Costs and benefits of a school-based health intervention in Portugal.

School-based programmes for preventing childhood obesity have been shown to be effective in improving eating habits and nutritional status, but few intervention programmes with a controlled design have included an economic evaluation. In this study, we conducted a cost-consequence analysis to evaluate the costs and the health benefits of the 'Planning Health in School' programme (PHS-pro) implemented in the Northern region of Portugal to 449 children of 10-14 years old. Previous study has showed that after PHS-pro, several anthropometric measures significantly improved in the intervention group (height, waist circumference and waist-height ratio) compared with the control group, followed by significant improvements on soft drinks, fruit and vegetables daily consumptions. Costs were estimated according the two phases of the programme: designing and preparation of schools, and school setting implementation, and included all the direct costs on human and material resources. PHS-pro total costs were estimated as 7915.53€/year with an intervention cost of 36.14€/year/child attending the programme. This is much lower than the direct costs for treating an obese adult in Portugal, which was calculated as 3849.15€/year. A scale-up costing projection for implementing the PHS-pro to a larger young population was estimated to be even lower: 18.18€/year/child. This cost-consequence analysis provided evidence that the PHS-pro was economically feasible especially if compared with the medical costs for treating adult obesity. The PHS-pro can be a beneficial investment and may give a promising contribution to addressing overweight over childhood and adolescence, which are developmental stages that determine adulthood chronic diseases.

Generic health literacy measurement instruments for children and adolescents: a systematic review of the literature.

BACKGROUND: Health literacy is an important health promotion concern and recently children and adolescents have been the focus of increased academic attention. To assess the health literacy of this population, researchers have been focussing on developing instruments to measure their health literacy. Compared to the wider availability of instruments for adults, only a few tools are known for younger age groups. The objective of this study is to systematically review the field of generic child and adolescent health literacy measurement instruments that are currently available. METHOD: A systematic literature search was undertaken in five databases (PubMed, CINAHL, PsycNET, ERIC, and FIS) on articles published between January 1990 and July 2015, addressing children and adolescents ≤18 years old. Eligible articles were analysed, data was extracted, and synthesised according to review objectives. RESULTS: Fifteen generic health literacy measurement instruments for children and adolescents were identified. All, except two, are self-administered instruments. Seven are objective measures (performance-based tests), seven are subjective measures (self-reporting), and one uses a mixed-method measurement. Most instruments applied a broad and multidimensional understanding of health literacy. The instruments were developed in eight different countries, with most tools originating in the United States (n = 6). Among the instruments, 31 different components related to health literacy were identified. Accordingly, the studies exhibit a variety of implicit or explicit conceptual and operational definitions, and most instruments have been used in schools and other educational contexts. While the youngest age group studied was 7-year-old children within a parent-child study, there is only one instrument specifically designed for primary school children and none for early years. CONCLUSIONS: Despite the reported paucity of health literacy research involving children and adolescents, an unexpected number of health literacy measurement studies in children's populations was found. Most instruments tend to measure their own specific understanding of health literacy and not all provide sufficient conceptual information. To advance health literacy instruments, a much more standardised approach is necessary including improved reporting on the development and validation processes. Further research is required to improve health literacy instruments for children and adolescents and to provide knowledge to inform effective interventions.

Health literacy in childhood and youth: a systematic review of definitions and models.

BACKGROUND: Children and young people constitute a core target group for health literacy research and practice: during childhood and youth, fundamental cognitive, physical and emotional development processes take place and health-related behaviours and skills develop. However, there is limited knowledge and academic consensus regarding the abilities and knowledge a child or young person should possess for making sound health decisions. The research presented in this review addresses this gap by providing an overview and synthesis of current understandings of health literacy in childhood and youth. Furthermore, the authors aim to understand to what extent available models capture the unique needs and characteristics of children and young people. METHOD: Six databases were systematically searched with relevant search terms in English and German. Of the n = 1492 publications identified, N = 1021 entered the abstract screening and N = 340 full-texts were screened for eligibility. A total of 30 articles, which defined or conceptualized generic health literacy for a target population of 18 years or younger, were selected for a four-step inductive content analysis. RESULTS: The systematic review of the literature identified 12 definitions and 21 models that have been specifically developed for children and young people. In the literature, health literacy in children and young people is described as comprising variable sets of key dimensions, each appearing as a cluster of related abilities, skills, commitments, and knowledge that enable a person to approach health information competently and effectively and to derive at health-promoting decisions and actions. DISCUSSION: Identified definitions and models are very heterogeneous, depicting health literacy as multidimensional, complex construct. Moreover, health literacy is conceptualized as an action competence, with a strong focus on personal attributes, while also recognising its interrelatedness with social and contextual determinants. Life phase specificities are mainly considered from a cognitive and developmental perspective, leaving children's and young people's specific needs, vulnerabilities, and social structures poorly incorporated within most models. While a critical number of definitions and models were identified for youth or secondary school students, similar findings are lacking for children under the age of ten or within a primary school context.

Combined exposure to tobacco smoke and ethanol in adolescent mice elicits memory and learning deficits both during exposure and withdrawal.

INTRODUCTION: Adolescents often associate tobacco smoking and consumption of alcoholic beverages. In spite of that, little is known about the neurobehavioral consequences of the dual exposure in the adolescent brain. In the present work, we assessed the effects of tobacco smoke and/or ethanol exposure during adolescence on memory/learning. METHODS: From postnatal day 30 to 45 (PN30-45), male and female Swiss mice were exposed to tobacco smoke (SMK-generated from research cigarettes type 3R4F, whole body exposure, 8hr/day) and/or ethanol (ETOH-25% solution, 2g/kg intraperitoneally injected every other day) as follows: (a) SMK+ETOH exposure; (b) SMK exposure; (c) ETOH exposure; (d) Control. Memory/learning was evaluated during exposure (PN44-45) and during short- (PN49-50) and long-standing withdrawal (PN74-75). At each timepoint, mice were trained and tested in a step-down passive avoidance task (0.3 mA, 3 s footshock). Two retention tests were carried out in each animal, one at 3hr after training to measure short-term memory and another at 24hr to measure long-term memory. RESULTS: During exposure, the short-term memory was impaired in all groups and the long-term memory was impaired in SMK and SMK+ETOH. During the short-standing withdrawal, a significant impairment was observed only in long-term memory of the male SMK+ETOH mice. At long-standing withdrawal, there were no significant differences between groups. CONCLUSIONS: Tobacco smoke and ethanol exposures during adolescence of mice negatively affect learning/memory performance. Deficits that were still present during SMK+ETOH short-standing withdrawal suggest that the combined exposure elicits a worsened memory/learning outcome and that males are more susceptible.

Development of adiposity, obesity and age at menarche: an 8-year follow-up study in Portuguese schoolgirls.

AIM: It has been suggested that the decline in menarcheal age is associated with the increase of obesity prevalence. OBJECTIVE: To examine the association between age at menarche and adiposity development from age 7 to 15 years. SUBJECTS: A cohort of 109 schoolgirls from Viana do Castelo (Northern Portugal). METHODS: Anthropometric measurements (height, weight, and triceps and subscapular skinfold thicknesses) were longitudinally obtained at 7, 8, 9, and 15 years. Waist circumference and self-reported age at menarche were obtained at age 15. Obesity was defined by the cut-off value of 30% body fat. Ages of <12 years, 12-13 years, and >13 years were classified as early menarche (EM), average menarche (AM) and late menarche (LM), respectively. RESULTS: Median menarcheal age was 12.0 years (range, 8-15 years), with 26.6% of girls classified as EM. Compared with their LM peers, EM girls were always fatter (p=0.001) and had higher waist circumference at age 15 (p=0.009). All variables showed significant negative associations with age at menarche, except subscapular to triceps skinfold ratio at all ages and height at age 15. At both ages 9 and 15 years, LM girls had the lowest prevalence of obesity (4.5% and 9.1%, respectively). The 8-year incidence of obesity in EM girls was 24.1%, while that in the AM plus LM group was 13.8% (p=0.005). CONCLUSION: EM seems to be a risk factor for the development of obesity during adolescence. However, this vulnerability may start to be programmed before menarche as girls with precocious menarche were already fatter than their late-maturing peers at age 7 years.

[Radiation organizing pneumonia: report of one case]. / Neumonía en organización por radiación en el paciente con cáncer de mama: caso clínico.

We report a 64-years-old woman who underwent sparing mastectomy with adjuvant radiotherapy for breast cancer. One month after the end of radiotherapy, she presented with malaise, fever, fatigue, cough and migratory bilateral pulmonary infiltrates on serial radiological images. The microbiological studies of broncha alveolar lavage were negative. The patient under went a trans bronchial biopsy and the pathological diagnosis was compatible with an organizing pneumonia presumably associated with radiotherapy. Systemic steroid treatment was successful with rapid and complete resolution of clinical and radiographic manifestations.

The "Planning Health in School" Programme (PHS-pro) to Improve Healthy Eating and Physical Activity: Design, Methodology, and Process Evaluation.

Few interventions have successfully promoted healthy eating and active living among children with effective changes in anthropometric health outcomes. Well-designed interventions involving multiple strategies to convert the knowledge already available into action are needed for preventing childhood obesity. In this study, an educational programme called "Planning Health in School" (PHS-pro) was designed, implemented and evaluated to contribute to the prevention of obesity in childhood. The PHS-pro aimed at improving the eating behaviours and lifestyles of Portuguese grade-6 children towards healthier nutritional status. This paper describes and evaluates the PHS-pro concerning: (i) the research design within the theoretical framework grounded on "The Transtheoretical Model" and the stages of change; (ii) the educational components and the application of the participatory methodology to engage children to meet their needs, as active participants in their change process; and (iii) the process evaluation of the intervention. The implementation of the PHS-pro took into account the views and inputs of the participants for evaluating the educational components that should be considered in the designing of interventions aiming to be effective strategies. From the health promotion perspective, this study is important because it examines new approaches and pathways to effectively prevent overweight and obesity in children.

Defining Life Skills in health promotion at school: a scoping review.

Background: Life Skills have been central to Health Promotion interventions and programmes with children and adolescents for over 40 years. School is a strategic setting for Life Skills education. Recently, policy-and decision-makers have focused on Life Skills development for youth. Research on Life Skills has gained momentum. Different terms are used to discuss and define Life Skills. Research identifies a lack of conceptual definition. The purpose of this study is to identify the definitions in the literature in English and French, and to reach a conceptual and consensual definition. Method: The Scoping Review methodology was used. Three research questions aim to identify how Life Skills are defined in the field of health promotion at school, to see whether a conceptual and consensual definition exists, and, if relevant, to propose a conceptual definition. The search was conducted in 5 databases by 3 reviewers. This study focused on full-text publications in English or French, human studies, health promotion in school, school pupils, teacher training, and with a definition of Life Skills. Publications on after-school activities, higher education outside teacher training, adult education, other than peer-reviewed scientific papers were excluded. Results: 48 publications were included in English and 7 in French. NVIVO was used to determine and compare the French and English terms used for Life Skills and their definitions. According to the three research questions, (i) the terms used to define Life Skills are diverse and numerous, with different purposes at school in relation to health promotion, and different taxonomies, and relate to different areas of research; (ii) no consensual, conceptual definition of Life Skills was found; (iii) further semantic, epistemological and ontological clarifications are required. Conclusion: Some conceptual definitions of Life Skills exist without consensus. Life Skills being at the crossroads between different fields could explain this and is illustrated by the multiplicity and diversity of the terms employed, and the various taxonomies and purposes used at school in health promotion. This may also explain why they are difficult to evaluate. Defining Life Skills consensually cannot be achieved due to the diversity of research perspectives from different fields.

The Impact of the 'Planning Health in School' Programme on a Pair of Twins with Obesity.

This case study describes the impact of the 'Planning Health in School' programme (PHS-pro) on the nutritional status and lifestyle behaviours of two twins with obesity. As part of a larger research project involving 449 adolescents in grade-6, PHS-pro aims at preventing obesity and guiding children towards healthy behaviours. Twins were evaluated for anthropometric measurements-height, weight, body mass index (BMI), waist circumference (WC), and lifestyle behaviours before (baseline) and after (8 months) PHS-pro and at a follow-up (one-year later). At the baseline, both twins were obese according to the international cut-off points of Cole. After PHS-pro, improvements in anthropometric parameters were found: the boy decreased his BMI by 10% and lost 9.0 cm in WC, while remaining obese; the girl decreased her BMI by 8% and lost 8.7 cm in WC, changing to the overweight category. At the follow-up, a slight increase in the anthropometric parameters was found in both twins; however, they did not return to the baseline values. The programme successfully promoted positive changes in behaviours and improved nutritional status, showing the long-term effects of the PHS-pro. Although it is a school-based intervention to prevent obesity, the PHS-pro is helpful in weight reduction even in children already with obesity.

Changes in adiposity status from childhood to adolescence: a 6-year longitudinal study in Portuguese boys and girls.

BACKGROUND: Cross-sectional data show high prevalence of overweight in Portuguese children, but there are few longitudinal studies describing the patterns of obesity development in the young. AIM: To examine the trajectories of obesity from late childhood to adolescence. SUBJECTS AND METHODS: Triceps and subscapular skinfold thickness measurements were carried out in 288 children at age 9 (baseline) and later at age 15 (follow-up). Percentage body fat (%BF) was estimated according to Slaughter equations and the health-related definition of obesity ( ≥ 25%BF in boys and ≥ 30%BF in girls) was used. RESULTS: In boys, the prevalence of obesity decreased from 21.9% to 14.8% (p < 0.05) while in girls it increased from 14.3% to 19.5%. The incidence of obesity in the 6-year study period was 2.6% and 8.3% for boys and girls, respectively (p < 0.05). In comparison with girls, the percentage of boys that reversed obesity was more than 3-fold higher (3% vs 9.7%, p < 0.05). Obesity tracked moderately in both sexes (Kappa = 0.6, p < 0.001). CONCLUSION: The results indicate a marked sex difference in the incidence and reversal of obesity from late childhood to adolescence that is unfavourable to girls. Consideration of this difference might be important when designing programmes for the prevention and treatment of obesity focusing on this period.

Children Learn, Children Do! Results of the "Planning Health in School", a Behavioural Change Programme.

The 'Planning Health in School' programme (PHS-pro) is a behavioural change intervention to assess and improve the eating habits of children, particularly the intake of fruit and vegetables, and to guide them towards healthy choices. The programme and its educational components are based on the Transtheoretical Model of stages of change to integrate nutritional literacy and build up problem-solving and decision-making skills. Children (n = 240, ages 10-12) of one large suburban school in Porto's metropolitan area (Portugal) were evaluated throughout PHS-pro implementation during one school year in a repeated time-series design. Children's outcome evaluations were conducted through seven 3-day food records for nine eating behaviour, documented after each learning module and through participatory activities which analysed attitudes, preferences and expectations. Changes were observed in children's eating behaviour, supported by changes in motivation as perceived in their attitudes and expectations. Significant changes were found in a higher consumption of vegetable soup (p = 0.003), milk products (p = 0.024), and fruit (p = 0.008), while the consumption of high-energy dense food (p = 0.048) and soft drinks (p = 0.042) significantly decreased. No positive effects on fried food, water, vegetables and bread consumption were found. The PHS-pro intervention proved to be effective in developing healthy eating behaviour in young people.

Effectiveness of the "Planning Health in School" Programme on Children's Nutritional Status.

Effective interventions for guiding children to change behaviours are needed to tackle obesity. We evaluated the effectiveness of the 'Planning Health in School' programme (PHS-pro) on children's nutritional status. A non-randomised control group pretest-posttest trial was conducted at elementary schools of a sub-urban municipality in Porto's metropolitan area (Portugal). A total of 504 children of grade-6, aged 10-14, were assigned in two groups: children of one school as the intervention group (IG), and three schools as the control group (CG). Anthropometric measures included height, weight, waist circumference (WC), BMI and waist-to-height ratio (WHtR), and lifestyle behaviours (self-reported questionnaire) were assessed at baseline and after PHS-pro. IG children grew significantly taller more than CG ones (p < 0.001). WC had reduced significantly in IG (-0.4 cm) whereas in the CG had increased (+0.3 cm; p = 0.015), and WHtR of IG showed a significant reduction (p = 0.002) compared with CG. After PHS-pro, IG children consumed significantly fewer soft drinks (p = 0.043) and ate more fruit and vegetables daily than CG. Physical activity time increased significantly in IG (p = 0.022), while CG maintained the same activity level. The PHS-pro did improve anthropometric outcomes effectively leading to better nutritional status and appears to be promising in reducing overweight and obesity.

The ethics of shared Covid-19 risks: an epistemological framework for ethical health technology assessment of risk in vaccine supply chain infrastructures.

This article addresses the topic of shared responsibilities in supply chains, with a specific focus on the application of the Internet of Things (IoT) in e-health environments, and Industry 4.0 issues-concerning data security, privacy, reliability and management, data mining and knowledge exchange as well as health prevention. In this article, we critically review methodologies and guidelines that have been proposed to approach these ethical aspects in digital supply chain settings. The emerging framework presents new findings on how digital technologies affect vaccine shared supply chain systems. Through epistemological analysis, the article derives new insights for transparency and accountability of supply chain cyber risk from Internet of Things systems. This research devises a framework for ethical awareness, assessment, transparency and accountability of the emerging cyber risk from integrating IoT technologies on shared Covid-19 healthcare supply chain infrastructure.

School health promotion: organization of services and roles of health professionals in seven European countries.

BACKGROUND: This comparative study is intended to provide a better understanding of how health promotion services are organized in school settings in Europe and to show how health professionals involved outside or within the school setting help to improve young people's health. METHODS: This study was based on an analysis of school health policies and the organization of school health services, where these existed, as well as on interviews with health and education professionals. The countries concerned were Belgium (French-speaking community), Denmark, France, Spain (Catalonia), Switzerland (Jura), Poland and Portugal. RESULTS: Although the provision of health services for children and adolescents varied considerably, the health services available were very similar in each of the countries. The emphasis put on particular aspects of these services varied depending on the political and institutional culture in each country. Three different types of school health service provision were identified: community-based, school-based or health needs-focused. CONCLUSION: All countries had health education and health promotion services but the provision of these services varied considerably from country to country. They were provided either by a specific category of professionals (health personnel or teachers) or considered to be the responsibility of the educational community as a whole.

Evolution during Three Ripening Stages of Évora Cheese.

The variability and heterogeneity found in Évora cheeses, Protected Designation of Origin (PDO), can affect consumers' choices. Assessing the ripening conditions and their effect can be helpful. To study the effect of ripening duration in Évora cheese PDO, sensory and chemical analyses were performed in cheese samples subjected to 30, 60, and 120 days of ripening under controlled conditions (temperature 14 to 15 °C and humidity 65 to 70%). Sensory analysis was conducted with a homogenous panel previously familiarized with the product after a short training period, and chemical analyses including pH, moisture, NaCl content, aw, and salt-in-moisture were determined. Panelists were able to distinguish the differences in the organoleptic characteristics of the three cheese stages, and chemical determinations showed significant differences between stages. Interrater agreement was higher in the sensory evaluation of cheeses with a longer maturation period. As expected, cheeses in the 120 days ripening period presented lower pH, moisture, and water activity and had higher salt-in-moisture content. This stage received the highest scores in hardness and color of the crust, intensity, pungency of the aroma, intensity of taste and piquancy, and firmness and granular characteristics of texture. Overall acceptance of cheese samples was positive, regardless of the ripening stage, which probably reflects both the homogeneity of taster profiles and the previous knowledge of this particular product. The degree of ripeness influences the physical, chemical, and sensory characteristics but does not affect the acceptance of this product by the consumer.

Mortality and Morbidity of Beef Calves in Free-Range Farms in Alentejo, Portugal-A Preliminary Study.

Extensive cow-calf beef cattle farms play a significant role in Portuguese livestock production, but records of important production variables, such as calf mortality, are scarce. To assess herd-level calf mortality and its potential economic impact, farmers from the Alentejo region were asked to fill a questionnaire regarding herd size, feeding and reproductive management practices, calf mortality (from birth to weaning), and detection of the main morbidity causes, as well as of sudden, unexplained deaths during the previous 12 months. Farmers were also requested to quantitatively assess the economic impact of calf mortality on their annual revenue. In the majority of farms, the herd size was larger than 100 animals. The median stocking rate was 0.41 adult animals/hectare, and 70% of farmers stated their farm was self-sufficient in forage. The percent of live births that resulted in weaned calves averaged 94.3%, which led to the assumption of a 5.7% calf mortality rate from birth to weaning. In the previous 12 months, 78.8% of the farms identified at least one case of calf diarrhea, 60.7% identified at least one case of respiratory disease, and 82.1% had at least one sudden, unexplained calf death. As expected, farmers that assessed a higher impact of calf losses on their annual economic revenue were also those who reported higher incidences of calf diarrhea, respiratory disease, and sudden, unexplained deaths. One-quarter of the farmers were unable to assess the economic impact of calf mortality on the farm's revenue. Herd size appears to have a predictive value on calf mortality in the first month of life, and from 30 days to weaning. The number of sudden, unexplained calf deaths seems to have a predictive value on overall calf mortality (from birth to weaning), suggesting that the farms' management practices probably play an important role in calf mortality throughout the suckling period. Further studies are needed to fully understand calf mortality in Portuguese extensive rearing systems.

[Impact of teachers' conceptions on sex education in four Mediterranean countries.]. / Description et déterminants des conceptions des enseignants de 4 pays méditerranéens sur l'éducation à la sexualité

Nowadays, sex education contributes to public health not only with regard to the prevention of HIV/AIDS, other sexually transmitted infections and sex abuse, but it is also concerned with addressing aspects such as interpersonal relationships and psychosocial implications. The school setting has emerged as a unique environment for access to information and scientific knowledge that contribute to better understanding of the various dimensions of sexuality. Teachers' and future teachers' conceptions about sex education are analysed in this paper. Data were obtained from a questionnaire designed by the European Biohead-Citizen research project. Responses were received from 2 537 teachers from four Mediterranean countries (Tunisia, Lebanon, Morocco and France) who completed the questionnaire. The methodology is based upon analyses of core components that support the discovery of teachers' conceptions. Following that exercise, standardised factorial scores were calculated. Results for in-service and pre-service teachers show high correlations between their conceptions and national culture, religious beliefs, and level of academic training. Detailed results are presented and discussed.

The future of health promotion in schools goes through the strengthening of teacher training at a global level.

Schools are considered to be settings for both health education and health promotion. But the core business of schools is actually focused on educational outcomes, not reducing health problems. In most countries, schools give low priority to health promotion, and school staffs, mainly teachers, are not aware of their role in health promotion. Studies show that teachers who have received health promotion training tend to be involved more frequently in health promotion projects and have a more comprehensive approach to health education. Pre-service and in-service staff training is then a main challenge. This is the reason why we have launched an initiative to join international forces to strengthen and advocate for teacher training in health promotion. The main goals are to develop research, affirm and reinforce the work done in teacher training in health promotion, support the institutes/colleges/universities in the provision of pre-service and in-service teacher training and stimulate international partnership work.

Hyperactivity and memory/learning deficits evoked by developmental exposure to nicotine and/or ethanol are mitigated by cAMP and cGMP signaling cascades activation.

Pregnant smoking women are frequently episodic drinkers. Here, we investigated whether ethanol exposure restricted to the brain growth spurt period when combined with chronic developmental exposure to nicotine aggravates memory/learning deficits and hyperactivity, and associated cAMP and cGMP signaling disruption. To further investigate the role of these signaling cascades, we verified whether vinpocetine (a phosphodiesterase inhibitor) ameliorates the neurochemical and behavioral outcomes. Swiss mice had free access to nicotine (NIC, 50 µg/ml) or water to drink during gestation and until the 8th postnatal day (PN8). Ethanol (ETOH, 5 g/kg, i.p.) or saline were injected in the pups every other day from PN2 to PN8. At PN30, animals either received vinpocetine (20 mg/kg, i.p.) or vehicle before being tested in the step-down passive avoidance or open field. Memory/learning was impaired in NIC, ETOH and NIC + ETOH mice, and vinpocetine mitigated ETOH- and NIC + ETOH-induced deficits. Locomotor hyperactivity identified in ETOH and NIC + ETOH mice was ameliorated by vinpocetine. While cyclic nucleotides levels in cerebral cortex and hippocampus were reduced by NIC, ETOH and NIC + ETOH, this outcome was more consistent in the latter group. As observed for behavior, vinpocetine normalized NIC + ETOH nucleotides levels. pCREB levels were also increased in response to vinpocetine, with stronger effects in the NIC + ETOH group. Exposure to both drugs of abuse worsens behavioral and neurochemical disruption. These findings and the amelioration of deleterious effects by vinpocetine support the idea that cAMP and cGMP signaling contribute to nicotine- and ethanol-induced hyperactivity and memory/learning deficits.