Politics and confidence toward the COVID-19 vaccination: A Brazilian cross-sectional study

This study has the aim of assessing the Brazilian perceptions, influencing factors and political positioning on the confidence concerning COVID-19 vaccination. To achieve the objective, the methods rely on a cross-sectional survey of Brazilian citizens, distributed through different social networks. The sample is composed of 1,670 valid responses, collected from almost all Brazilian states and state capitals. To analyze the data and give a clear view of the variables' relationship, the study used bivariate and comparative graphs. Results show a higher level of confidence in vaccines from Pfizer and AstraZeneca, while the lower level of confidence is associated with vaccines from Sinopharm and Sputinik5. Vaccine efficacy is the most significant influencing factor that helps in the decision to get vaccinated. Also, individuals are less willing to get vaccinated if their political preferences are related to the right-wing. The results led to three main health and social implications: i) the vaccination strategy campaigns should take in count vaccine efficacy and political aspects; ii) the vaccination process should be adapted to regions with different political positions; and iii) a reinforcement in the educational policies of the vaccine's importance to the public health, to avoid the politization of a health issue.

Vaccine hesitancy comes in waves: Longitudinal evidence on willingness to vaccinate against COVID-19 from seven European countries

AIM

This paper investigates the prevalence and determinants of three main states of people's willingness to be vaccinated (WTBV) against COVID-19 - willing, unwilling and hesitant - and the occurrence and predictors of shifts between these states over time. Understanding the dynamics of vaccine intentions is crucial for developing targeted campaigns to increase uptake and emergency response preparedness.

STUDY DESIGN

A panel survey consisting of 9 quarterly waves of data collected between April 2020 and January 2022. Baseline data included 24 952 adults from Germany, UK, Denmark, the Netherlands, France, Portugal, and Italy recruited from online panels to construct census-matched nationally representative samples.

METHODS AND MEASURES

Self-reported COVID-19 vaccine intention was the main outcome. Multinomial logit random effects models were used to analyze the relationships of interest. All results reported as relative risk ratios (RRR).

RESULTS

Hesitancy to get vaccinated was the most unstable vaccine intention, with on average 42% of ever hesitant respondents remaining in this state through future waves, followed by the 'unwilling' (53%) and 'willing (82%). Following COVID-19 news, trust in information from the government, GPs and the WHO, risk preferences, risk perceptions, and confidence in vaccines (or lack thereof) predicted vaccination intention reversals. Risk preferences acted both as an impediment and as a facilitator for the vaccine uptake depending on the initial vaccine intention.

CONCLUSIONS AND RELEVANCE

This study revealed the dynamic nature of COVID-19 vaccine intentions and its predictors in 7 European countries. The findings provide insights to policymakers for designing more effective communication strategies, particularly targeted at hesitant and unwilling to vaccinate population groups, to increase vaccine uptake for future public health emergencies.

Braving the waves: exploring capability well-being patterns in seven European countries during the COVID-19 pandemic

The COVID-19 pandemic considerably impacted the lives of European citizens. This study aims to provide a nuanced picture of well-being patterns during the pandemic across Europe with a special focus on relevant socio-economic sub-groups. This observational study uses data from a repeated, cross-sectional, representative population survey with nine waves of data from seven European countries from April 2020 to January 2022. The analysis sample contains a total of 25,062 individuals providing 64,303 observations. Well-being is measured using the ICECAP-A, a multi-dimensional instrument for approximating capability well-being. Average levels of ICECAP-A index values and sub-dimension scores were calculated across waves, countries, and relevant sub-groups. In a fixed effects regression framework, associations of capability well-being with COVID-19 incidence, mortality, and the stringency of the imposed lockdown measures were estimated. Denmark, the Netherlands, and France experienced a U-shaped pattern in well-being (lowest point in winter 2020/21), while well-being in the UK, Germany, Portugal, and Italy followed an M-shape, with increases after April 2020, a drop in winter 2020, a recovery in the summer of 2021, and a decline in winter 2021. However, observed average well-being reductions were generally small. The largest declines were found in the well-being dimensions attachment and enjoyment and among individuals with a younger age, a financially unstable situation, and lower health. COVID-19 mortality was consistently negatively associated with capability well-being and its sub-dimensions, while stringency and incidence rate were generally not significantly associated with well-being. Further investigation is needed to understand underlying mechanisms of presented patterns.

Pandemia, Saúde e Proteção: O Que nos Diz o Health at a Glance 2022?

N/a.

COVID-19 contact tracing as an indicator for evaluating the pandemic situation: a simulation study

BACKGROUND

Contact tracing is a fundamental intervention in Public Health. When systematically applied, it enables the breaking of chains of transmission, important in controlling COVID-19 transmission. In a theoretically perfect contact tracing, all new cases should occur among quarantined individuals and an epidemic should vanish. However, the availability of resources influences the capacity to perform contact tracing. Therefore, it prompts the need to estimate its effectiveness threshold. We propose that this effectiveness threshold may be indirectly estimated by the ratio of COVID-19 cases arising from quarantined high-risk contacts, where higher ratios indicate better control and under a threshold contact tracing may fail and other restrictions become necessary.

OBJECTIVE

To study the ratio of COVID-19 cases in high-risk contacts quarantined through contact tracing and its potential use as an ancillary pandemic control indicator.

METHODS

We built a 6-compartment epidemiological model to emulate COVID-19 infection flow according to publicly available data from Portuguese authorities. Our model extended the usual SEIR model by adding a compartment Q with individuals in mandated quarantine that could develop infection or return to the susceptible pool; and a compartment P with individuals protected from infection due to vaccination. To model infection dynamics, data on SARS-CoV-2 infection risk, time until infection and vaccine efficacy were collected. Estimation was needed for vaccine data, to reflect the timing of inoculation and booster efficacy. Two simulations were built: the first (A) adjusting for the presence and absence of variants or vaccination, and the second (B) maximizing infection risk in quarantined individuals. Both simulations were based on a set of 100 unique parameterizations. The daily ratio of infected cases arising from high-risk contacts (q estimate) was calculated. A theoretical effectiveness threshold of contact tracing was defined for 14-day average q estimates based on the classification of COVID-19 daily cases according to the Pandemic phases and was compared with the timing of population lockdowns in Portugal. A sensitivity analysis was performed to understand the relation between different parameter values and the threshold obtained.

RESULTS

An inverse relationship was found between the q estimate and the daily cases in both simulations (correlations over -0.70). The theoretical effectiveness thresholds for both simulations attained an Alert phase predictive positive value of over 70% and could have anticipated the need for additional measures in at least 4 days for the second and fourth lockdowns. Sensitivity analysis showed that only the infection risk and the booster dose efficacy at inoculation significantly impacted the q estimates.

CONCLUSIONS

We demonstrate the impact of applying an effectiveness threshold for contact tracing in decision-making. While only theoretical thresholds could be provided, their relationship with the number of confirmed cases and prediction of pandemic phases shows the role as indirect indicator of the efficacy of contact tracing.

CLINICALTRIAL

Health-related quality of life in seven European countries throughout the course of the COVID-19 pandemic: evidence from the European COvid Survey (ECOS)

PURPOSE

To investigate health-related quality of life (HRQoL) over the course of the COVID-19 pandemic in seven European countries and its association with selected sociodemographic as well as COVID-19-related variables.

METHODS

We used longitudinal data from nine quarterly waves collected between April 2020 and January 2022 (sample size per wave ranging from N = 7025 to 7300) of the European COvid Survey (ECOS), a representative survey of adults in Germany, United Kingdom, Denmark, Netherlands, France, Portugal and Italy. HRQoL was measured using the EQ-5D-5L. The association of self-reported COVID-19 infection, perceived health risk from COVID-19, selected sociodemographic variables and the COVID-19 stringency index with HRQoL was analyzed by logistic and linear fixed effects regressions.

RESULTS

On average across all nine waves, the proportion of respondents reporting any problems in at least one of the EQ-5D dimensions ranged between 63.8% (Netherlands) and 71.0% (Denmark). Anxiety/depression was the most frequently affected EQ-5D dimension in four countries (Portugal: 52.0%; United Kingdom: 50.2%; Italy: 49.2%; France: 49.0%), whereas pain/discomfort ranked first in three countries (Denmark: 58.3%; Germany: 55.8%; Netherlands: 49.0%). On average across all nine waves, the EQ-VAS score ranged from 70.1 in the United Kingdom to 78.4 in Portugal. Moreover, the EQ-5D-5L index ranged from .82 in Denmark to .94 in France. The occurrence of COVID-19 infection, changes in the perceived risk to one's own health from COVID-19, the occurrence of income difficulties and an increase in the COVID-19 stringency index were associated with increased likelihood of problems in EQ-5D dimensions, reduced EQ-VAS score and reduced EQ-5D-5L index.

CONCLUSIONS

Across seven European countries, we found large proportions of respondents reporting problems in HRQoL dimensions throughout the pandemic, especially for anxiety/depression. Various sociodemographic and COVID-19-related variables were associated with HRQoL in longitudinal analysis.

Perceptions of institutional performance and compliance to non-pharmaceutical interventions: How performance perceptions and policy compliance affect public health in a decentralized health system

Trust in institutions is a key driver to shape population attitudes and behavior, such as compliance of non-pharmaceutical interventions (NPI). During the COVID-19 pandemic, this was fundamental and its compliance was supported by governmental and non-governmental institutions. Nevertheless, the situation of political polarization in some countries with decentralized health systems increased the difficulty of such interventions. This study analyzes the association between non-pharmaceutical interventions' compliance and individual perception regarding institutions' performance during the COVID-19 pandemic in Brazil. A web survey was conducted in Brazil between November 2020 and February 2021. Bivariate analysis and ordered logit regressions were performed to assess the association between NPIs compliance and perceived institutions' performance. Results suggest a negative association between NPIs' compliance and Federal Government and Ministry of health perceived performance, which may reflect the political positioning of the respondents. Moreover, we find a positive association between NPI compliance and the perceived performance of the remaining institutions (state government, federal supreme court, national congress, WHO, media and SUS). Our contribution goes beyond the study of a relationship between non-pharmaceutical interventions' compliance and institutions' performance, by pointing out the importance of subnational and local governmental spheres in a decentralized health system, as well as highlighting the importance of social communication based on health organizations' information and scientific institutions.

Depression and anxiety in later COVID-19 waves across Europe: New evidence from the European COvid Survey (ECOS)

We aimed to investigate the prevalence of probable depression and anxiety and their correlates during later stages of the COVID-19 pandemic in eight European countries. Longitudinal data (wave 7 in June/July 2021: n=8,032; wave 8 in September 2021: n=8,250; wave 9 in December 2021/January 2022: n=8,319) were used from the European COvid Survey - a representative sample of community-dwelling adults from several European countries (Germany, United Kingdom, Denmark, Netherlands, France, Portugal, Italy and Spain). In wave 7 (wave 8; wave 9), 23.8% (22.0%; 24.3%) of all respondents had probable depression and 22.6% (22.1%; 23.7%) had probable anxiety. These prevalence rates substantially differed between the European countries. Regressions showed that emerging difficulties with the income were associated with both increases in depressive symptoms and anxiety symptoms. An increase in one's own perceived risk of getting infected with the SARS-CoV-2, the birth of a child and an increase in the Covid-19 stringency index were associated with increases in depressive symptoms. The significance of probable depression and anxiety during later stages of the COVID-19 pandemic in eight European countries was highlighted. Avoiding income difficulties may also contribute to mental health.

A Inovação em Saúde Vista por Dentro

Existe com frequência, em Portugal e em muitos países europeus, uma falta de articulação entre a prática diária dos profissionais da saúde e as iniciativas rotuladas como inovadoras que muitas vezes ocorrem nas próprias organizações onde trabalham. Esta falta de alinhamento entre a prática corrente e a inovação, venha de onde vier, é muito menos frequentenos chamados países anglo-saxónicos onde existe uma cultura de inovação institucional que tem raízes numa forma mais aberta e organizada de gerar e utilizar o conhecimento para benefício da sociedade. O papel das instituições na criação de valor económico e social a partir do conhecimento tem sido pouco estudado entre nós na área da saúde. Recentemente, finalizamos um projeto que analisou, através de um inquérito aplicado a gestores de topo de instituições da área da saúde, como se desenvolve o processo de tomada de decisão que conduz ao aparecimento de inovações com impacto económico e social. Utilizámos como base o modelo proposto por Thakur et al (2012),1 publicado no Journal of Business Research, e tomámos igualmente em conta a análise das inovações consideradas mais promissoras em saúde identificadas no Global Innovation Index (Creating Healthy Lives – The Future of Medical Innovation), 2019. A realização deste trabalho, cujos resultados centrais são agora disponibilizados em livro,2 só foi possível graças a uma cooperação entre o Health Cluster Portugal (HCP), associação que engloba mais de uma centena de organizações ligadas à saúde e o Health Economics & Management Knowledge Center da Nova School of Business & Economics. Esta partilha entre o saber e a experiência de gestores de topo dos vários subclusters do HCP (instituições de investigação ou ensino e formação; prestadores de cuidados; empresas farmacêuticas; empresas de tecnologias médicas; empresas e organizações de consultoria; empresas de outras áreas (logística, distribuição, têxtil e mobiliário) e a academia, possibilitou, através da análise das entrevistas e posterior tratamento com uma metodologia cientificamente validada, a identificação de percursos muitas vezes surpreendentes, mas sempre encorajadores. As entrevistas seguiram a aplicação de um guião estruturado, construído em torno de cinco dimensões centrais ao processo de inovação: criação de ideias inovadoras, processo de tomada de decisão para as viabilizar, implementação, avaliação e aprendizagem interna para a geração de novas ideias e inovações. Pretendemos, desta forma, contribuir para o desenvolvimento de uma cultura nacional de inovação nas múltiplas áreas da saúde agora que já passámos, em Portugal, o período em que inovar era “trazer novidades” para o nosso país, divulgá-las e, quando possível, muitas vezes “contraventos e marés”, aplicá-las numa pequena escala. Esse período, quase heroico, fez, e ainda faz, com que oportunidades importantes fiquem por explorar e que muitas inovações nunca cheguem a fazer parte do nosso quotidiano. A abordagem seguida no projeto pretende identificar como a inovação na saúde é vista pelos decisores institucionais e como ocorre todo o processo dentro da respetiva organização. Das múltiplas experiências partilhadas identificam-se padrões. Estes padrões permitem compreender não só os sucessos, mas também as razões dos insucessos. Para os leitores que estejam em entidades do sector da saúde, esperamos que a leitura deixe o desafio de contextualizar a sua organização face às perguntas que colocamos. Este esforço insere-se numa procura do que poderia ser não só um sistema nacional de inovação, mas também como se poderá promover em cada instituição, uma cultura estável e continuada de inovação não só top down como bottom up. Destacam-se, a nosso ver, três grandes temas das perguntas feitas e das respostas obtidas: como se internaliza institucionalmente uma inovação para guiar as decisões que a viabilizam, qual o papel da liderança institucional nesse processo e como se podem escalar essas inovações, a nível nacional e internacional. A principal conclusão é a inexistência de soluções padrão uma vez que cada projeto inovador é uma situação com singularidades próprias necessitando de um enquadramento institucional próprio para ser bem-sucedido. Compreender os princípios base, e estabelecer o próprio caminho é a receita, aproveitando ainda assim o conhecimento de como as dificuldades foram ultrapassadas noutros contextos. O objetivo de analisar o processo de inovação na saúde numa perspetiva institucional e não do utilizador, ou das políticas públicas, permitiu constatar que os entrevistados, decisores de instituições públicas e privadas, dominam amplamente o tema e identificam obstáculos que parecem resultar de uma ausência de um sistema nacional de inovação da saúde, englobando todos os intervenientes, isto apesar das iniciativas da COTEC, ANI e, mais recentemente, da AICIB. Esta falha de um referencial sistémico nacional para a inovação em saúde, impede, provavelmente, que as próprias empresas, organizações e instituições envolvidas possam fazer pleno uso dos recursos internos de que dispõem. A mobilização de recursos externos, mas internos a Portugal, é uma dificuldade apontada para um maior sucesso da inovação em saúde. Em particular surgem referências aos constrangimentos económicos, burocráticos e de recursos humanos que nem a contratação de consultores externos especializados aparenta ajudar. As entrevistas realizadas corroboram uma opiniãogeneralizada de décadas, de elevados «custos de contexto» em Portugal. Significa que se houve caminho que foi feito no sentido de reduzir esses custos de contexto, muito mais ainda está por fazer. Não sendo propriamente novidade, reforça a necessidade de manter uma atenção constante a este fator, pois nem mesmo as empresas com maior sucesso o conseguem evitar. Fica também a convicção de que, se o sistema nacional de inovação em saúde existisse, as instituições seriam capazes de responder com maior sucesso, como aliás já fazem, nalguns casos, a nível internacional. É ainda generalizado o entendimento de haver inovações incrementais ou disruptivas, que podem ser de produto, serviço ou processo. O conceito de inovação é também muitas vezes associado a um elemento que se vai melhorando e que muitas vezes se transforma de novo sendo que a convicção de grande parte dos entrevistados vai no sentido de que a inovação, economicamente viável, tem de envolver soluções que melhorem a prestação dos cuidados de saúde. Este estudo demonstra, pela voz dos próprios agentes que promovem a inovação em saúde, que há ainda um caminho a percorrer para que, em Portugal, as diversas formas de inovação possam ser consideradas elementos estruturantes da prestação dos cuidados de saúde e, simultaneamente, atrativas como “investimento e subsequente fonte de receitas” para as instituições envolvidas. Para concluir será ainda de realçar a diferença entre instituições públicas e privadas, em que para as primeiras a ideia de singrar no mercado com inovações está limitada pela sua escassa autonomia, por exemplo na área da contratualização, o que as leva a perderem oportunidades de afirmar o sector público da saúde como gerador de valor económico. Isto conduz a que não haja formas sistemáticas de fazer essa ligação entre inovações desenvolvidas no sector público e o mercado privado que sejam vantajosas para todos, incluindo para quem beneficiaria de melhores cuidados de saúde. REFERÊNCIAS1. Thakur R, Hsu SH, Fontenot G. Innovation in healthcare: Issues and future trends. J Business Res. 2012;65:562-9. doi: 10.1016/j.jbusres. 2011.02.022.2. Breia da Fonseca FP, Pita Barros P, Bensabat Rendas A. Inovação em saúde por quem a pratica. Coimbra: Edições Almedina; 2022.

How do European Mature Adults and Elderly Perceive SARS-COV-2 and Associated Control Measures? A Cross-Country Analysis of Mental Health Symptoms in June and July 2020

Objectives: Recent literature points out that elderly people are psychologically resilient to COVID-19, but the studies were performed in specific contexts. We measured the link between the worsening of mental health symptoms, the epidemiologic situation, and control measures among European people aged 50 or older.

Methods: We used data from the 2020 wave of SHARE, merged with Oxford COVID-19 Government Response Tracker data (n = 38,358). We modeled the risk of worsening of depression, anxiety, sleeping trouble, and loneliness symptoms’ self-perception, as functions of control measures and 7-days death incidence, using logistic regressions.

Results: The worsening of anxiety and depression perception were more common (16.2 and 23.1%, respectively), compared to that of sleeping troubles and loneliness (8.1 and 11.5%, respectively). The worsening of depression and anxiety perception was negatively related to the rigor of control measures. The seven-days death incidence was positively linked to all symptoms except sleeping troubles.

Conclusion: Older people were the most exposed to death risk and were affected psychologically by the COVID-19 epidemiological situation; yet control measures were protective (or neutral) to their mental health condition.

Prevalence and determinants of probable depression and anxiety during the COVID-19 pandemic in seven countries: Longitudinal evidence from the European COvid Survey (ECOS)

BACKGROUND

Our aim was to present data on the prevalence of probable depression and anxiety and to determine their correlates during the COVID-19 pandemic in seven European countries using a longitudinal approach.

METHODS

Longitudinal data (wave 4 in November 2020: n = 7,115; wave 5 in January 2021: n = 7,068; wave 6 in April 2021: n = 7,204) were taken from the European COvid Survey (ECOS), a representative sample of non-institutionalized inhabitants from Germany, United Kingdom, Denmark, Netherlands, France, Portugal and Italy aged 18+. Probable depression and anxiety were quantified using the established and validated PHQ-4 (2-item depression scale, PHQ-2 / 2-item anxiety scale, GAD-2).

RESULTS

In wave 4 (wave 5; wave 6), 26.6% (25.5%; 23.8%) of all respondents had probable depression and 25.7% (23.6%; 22.1%) had probable anxiety. Prevalence rates for probable depression and probable anxiety differed significantly between countries. Among all countries and waves, particularly high prevalence rates were found among individuals aged 18 to 29 years. Longitudinal analysis showed that the likelihood of probable depression was positively associated with increasing age, great income difficulties and lower health-related quality of life. The likelihood of probable anxiety was positively associated with income difficulties, and lower health-related quality of life.

LIMITATIONS

Screening tool was used to quantify the outcomes.

CONCLUSION

The magnitude of probable depression and anxiety during the COVID-19 pandemic in European countries was highlighted. Moreover, determining the factors associated with probable depression or anxiety (e.g., income difficulties, worse health-related quality of life) may assist in identifying individuals at increased risk.

Running away from the jab: factors associated with COVID-19 vaccine hesitancy in Brazil

OBJECTIVE:

To investigate how sociodemographic conditions, political factors, organizational confidence, and non-pharmaceutical interventions compliance affect the COVID-19 vaccine hesitancy in Brazil.

METHODS:

Data collection took place between November 25th, 2020 and January 11th, 2021 using a nationwide online survey. Subsequently, the researches performed a descriptive analysis on the main variables and used logistic regression models to investigate the factors associated with COVID-19 vaccine hesitancy.

RESULTS:

Less concern over vaccine side effects could improve the willingness to be vaccinated (probability changed by 7.7 pp; p < 0.10). The current vaccine distrust espoused by the Brazilian president is associated with vaccine hesitancy, among his voter base. Lower performance perception (“Very Bad” with 10.7 pp; p < 0.01) or higher political opposition (left-oriented) regarding the current presidency is associated with the willingness to be vaccinated. Higher compliance with non-pharmaceutical interventions (NPIs) is usually positively associated with the willingness to take the COVID-19 vaccine (+1 score to NPI compliance index is associated with higher willingness to be vaccinated by 1.4 pp, p < 0.05).

CONCLUSION:

Willingness to be vaccinated is strongly associated with political leaning, perceived federal government performance, vaccine side effects, and compliance with non-pharmaceutical interventions (NPIs).

Introduction to the Expert Panel on Effective ways of investing in health (EXPH) and its mandate

EXPH members and Opinion collaborators

The Expert Panel on Effective ways of investing in health (EXPH) is an interdisciplinary and independent group established by the European Commission to provide non-binding independent advice on matters related to effective, accessible and resilient health systems. The mandate from the European Commission asked EXPH to address the following questions: 1. What are the specific factors influencing mental health (MH) of the health workforce and essential workers? 2. What interventions could be effective in addressing MH support needs of health workers and essential workers, including those with preexisting MH conditions? Using existing data, assess the cost of MH problems in the health workforce and the cost-effectiveness of MH interventions. What are the conditions for the delivery of these interventions in a cost-effective, affordable and inclusive manner? 3) How can the EU address these concerns?

Resilience Testing of Health Systems: How Can It Be Done?

The resilience of health systems has received considerable attention as of late, yet little is known about what a resilience test might look like. We develop a resilience test concept and methodology. We describe key components of a toolkit and a 5-phased approach to implementation of resilience testing that can be adapted to individual health systems. We develop a methodology for a test that is balanced in terms of standardization and system-specific characteristics/needs. We specify how to work with diverse stakeholders from the health ecosystem via participatory processes to assess and identify recommendations for health system strengthening. The proposed resilience test toolkit consists of “what if” adverse scenarios, a menu of health system performance elements and indicators based on an input-output-outcomes framework, a discussion guide for each adverse scenario, and a traffic light scorecard template. The five phases of implementation include Phase 0, a preparatory phase to adapt the toolkit materials; Phase 1: facilitated discussion groups with stakeholders regarding the adverse scenarios; Phase 2: supplemental data collection of relevant quantitative indicators; Phase 3: summarization of results; Phase 4: action planning and health system transformation. The toolkit and 5-phased approach can support countries to test resilience of health systems, and provides a concrete roadmap to its implementation.

Risk communication during COVID-19: A descriptive study on familiarity with, adherence to and trust in the WHO preventive measures

BACKGROUND

Risk communication is a key component of public health interventions during an outbreak. As the coronavirus pandemic unfolded in late 2019, the World Health Organization (WHO) was at the forefront in the development of risk communication strategies. The WHO introduced a range of activities with the purpose of enabling the public to avail verified and timely information on COVID-19 prevention behaviors. Given the various WHO activities to protect the public health during COVID-19, it is important to investigate the extent of familiarity and uptake of the WHO recommendations among the public during the first wave of the pandemic.

METHODS

To do this, we conducted a large-scale Pan-European survey covering around 7500 individuals that are representative of populations from seven European countries, collected online during April 2-April 15, 2020. We use descriptive statistics including proportions and correlations and graphical representations such as bar charts to analyze and display the data.

RESULTS

Our findings suggest that information from the WHO in the context of COVID-19 is well trusted and acted upon by the public. Overall familiarity and adherence were quite high in most countries. Adherence was higher for social distancing recommendations compared to hygiene measures. Familiarity and adherence were higher among older, female, and highly educated respondents. However, country level heterogeneities were observed in the level of trust in information from the WHO, with countries severely affected by the pandemic reporting lower levels of trust.

CONCLUSION

Our findings call for efforts from health authorities to get regular feedback from the public on their familiarity and compliance with recommendations for preventive measures at all stages of the pandemic, to further develop and adapt risk communication as the pandemic evolves.

Blood donation in times of crisis: Early insight into the impact of COVID-19 on blood donors and their motivation to donate across European countries

Background

In this survey, we aimed to provide early insight into the impact of COVID‐19 on blood donors and their motivation to donate during the crisis.

Study design and methods

We asked representative samples in 7 European countries (Denmark, France, Germany, Italy, Portugal, the Netherlands and the UK) about their blood donation activity and motivation to donate using an online survey. We analysed donor turnout during the COVID‐19 period descriptively and using logistic regression.

Results

Of the 7122 people that responded to the survey, 1205 (16·9%) blood donors were identified, with 33·8% donating during the first 4–5 months of the COVID‐19 period. We observed that around half of donors donated less than normal. The vast majority of donors that did donate made a special effort to do so in response to COVID‐19. The majority of donors were also not aware of their blood being tested for COVID‐19 antibodies. Although the perceived risk of infection among all respondents whilst donating blood was relatively low, those who anticipated a high risk of infection were much less likely to donate (OR = 0·540; P‐value = 0·006). Furthermore, those that were adherent to COVID guidelines were also less likely to donate (OR = 0·583; P‐value = 0·000).

Discussion

We suggest that blood collection services consider specialist campaigns that focus on the altruistic motivation of donors during the crisis and that they continue to communicate the additional safety measures in place with the aim of reducing the fear of infection whilst donating blood.

Does working at home compromise mental health? A study on European mature adults in COVID times

INTRODUCTION

The COVID-19 pandemic has transformed working at home (WAH) into the exclusive mode of working for many European workers. Although WAH will likely remain after COVID-19, its consequences on workers' health are unclear. This study examines the association of WAH and the change of four mental health (MH) domains.

METHODS

We used data from the last wave of the Survey on Health, Aging, and Retirement in Europe, collected in June and July 2020 on European people aged 50 and older. We restricted our analysis to people aged 50-65 who were working before COVID-19 (N = 7065). We modeled the risk of worsening of depression and anxiety feelings, sleeping trouble, and feelings of loneliness as a function of the working situation (usual setting, at home and usual setting, at home only), using logistic regressions. A first model adjusted for sociodemographic variables, a second one adding country fixed effects, and the last one adding the stringency of COVID-19-related restrictions.

RESULTS

WAH was significantly associated with a worsening of all MH symptoms. Nevertheless, when the stringency index was factored in, no significant association of WAH was found with any of the health outcomes except for anxiety feelings (+4.3% points). However, the increased anxiety feelings among people in WAH were not greater than the one observed among nonworkers.

DISCUSSION

Our findings show that WAH was not a major cause of mental health deterioration among European mature adults during the first month of the pandemic. Further evidence is needed on WAH under post-COVID-19 "normal" circumstances.

Concerns and adjustments: How the Portuguese population met COVID-19

BACKGROUND

The COVID-19 pandemic has led to disruptive changes worldwide, with different implications across countries. The evolution of citizens' concerns and behaviours over time is a central piece to support public policies.

OBJECTIVE

To unveil perceptions and behaviours of the Portuguese population regarding social and economic impacts of the COVID-19 pandemic, allowing for more informed public policies.

METHODS

Online panel survey distributed in three waves between March 13th and May 6th 2020. Data collected from a non-representative sample of 7,448 respondents includes socio-demographic characteristics and self-reported measures on levels of concern and behaviours related to COVID-19. We performed descriptive analysis and probit regressions to understand relationships between the different variables.

RESULTS

Most participants (85%) report being at least very concerned with the consequences of the COVID-19 pandemic and social isolation reached a high level of adherence during the state of emergency. Around 36% of the sample anticipated consumption decisions, stockpiling ahead of the state of emergency declaration. Medical appointments suffered severe consequences, being re-rescheduled or cancelled. We find important variation in concerns with the economic impact across activity sectors.

CONCLUSION

We show that high level of concern and behaviour adaptation in our sample preceded the implementation of lockdown measures in Portugal around mid-March. One month later, a large share of individuals had suffered disruption in their routine health care and negative impacts in their financial status.

Battling the infodemics: health communication effectiveness during COVID-19

The coronavirus disease (COVID-19) outbreak in many parts of the world has posed serious concerns to the public health. During this period of crisis, the World Health Organization (WHO) reminds all countries and communities that the spread of this virus can be significantly slowed or even reversed through the implementation of robust containment and control measures. The WHO has also asked the public to be careful while reading and spreading health recommendations from untrustworthy online sources of information. Myths and misbeliefs about the prevention and spread of COVID-19 not only create global panic but also pose risks to people's lives and public health in general. Rampant misinformation on the disease slows down the efforts of public health bodies to contain the outbreak. Therefore, the role of public health bodies in communicating the right message and in the right form to the public is crucial.

In our study, we aim to assess the effectiveness of communication strategies used by international and national public health authorities to inform the public on COVID-19 risks and prevention. In particular, we conduct a survey experiment on a large sample (N = 4000) of adults from seven European countries to test the efficacy of public health messages in a form of prevention and corrective information provision. The study seeks to investigate how people's risk perceptions and behaviors change subject to the preventive information provision or treatment with the information countering widely spread misperceptions about the COVID-19 as compared to the control group.

The findings of this research will be relevant for policymakers and public health professionals in the development of effective communication strategies during disease outbreaks.

Key messages

Risk perceptions towards COVID-19 and their determinants across European countries are unknown. Unclear effectiveness of public health messages in a form of prevention and corrective information provision.

United but divided: Policy responses and people's perceptions in the EU during the COVID-19 outbreak

To understand the public sentiment toward the measures used by policymakers for COVID-19 containment, a survey among representative samples of the population in seven European countries was carried out in the first two weeks of April 2020. The study addressed people's support for containment policies, worries about COVID-19 consequences, and trust in sources of information. Citizens were overall satisfied with their government's response to the pandemic; however, the extent of approval differed across countries and policy measures. A north-south divide in public opinion was noticeable across the European states. It was particularly pronounced for intrusive policy measures, such as mobile data use for movement tracking, economic concerns, and trust in the information from the national government. Considerable differences in people's attitudes were noticed within countries, especially across individual regions and age groups. The findings suggest that the epidemic acts as a stressor, causing health and economic anxieties even in households that were not directly affected by the virus. At the same time, the burden of stress was unequally distributed across regions and age groups. Based on the data collected, we draw lessons from the containment stage and identify several insights that can facilitate the design of lockdown exit strategies and future containment policies so that a high level of compliance can be expected.

United but divided: Policy responses and people's perceptions in the EU during the COVID-19 outbreak

To understand the public sentiment toward the measures used by policymakers for COVID-19 containment, a survey among representative samples of the population in seven European countries was carried out in the first two weeks of April 2020. The study addressed people's support for containment policies, worries about COVID-19 consequences, and trust in sources of information. Citizens were overall satisfied with their government's response to the pandemic; however, the extent of approval differed across countries and policy measures. A north-south divide in public opinion was noticeable across the European states. It was particularly pronounced for intrusive policy measures, such as mobile data use for movement tracking, economic concerns, and trust in the information from the national government. Considerable differences in people's attitudes were noticed within countries, especially across individual regions and age groups. The findings suggest that the epidemic acts as a stressor, causing health and economic anxieties even in households that were not directly affected by the virus. At the same time, the burden of stress was unequally distributed across regions and age groups. Based on the data collected, we draw lessons from the containment stage and identify several insights that can facilitate the design of lockdown exit strategies and future containment policies so that a high level of compliance can be expected.

Entry and price competition in the over-the-counter drug market after deregulation: Evidence from Portugal

In the last two decades, many European countries allowed the sale of over-the-counter (OTC) drugs outside pharmacies. This was expected to lower retail prices through increased competition. Evidence of such price reductions is scarce. We assess the impact of supermarket and outlet entry in the OTC drug market on OTC prices charged by incumbent pharmacies using a difference-in-differences strategy. We use price data on five popular OTC drugs for all retailers located in Lisbon for three distinct points in time (2006, 2010, and 2015). Our results suggest that competitive pressure in the market is mainly exerted by supermarkets, which charge, on average, 20% lower prices than pharmacies. The entry of a supermarket among the main competitors of an incumbent pharmacy is associated with an average 4% to 6% decrease in prices relative to the control group. These price reductions are long-lasting but fairly localized. We find no evidence of price reductions following OTC outlet entry. Additional results from a reduced-form entry model and a propensity score matching difference-in-differences approach support the view that these effects are causal.

Strengthening vaccination programmes and health systems in the European Union: A framework for action

Vaccination is one of the most cost-effective public health interventions. However, the EU is facing increasing outbreaks of vaccine preventable diseases, with some fatal cases of measles. This paper reviews the main factors influencing vaccination uptake, and assesses measures expected to improve vaccination coverage. Obstacles to vaccination include concerns about vaccine safety and side effects, lack of trust, social norms, exposure to rumours and myths, and access barriers. Responses fall into three broad categories. Regulation, including the introduction of mandatory vaccination, can be justified but it is important to be sure that it is an appropriate solution to the existing problem and does not risk unintended consequences. Facilitation involves ensuring that there is an effective vaccination programme, comprehensive in nature, and reducing the many barriers, in terms of cost, distance, and time, to achieving high levels of uptake, especially for marginalised or vulnerable populations. Information is crucial, but whether in the form of public information campaigns or interactions between health workers and target populations, must be designed very carefully to avoid the risk of backfire. There is no universal solution to achieving high levels of vaccine uptake but rather a range or combinations of options. The choice of which to adopt in each country will depend on a detailed understanding of the problem, including which groups are most affected.

How to govern the digital transformation of health services

The impact of digitalization of health services has been profound and is expected to be even more profound in the future. It is important to evaluate whether digital health services contribute to health system goals in an optimal way. This should be done at the level of the service, not the 'digital transformation'. Decisions to adopt new digital health services, at different levels of the health care system, are ideally based on evidence regarding their performance in light of health system goals. In order to evaluate this, a broad perspective should be taken in evaluations of digital health services. Attainment of the broad health system goals, including quality, efficiency and equity, are objectives against which to judge new digital health services. These goals in a broad sense are unaltered by the process of digitalization. Governance should be designed and tailored in such a way to capture all relevant changes in an adequate way. When evaluating digital health services many specific aspects need to be considered. Like for other innovations and (new) technologies, such promises may or may not materialize and potential benefits may also be accompanied by unintended and/or negative (side) effects in the short or long term. Hence, the introduction, implementation, use and funding of digital health technologies should be carefully evaluated and monitored. Governments should play a more active role in the further optimization both of the process of decision making (both at the central and decentral level) and the related outcomes. They need to find a balance between centralized and decentralized activity. Moreover, the broader preparation of the health care system to be able to deal with digitalization, from education, through financial and regulatory preconditions, to implementation of monitoring systems to monitor its effects on health system performance remains important.

[Are Socioeconomic Inequalities in the Process of Registration with Family Physicians Decreasing in Portugal?]

INTRODUCTION

The percentage of citizens who were not registered with a family physician in Portugal reached 16.6% in 2011. In 2012 the Ministry of Health implemented several measures aiming at improving access to family physicians. One clear objective was that all individuals would be registered with a family physician by 2014. We evaluate the evolution of the socioeconomic inequalities regarding registration with family physicians in Portugal between 2009 and 2014.

MATERIAL AND METHODS

We use data at the primary health care unit level on the number of individuals who are not registered with a family physician and the purchasing power of the population served by each unit. The analysis is done using concentration measures.

RESULTS

We find a higher concentration of individuals not registered with a family physician among units serving populations with higher socioeconomic status, although this has been decreasing over the years analyzed. Amongst units serving the most disadvantaged populations, we find a situation close to perfect equality.

DISCUSSION

Our results may reflect the fact that populations with higher economic status live in urban areas where there is greater shortage of family physicians. Alternatively, it may be that these populations choose not to have a family physician within the public system, thus relying on private providers.

CONCLUSION

Our findings convey a reduction in existing socioeconomic inequalities in terms of registration with a primary care physician, during the period under analysis. This reduction took place among the populations which experienced more inequality.

Selfie Aging Index: An Index for the Self-assessment of Healthy and Active Aging

Introduction

Governments across Europe want to promote healthy and active aging, as a matter of both public health and economic sustainability. Designing policies focused on the most vulnerable groups requires information at the individual level. However, a measure of healthy and active aging at the individual level does not yet exist.

Objectives

This paper develops the Selfie Aging Index (SAI), an individual-level index of healthy and active aging. The SAI is developed thinking about a tool that would allow each person to take a selfie of her aging status. Therefore, it is based entirely on self-assessed indicators. This paper also illustrates how the SAI may look like in practice.

Methods

The SAI is based on the Biopsychosocial Assessment Model (MAB), a tool for the multidimensional assessment of older adults along three domains: biological, psychological, and social. Indicators are selected and their weights determined based on an ordered probit model that relates the MAB indicators to self-assessed health, which proxies healthy and active aging. The ordered probit model predicts the SAI based on the estimated parameters. Finally, predictions are rescaled to the 0–1 interval. Data for the SAI development come from the Study of the Aging Profiles of the Portuguese Population and the Survey of Health, Aging, and Retirement in Europe.

Results

The selected indicators are BMI, having difficulties moving around indoors and performing the activities of daily living, feeling depressed, feeling nervous, lacking energy, time awareness score, marital status, having someone to confide in, education, type of job, exercise, and smoking status. The model also determines their weights.

Conclusion

Results shed light on various factors that contribute significantly to healthy and active aging. Two examples are mental health and exercise, which deserve more attention from individuals themselves, health-care professionals, and public health policy. The SAI has the potential to put the individual at the center of the healthy and active aging discussion, contribute to patient empowerment, and promote patient-centered care. It can become a useful instrument to monitor healthy and active aging for different actors, including individuals themselves, health-care professionals, and policy makers.

A quick and selected overview of the expert panel on effective ways of investing in health

The European Commission created the Expert Panel on Effective Ways of Investing in Health (EXPH) in 2012. The EXPH started its activities in July 2013 and ended its first term in May 2016. A personal review of the Expert Panel contributions in its first term is provided.

[Economic Crisis and Portuguese National Health Service Physicians: Findings from a Descriptive Study of Their Perceptions and Reactions from Health Care Units in the Greater Lisbon Area]

INTRODUCTION

In Europe, scant scientific evidence exists on the impact of economic crisis on physicians. This study aims at understanding the adjustments made by public sector physicians to the changing conditions, and their perceptions on the market for medical services in the Lisbon metropolitan area.

MATERIAL AND METHODS

A random sample of 484 physicians from São José Hospital and health center groups in Cascais and Amadora, to explore their perceptions of the economic crisis, and the changes brought to their workload. This paper provides a descriptive statistical analysis of physicians' responses.

RESULTS

In connection to the crisis, our surveyed physicians perceived an increase in demand but a decrease of supply of public health services, as well as an increase in the supply of health services by the private sector. Damaging government policies for the public sector, and the rise of private services and insurance providers were identified as game changers for the sector. Physicians reported a decrease in public remuneration (- 30.5%) and a small increase of public sector hours. A general reduction in living standard was identified as the main adaptation strategy to the crisis. Passion for the profession, its independence and flexibility, were the most frequently mentioned compensating factors. A percentage of 15% of physicians declared considering migration as a possibility for the near future.

DISCUSSION

The crisis has brought non-negligible changes to physicians' working conditions and to the wider market for medical services in Portugal.

CONCLUSION

The physicians' intrinsic motivation for the professions helped counterbalance salary cuts and deteriorating working conditions.

[Scientific Research Policy for Health in Portugal: II - Facts and Suggestions]

After more than 40 years of democracy and 30 years of European integration, Portugal has bridged the research gap it had previously. However, when compared to global and European research policies, Portugal still has a long way go regarding investment in research and development. Health Research in Portugal has been managed by the Fundação para a Ciência e Tecnologia and the National Health Institute Doctor Ricardo Jorge, and it has not been a political priority, emphasized by the absence of a national scientific research plan for health, resulting in a weak coordination of actors in the field. The strategic guidelines of the 2004 - 2010 National Health Plan are what comes closest to a health research policy, but these were not implemented by the institutions responsible for scientific research for the health sector. Trusting that adopting a strategy of incentives to stimulate health research is an added-value for the Portuguese health system, the authors present five strategic proposals for research in health in Portugal.

Exploring public sector physicians' resilience, reactions and coping strategies in times of economic crisis; findings from a survey in Portugal's capital city area

BACKGROUND

Evidence is accumulating on the impact of the recent economic crisis on health and health systems across Europe. However, little is known about the effect this is having on physicians - a crucial resource for the delivery of healthcare services. This paper explores the adaptation to the crisis of public sector physicians and their ability to keep performing their functions, with the objective of gaining a better understanding of health workers' resilience under deteriorating conditions.

METHODS

We conducted a survey among 484 public primary care and hospital physicians in Portugal's capital city area and explored their perceptions of the crisis, adaptation and coping strategies. We used ordinal and logistic regression models to link changes in hours worked and intentions to migrate with physicians' characteristics and specific answers.

RESULTS

We found little evidence of physicians changing their overall allocation of working time before and after the crisis, with their age, types of specialisation, valuation of job flexibility and independence significantly associated with changes in public sector hours between 2010 and 2015. Being divorced, not Portuguese, of younger age, and working a high number of hours per week, were found to increase the probability of physicians considering migration, the same as having a poor opinion of recent government health policies. On the other hand, enjoying their current working environment, not wanting to disrupt provision of service, and leisure time were found to protect against scaling down public sector hours or considering migration.

CONCLUSIONS

Our work on Portuguese physicians contributes to the debate on health workers' resilience, showing the value of understanding the influence of personal characteristics and opinions on their adaptation to changing circumstances, before designing policies to improve their working conditions and retention.

[Scientific Research Policy for Health in Portugal: I - European and National Environment]

The global debate on scientific research policy for human health has been led by World Health Organisation with important contributions from other stakeholders such as Council on Health Research for Development, the World Bank and the Global Forum for Health Research. Recently it has been dominated by the thematic agendas of major global financiers. There is a growing interest worldwide in making better use of the evidence resulting from scientific research in health, in the decision-making process regarding health policies, which is fraught with difficulties, as it is the case in Europe. After more than 40 years of democracy and 30 years of European integration, Portugal has bridged the research gap it had previously. However, when compared to global and European research policies, Portugal still has a long way to go regarding investment in research and development.

Competition policy for health care provision in Portugal

We review the role of competition among healthcare providers in Portugal, which has a public National Health Service (NHS) at the core of the health system. There is little competition among healthcare providers within the NHS. Competition among NHS primary care providers is hindered by excess demand (many residents in Portugal do not have a designated family doctor). Competition among NHS hospitals has been traditionally limited to cases of maximum guaranteed waiting time for surgery being exceeded. The Portuguese Competition Authority enforces competition law. It has focused on mergers between private hospitals and abuse of market power (including cartel cases) by private healthcare providers. The Healthcare Regulation Authority produced several reports on particular areas of activity by private healthcare providers. The main conclusion of these reviews was lack of conditions for effective competition, with the exception of dentistry. Within the NHS, the use of tendering procedures was able to create "competition for the market" in particular areas though it was not problem free. Details in the particular design adopted matter a lot. Overall, the scope for competition policy and for competition among healthcare providers to have a main role in a health system based on a public National Health Service seems limited, with more relevance to "competition for the market" situations than to "competition in the market".

Pharmaceutical regulation in 15 European countries review

In the context of pharmaceutical care, policy-makers repeatedly face the challenge of balancing patient access to effective medicines with affordability and rising costs. With the aim of guiding the health policy discourse towards questions that are important to actual and potential patients, this study investigates a broad range of regulatory measures, spanning marketing authorization to generic substitution and resulting price levels in a sample of 16 European health systems (Austria, Belgium, Denmark, England, Finland, France, Germany, Greece, Ireland, Italy, the Netherlands, Poland, Portugal, Scotland, Spain and Sweden). All countries employ a mix of regulatory mechanisms to contain pharmaceutical expenditure and ensure quality and efficiency in pharmaceutical care, albeit with varying configurations and rigour. This variation also influences the extent of publicly financed pharmaceutical costs. Overall, observed differences in pharmaceutical expenditure should be interpreted in conjunction with the differing volume and composition of consumption and price levels, as well as dispensation practices and their impact on measurement of pharmaceutical costs. No definitive evidence has yet been produced on the effects of different cost-containment measures on patient outcomes. Depending on the foremost policy concerns in each country, different levers will have to be used to enable the delivery of appropriate care at affordable prices.

Dedicated Pediatricians in Emergency Department: Shorter Waiting Times and Lower Costs

BACKGROUND

Dedicated pediatricians in emergency departments (EDs) may be beneficial, though no previous studies have assessed the related costs and benefits/harms. We aimed to evaluate the net benefits and costs of dedicated emergency pediatricians in a pediatric ED.

METHODS

Cost-consequences analysis of visits to a pediatric ED of a tertiary hospital. Two pediatric ED Medical Teams (MT) were compared: MT-A (May-September 2012), with general pediatrics physicians only; and MT-B (May-September 2013), with emergency dedicated pediatricians. The main outcomes analyzed were relevant clinical outcomes, patient throughput time and costs.

RESULTS

We included 8,694 children in MT-A and 9,417 in MT-B. Medication use in the ED increased from 42.3% of the children in MT-A to 49.6% in MT-B; diagnostic tests decreased from 24.2% in MT-A to 14.3% in MT-B. Hospitalization increased from 1.3% in MT-A to 3.0% in MT-B; however, there was no significant difference in diagnosis-related group relative weight of hospitalized children in MT-A and MT-B (MT-A, 0.979; MT-B, 1.075). No differences were observed in ED readmissions or in patients leaving without being seen by a physician. The patient throughput time was significantly shorter in MT-B, with faster times to first medical observation. Within the cost domains analyzed, the total expenditures per children observed in the ED were 16% lower in MT-B: 37.87 euros in MT-A; 31.97 euros in MT-B.

CONCLUSION

The presence of dedicated emergency pediatricians in a pediatric ED was associated with significantly lower waiting times in the ED, reduced costs, and similar clinical outcomes.

Custos da Saúde: Alguns Princípios

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Catastrophic healthcare expenditure - drivers and protection: the Portuguese case

The objective of this paper is to assess the extent of catastrophic healthcare expenditure, which can lead to impoverishment, even in a country with a National Health Service, such as Portugal. The level of catastrophic healthcare expenditure will be identified before the determinants of these catastrophic payments are analyzed. Afterwards, the effects of existing exemptions to copayments in health care use will be tested and the relationship between catastrophe and impoverishment will be discussed. Catastrophe is calculated from the Portuguese Household Budget Surveys of 2000 and 2005, and then analyzed using logistic regression models. The results show that catastrophe due to healthcare out-of-pocket payments are a sizeable issue in Portugal. Exemptions from out-of-pocket expenses for medical care should be created to prevent vulnerable groups from facing catastrophic healthcare spending. These vulnerable groups include children, people with disabilities and individuals suffering from chronic conditions. Disability proxies offer straightforward policy options for an exemption for the elderly with recognized disabilities. An exemption of retired people with disabilities is therefore recommended to policymakers as it targets a vulnerable group with high risk of facing catastrophic healthcare expenditure.

The simple economics of risk-sharing agreements between the NHS and the pharmaceutical industry

The introduction of new (and expensive) pharmaceutical products is one of the major challenges for health systems. The search for new institutional arrangements is natural. The use of the so-called risk-sharing agreements is one example. Recent discussions have somewhat neglected the economic fundamentals underlying risk-sharing agreements. We argue here that risk-sharing agreements, although attractive due to the principle of paying by results, also entail risks. Too many patients may be put under treatment. Prices are likely to be adjusted upward, in anticipation of future risk-sharing agreements between the pharmaceutical company and the third-party payer. An available instrument is a verification cost per patient treated, which allows obtaining the first-best allocation of patients to the new treatment, under the agreement. Overall, the welfare effects of risk-sharing agreements are ambiguous, and caution is urged regarding their use.