova de Gaia, Portugal
| | - Maria Fernanda Teixeira
- Serviço de Pediatria, Centro Materno Infantil do Norte, Centro Hospitalar Universitário do Porto, Porto, Portugal
| | - Joana Branco
- Serviço de Pneumologia, Hospital Beatriz Ângelo, Loures, Portugal
| | - Marta Santalha
- Serviço de Pediatria, Hospital da Senhora da Oliveira, Guimarães, Portugal
| | - Maria João Vasconcelos
- Serviço de Imunoalergologia, Centro Hospitalar Universitário de São João, Porto, Portugal
| | - Carlos Lozoya
- Serviço de Imunoalergologia, Hospital Amato Lusitano, Unidade Local de Saúde de Castelo Branco, Castelo Branco, Portugal
| | - Natacha Santos
- Serviço de Imunoalergologia, Centro Hospitalar Universitário do Algarve, Portimão, Portugal
| | - Francisca Cardia
- Unidade de Saúde Familiar Terras de Azurara, Agrupamento de Centros de Saúde Dão Lafões, Mangualde, Portugal
| | - Ana Sofia Moreira
- Unidade de Imunoalergologia, Hospital do Divino Espirito Santo, Ponta Delgada, Portugal
| | - Luís Taborda-Barata
- Department of Allergy & Clinical Immunology, Cova da Beira University Hospital Centre, Covilhã, Portugal.,Centro de Investigação em Ciências da Saúde - Health Sciences Research Centre & NuESA -Environment & Health Study Group, Faculty of Health Sciences, University of Beira Interior, Covilhã, Portugal
| | - Cláudia Sofia Pinto
- Serviço de Pneumologia, Hospital São Pedro de Vila Real, Centro Hospitalar de Trás-os-Montes e Alto Douro, Vila Real, Portugal
| | - Rosário Ferreira
- Departamento de Pediatria, Hospital de Santa Maria, Centro Hospitalar de Lisboa Norte, Lisboa, Portugal
| | | | - Tania Monteiro Ferreira
- Unidade de Saúde Familiar Progresso e Saúde, Agrupamento de Centros de Saúde Baixo Mondego, Tocha, Portugal
| | - Raquel Câmara
- Serviço de Pneumologia, Hospital Nossa Senhora do Rosário, Centro Hospitalar Barreiro Montijo, Barreiro, Portugal
| | - Rui Lobo
- Unidade de Saúde Familiar João Semana, Agrupamento de Centros de Saúde Baixo Vouga, Ovar, Portugal
| | - Diana Bordalo
- Serviço de Pediatria, Unidade Hospitalar de Famalicão, Centro Hospitalar do Médio Ave, Vila Nova de Famalicão, Portugal
| | - Cristina Guimarães
- Unidade de Saúde Familiar Caminhos do Cértoma, Agrupamento de Centros de Saúde Baixo Mondego, Pampilhosa, Portugal
| | - Maria Espírito Santo
- Unidade de Saúde Familiar Arte Nova, Agrupamento de Centros de Saúde Baixo Vouga, Oliveirinha, Portugal
| | | | - Maria José Cálix Augusto
- Serviço de Pediatria, Hospital de São Teotónio, Centro Hospitalar Tondela-Viseu, Viseu, Portugal
| | - Ricardo Gomes
- Serviço de Pneumologia, Hospital Garcia de Orta, Almada, Portugal
| | - Inês Vieira
- Unidade de Cuidados Saúde Personalizados Arnaldo Sampaio, Agrupamento de Centros de Saúde Pinhal Litoral, Leiria, Portugal
| | - Sofia da Silva
- Unidade de Saúde Familiar Cuidarte, Unidade Local de Saúde do Alto Minho, Portuzelo, Portugal
| | - Maria Marques
- Serviço de Imunoalergologia, Centro Hospitalar Universitário do Porto, Porto, Portugal
| | - João Cardoso
- Serviço de Pneumologia, Hospital Santa Marta, Centro Hospitalar Universitário de Lisboa Central, Lisboa, Portugal
| | - Ana Morete
- Allergy Unit, Instituto and Hospital CUF, Porto, Portugal.,Serviço de Imunoalergologia, Hospital Infante D Pedro, Centro Hospitalar Baixo Vouga, Aveiro, Portugal
| | - Margarida Aroso
- Unidade de Saúde Familiar Pedras Rubras, Agrupamento de Centros de Saúde do Grande Porto III - Maia/Valongo, Maia, Portugal
| | - Ana Margarida Cruz
- Unidade de Saúde Familiar Bom Porto, Agrupamento de Centros de Saúde do Grande Porto V - Porto Ocidental, Porto, Portugal
| | - Carlos Nunes
- Imunoalergologia, Centro de Imunoalergologia do Algarve, Portimão, Portugal
| | - Rita Câmara
- Serviço de Imunoalergologia, Serviço de Saúde da Região Autónoma da Madeira, Funchal, Portugal
| | - Natalina Rodrigues
- Unidade de Saúde Familiar Mondego, Agrupamento de Centros de Saúde Baixo Mondego, Coimbra, Portugal
| | - Carmo Abreu
- Serviço de Imunoalergologia, Hospital São Pedro de Vila Real, Centro Hospitalar De Trás-Os-Montes E Alto Douro, Vila Real, Portugal
| | - Ana Luísa Albuquerque
- Unidade de Saúde Familiar Coimbra Centro, Agrupamento de Centros de Saúde Baixo Mondego, Coimbra, Portugal
| | - Claúdia Vieira
- Unidade de Saúde Familiar Corgo, Agrupamentos de Centros de Saúde Douro I - Marão e Douro Norte, Vila Real, Portugal
| | - Carlos Santos
- Unidade de Saúde Familiar Santo António, Agrupamento de Centros de Saúde do Cávado III - Barcelos/Esposende, Barcelos, Portugal
| | - Rosália Páscoa
- Department of Community Medicine, Information and Health Decision Sciences (MEDCIDS), Faculty of Medicine, University of Porto, Porto, Portugal.,Center for Health Technology and Services Research (CINTESIS), Faculty of Medicine, University of Porto, Porto, Portugal.,Unidade de Saúde Familiar Abel Salazar, Agrupamento de Centros de Saúde do Gaia, Vila Nova de Gaia, Portugal
| | - Carla Chaves-Loureiro
- Serviço Pediatria Ambulatória, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - Adelaide Alves
- Serviço de Pneumologia, Unidade I, Centro Hospitalar Vila Nova de Gaia/Espinho, Vila Nova de Gaia, Portugal
| | - Ângela Neves
- Unidade de Saúde Familiar Araceti, Agrupamento de Centros de Saúde Baixo Mondego, Arazede, Portugal
| | - José Varanda Marques
- Unidade de Saúde Familiar Viseu-Cidade, Agrupamento de Centros de Saúde do Dão Lafões, Viseu, Portugal
| | - Bruno Reis
- Unidade de Cuidados Saúde Personalizados Sicó, Agrupamento de Centros de Saúde Pinhal Litoral, Leiria, Portugal
| | - Manuel Ferreira-Magalhães
- Center for Health Technology and Services Research (CINTESIS), Faculty of Medicine, University of Porto, Porto, Portugal.,Serviço de Pediatria, Centro Materno Infantil do Norte, Centro Hospitalar Universitário do Porto, Porto, Portugal
| | - João Almeida Fonseca
- Department of Community Medicine, Information and Health Decision Sciences (MEDCIDS), Faculty of Medicine, University of Porto, Porto, Portugal
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4
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Amaral R, Jácome C, Almeida R, Pereira AM, Alves-Correia M, Mendes S, Rodrigues JCC, Carvalho J, Araújo L, Costa A, Silva A, Teixeira MF, Ferreira-Magalhães M, Alves RR, Moreira AS, Fernandes RM, Ferreira R, Pinto PL, Neuparth N, Bordalo D, Bom AT, Cálix MJ, Ferreira T, Gomes J, Vidal C, Mendes A, Vasconcelos MJ, Silva PM, Ferraz J, Morête A, Pinto CS, Santos N, Loureiro CC, Arrobas A, Marques ML, Lozoya C, Lopes C, Cardia F, Loureiro CC, Câmara R, Vieira I, da Silva S, Silva E, Rodrigues N, Fonseca JA. Profiling Persistent Asthma Phenotypes in Adolescents: A Longitudinal Diagnostic Evaluation from the INSPIRERS Studies. Int J Environ Res Public Health 2021; 18:ijerph18031015. [PMID: 33498858 PMCID: PMC7908090 DOI: 10.3390/ijerph18031015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/13/2020] [Revised: 01/18/2021] [Accepted: 01/20/2021] [Indexed: 02/07/2023]
Abstract
We aimed to identify persistent asthma phenotypes among adolescents and to evaluate longitudinally asthma-related outcomes across phenotypes. Adolescents (13–17 years) from the prospective, observational, and multicenter INSPIRERS studies, conducted in Portugal and Spain, were included (n = 162). Latent class analysis was applied to demographic, environmental, and clinical variables, collected at a baseline medical visit. Longitudinal differences in clinical variables were assessed at a 4-month follow-up telephone contact (n = 128). Three classes/phenotypes of persistent asthma were identified. Adolescents in class 1 (n = 87) were highly symptomatic at baseline and presented the highest number of unscheduled healthcare visits per month and exacerbations per month, both at baseline and follow-up. Class 2 (n = 32) was characterized by female predominance, more frequent obesity, and uncontrolled upper/lower airways symptoms at baseline. At follow-up, there was a significant increase in the proportion of controlled lower airway symptoms (p < 0.001). Class 3 (n = 43) included mostly males with controlled lower airways symptoms; at follow-up, while keeping symptom control, there was a significant increase in exacerbations/month (p = 0.015). We have identified distinct phenotypes of persistent asthma in adolescents with different patterns in longitudinal asthma-related outcomes, supporting the importance of profiling asthma phenotypes in predicting disease outcomes that might inform targeted interventions and reduce future risk.
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Affiliation(s)
- Rita Amaral
- Center for Health Technology and Services Research (CINTESIS), Faculty of Medicine, University of Porto, 4200-319 Porto, Portugal; (C.J.); (R.A.); (A.M.P.); (S.M.); (J.A.F.)
- Department of Community Medicine, Information and Health Decision Sciences (MEDCIDS), Faculty of Medicine, University of Porto, 4200-319 Porto, Portugal;
- Department of Cardiovascular and Respiratory Sciences, Porto Health School, Polytechnic Institute of Porto, 4200-072 Porto, Portugal
- Department of Women’s and Children’s Health, Paediatric Research, Uppsala University, SE-751 05 Uppsala, Sweden
- Correspondence: ; Tel.: +351-917-006-669
| | - Cristina Jácome
- Center for Health Technology and Services Research (CINTESIS), Faculty of Medicine, University of Porto, 4200-319 Porto, Portugal; (C.J.); (R.A.); (A.M.P.); (S.M.); (J.A.F.)
- Department of Community Medicine, Information and Health Decision Sciences (MEDCIDS), Faculty of Medicine, University of Porto, 4200-319 Porto, Portugal;
| | - Rute Almeida
- Center for Health Technology and Services Research (CINTESIS), Faculty of Medicine, University of Porto, 4200-319 Porto, Portugal; (C.J.); (R.A.); (A.M.P.); (S.M.); (J.A.F.)
- Department of Community Medicine, Information and Health Decision Sciences (MEDCIDS), Faculty of Medicine, University of Porto, 4200-319 Porto, Portugal;
| | - Ana Margarida Pereira
- Center for Health Technology and Services Research (CINTESIS), Faculty of Medicine, University of Porto, 4200-319 Porto, Portugal; (C.J.); (R.A.); (A.M.P.); (S.M.); (J.A.F.)
- Department of Community Medicine, Information and Health Decision Sciences (MEDCIDS), Faculty of Medicine, University of Porto, 4200-319 Porto, Portugal;
- Allergy Unit, CUF Porto Hospital and Institute, 4100-180 Porto, Portugal; (M.A.-C.); (L.A.)
| | - Magna Alves-Correia
- Allergy Unit, CUF Porto Hospital and Institute, 4100-180 Porto, Portugal; (M.A.-C.); (L.A.)
| | - Sandra Mendes
- Center for Health Technology and Services Research (CINTESIS), Faculty of Medicine, University of Porto, 4200-319 Porto, Portugal; (C.J.); (R.A.); (A.M.P.); (S.M.); (J.A.F.)
| | - José Carlos Cidrais Rodrigues
- Serviço de Pediatria, Hospital Pedro Hispano, Unidade Local de Saúde de Matosinhos, 4464-513 Matosinhos, Portugal; (J.C.C.R.); (J.C.); (C.L.)
| | - Joana Carvalho
- Serviço de Pediatria, Hospital Pedro Hispano, Unidade Local de Saúde de Matosinhos, 4464-513 Matosinhos, Portugal; (J.C.C.R.); (J.C.); (C.L.)
| | - Luís Araújo
- Allergy Unit, CUF Porto Hospital and Institute, 4100-180 Porto, Portugal; (M.A.-C.); (L.A.)
| | - Alberto Costa
- Serviço de Pediatria, Hospital Senhora da Oliveira, 4835-044 Guimarães, Portugal; (A.C.); (A.S.)
| | - Armandina Silva
- Serviço de Pediatria, Hospital Senhora da Oliveira, 4835-044 Guimarães, Portugal; (A.C.); (A.S.)
| | - Maria Fernanda Teixeira
- Serviço de Pediatria, Centro Materno Infantil do Norte, Centro Hospitalar Universitário do Porto, 4099-001 Porto, Portugal;
| | - Manuel Ferreira-Magalhães
- Department of Community Medicine, Information and Health Decision Sciences (MEDCIDS), Faculty of Medicine, University of Porto, 4200-319 Porto, Portugal;
- Serviço de Pediatria, Centro Materno Infantil do Norte, Centro Hospitalar Universitário do Porto, 4099-001 Porto, Portugal;
| | - Rodrigo Rodrigues Alves
- Serviço de Imunoalergologia, Hospital do Divino Espírito Santo, 9500-370 Ponta Delgada, Portugal;
| | - Ana Sofia Moreira
- Unidade de Imunoalergologia, Hospital do Divino Espírito Santo, 9500-370 Ponta Delgada, Portugal;
| | - Ricardo M. Fernandes
- Departamento de Pediatria, Hospital de Santa Maria, Centro Hospitalar de Lisboa Norte, 1649-035 Lisboa, Portugal; (R.M.F.); (R.F.); (A.M.)
| | - Rosário Ferreira
- Departamento de Pediatria, Hospital de Santa Maria, Centro Hospitalar de Lisboa Norte, 1649-035 Lisboa, Portugal; (R.M.F.); (R.F.); (A.M.)
| | - Paula Leiria Pinto
- Serviço de Imunoalergologia, Hospital de Dona Estefânia, Centro Hospitalar Universitário de Lisboa Central, 1150-199 Lisboa, Portugal; (P.L.P.); (N.N.)
| | - Nuno Neuparth
- Serviço de Imunoalergologia, Hospital de Dona Estefânia, Centro Hospitalar Universitário de Lisboa Central, 1150-199 Lisboa, Portugal; (P.L.P.); (N.N.)
- Pathophysiology, CHRC/CEDOC, High Burden and High Mortality Diseases Thematic Line Coordinator, Nova Medical School, 1150-190 Lisboa, Portugal
| | - Diana Bordalo
- Serviço de Pediatria, Unidade Hospitalar de Famalicão, Centro Hospitalar do Médio Ave, 4780-371 Vila Nova de Famalicão, Portugal;
| | - Ana Todo Bom
- Serviço de Imunoalergologia, Centro Hospitalar e Universitário de Coimbra, 3000-075 Coimbra, Portugal;
| | - Maria José Cálix
- Serviço de Pediatria, Hospital de São Teotónio, Centro Hospitalar Tondela–Viseu, 3504-509 Viseu, Portugal;
| | - Tânia Ferreira
- Unidade de Saúde Familiar Progresso e Saúde, ACeS Baixo Mondego, 3060-716 Tocha, Portugal;
| | - Joana Gomes
- Serviço de Imunoalergologia, Unidade I, Centro Hospitalar Vila Nova de Gaia/Espinho, 4434-502 Vila Nova de Gaia, Portugal;
| | - Carmen Vidal
- Servicio de Alergia, Complejo Hospitalario Universitario de Santiago, 15706 Santiago De Compostela, Spain;
| | - Ana Mendes
- Departamento de Pediatria, Hospital de Santa Maria, Centro Hospitalar de Lisboa Norte, 1649-035 Lisboa, Portugal; (R.M.F.); (R.F.); (A.M.)
| | - Maria João Vasconcelos
- Serviço de Imunoalergologia, Centro Hospitalar Universitário de São João, 4200–319 Porto, Portugal;
| | | | - José Ferraz
- Imunoalergologia, Hospital Privado de Alfena, Trofa Saúde, 4445-243 Alfena, Portugal;
| | - Ana Morête
- Serviço de Imunoalergologia, Hospital Infante D. Pedro, Centro Hospitalar Baixo Vouga, 3814-501 Aveiro, Portugal;
| | - Claúdia Sofia Pinto
- Serviço de Pneumologia, Hospital São Pedro de Vila Real, Centro Hospitalar De Trás-Os-Montes E Alto Douro, 5000-508 Vila Real, Portugal;
| | - Natacha Santos
- Serviço de Imunoalergologia, Centro Hospitalar Universitário do Algarve, 8000-386 Portimão, Portugal;
| | | | - Ana Arrobas
- Serviço de Pneumologia, Centro Hospitalar e Universitário de Coimbra, 3000-075 Coimbra, Portugal;
| | - Maria Luís Marques
- Serviço de Imunoalergologia, Centro Hospitalar Universitário do Porto, 4099-001 Porto, Portugal;
| | - Carlos Lozoya
- Serviço de Imunoalergologia, Hospital Amato Lusitano, Unidade Local de Saúde de Castelo Branco, 6000-085 Castelo Branco, Portugal;
| | - Cristina Lopes
- Serviço de Pediatria, Hospital Pedro Hispano, Unidade Local de Saúde de Matosinhos, 4464-513 Matosinhos, Portugal; (J.C.C.R.); (J.C.); (C.L.)
- Imunologia Básica e Clínica, Faculdade de Medicina, Universidade do Porto, 4200-319 Porto, Portugal
| | - Francisca Cardia
- Unidade de Saúde Familiar Terras de Azurara, ACES Dão Lafões, 3530-113 Mangualde, Portugal;
| | - Carla Chaves Loureiro
- Departamento de Pediatria, Serviço de Pediatria Ambulatória, Centro Hospitalar e Universitário de Coimbra, 3000-075 Coimbra, Portugal;
| | - Raquel Câmara
- Serviço de Pneumologia, Hospital Nossa Senhora do Rosário, Centro Hospitalar Barreiro Montijo, 2834-003 Barreiro, Portugal;
| | - Inês Vieira
- UCSP Dr. Arnaldo Sampaio, ACES Pinhal Litoral, 2419-014 Leiria, Portugal;
| | - Sofia da Silva
- USF Cuidarte, Unidade Local de Saúde do Alto Minho, 4925-083 Portuzelo, Portugal;
| | - Eurico Silva
- Unidade de Saúde Familiar João Semana, ACeS Baixo Vouga, 3880-225 Ovar, Portugal;
| | - Natalina Rodrigues
- Unidade de Saúde Familiar Mondego, ACES Baixo Mondego, 3045-059 Coimbra, Portugal;
| | - João A. Fonseca
- Center for Health Technology and Services Research (CINTESIS), Faculty of Medicine, University of Porto, 4200-319 Porto, Portugal; (C.J.); (R.A.); (A.M.P.); (S.M.); (J.A.F.)
- Department of Community Medicine, Information and Health Decision Sciences (MEDCIDS), Faculty of Medicine, University of Porto, 4200-319 Porto, Portugal;
- Allergy Unit, CUF Porto Hospital and Institute, 4100-180 Porto, Portugal; (M.A.-C.); (L.A.)
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