Internal consistency of the Strengths and Difficulties Questionnaire in Amazonian children.

OBJECTIVE: To describe the frequency of behavioral problems and the internal consistency of the parent version of the Strengths and Difficulties Questionnaire (SDQ-P) in Amazonian preschool children during the covid-19 pandemic. METHODS: Data from the Maternal and Child Health and Nutrition in Acre (MINA-Brazil) study, a population-based birth cohort in the Western Brazilian Amazon, were used. The SDQ-P was applied in 2021 at the five-year follow-up visit to parents or caregivers of 695 children (49.4% of which were girls). This instrument is a short behavioral screening questionnaire composed of 25 items reorganized into five subscales: emotional symptoms, conduct problems, hyperactivity/inattention, peer relationship problems, and prosocial behavior. Cases of behavioral problems were defined according to the original SDQ cut-offs based on United Kingdom norms. Moreover, cut off points were estimated based on the SDQ-P percentile results of our study sample. Internal consistency was assessed by calculating Cronbach's alpha coefficient and McDonald's omega for each scale. RESULTS: According to the cut-offs based on our studied population distribution, 10% of all children had high or very high total difficulty scores, whereas it was almost twice when the original SDQ cut-offs based on United Kingdom norms, were applied (18%). Differences were also observed in the other scales. Compared to girls, boys showed higher means of externalizing problem and lower means of prosocial behavior. The five-factor model showed a moderate internal consistency of the items for all scales (0.60 ≤ α ≤ 0.40), except for total difficulty scores, which it considered substantial (α > 0.61). CONCLUSIONS: Our results support the usefulness of SDQ in our study population and reinforce the need for strategies and policy development for mental health care in early life in the Amazon.

Patterns of healthcare use among children with immigrant and non-immigrant backgrounds in 2019 and 2020: evidence from the CRIAS cohort study in the metropolitan area of Lisbon, Portugal.

BACKGROUND: International migrant families may face various barriers in the access and use of health services. Evidence on immigrant children's health care or prevention facilities' utilisation patterns is scarce in Portugal. Therefore, the objectives of this study were to compare health services use between immigrant and non-immigrant children in the Metropolitan Area of Lisbon in 2019-2020 with the aim of informing public policies towards equitable access to, and use of health services. METHODS: The CRIAS (Health Trajectories of Immigrant Children) prospective cohort study enrolled 420 children (51.6% immigrant) born in 2015 and attending primary health care (PHC) services in 2019. We compared primary health care facilities and hospital paediatric emergency department (ED) utilisation patterns in the public National Health Service, together with reported private practitioners use, between immigrant and non-immigrant children in 2019 and 2020. The Pearson chi-squared test, Fisher-Freeman-Halton Exact test, two-proportion z-test and Mann‒Whitney U test were used to examine the differences between the two groups. RESULTS: In 2019, no significant differences in PHC consultations attendance between the two groups were observed. However, first-generation immigrant children (children residing in Portugal born in a non-European Union country) accessed fewer routine health assessments compared to non-immigrant children (63.4% vs. 79.2%). When children were acutely ill, 136 parents, of whom 55.9% were parents of non-immigrant children, reported not attending PHC as the first point of contact. Among those, nearly four times more non-immigrant children sought healthcare in the private sector than immigrant children (p < 0.001). Throughout 2019, immigrant children used ED more often than non-immigrant children (53.5% vs. 40.4%, p = 0.010), as their parents reported difficulties in accessing PHC. In 2020, during the COVID-19 pandemic, fewer immigrant children accessed PHC compared to non-immigrant children (70% vs. 80%, p = 0.018). Both non-immigrant and immigrant children reduced ED use by 2.5 times, with a higher decrease among immigrant children (46% vs. 34%). In both 2019 and 2020, over 80% of immigrant and non-immigrant children used ED for conditions classified as having low clinical priority. CONCLUSION: Beyond identifying health care use inequalities between immigrant and non-immigrant children, the study points to urgent needs for public policy and economic investments to strengthen PHC for all children rather than for some.

Internal consistency of the Strengths and Difficulties Questionnaire in Amazonian children / Consistência interna do Questionário de Capacidades e Dificuldades em crianças amazônicas

ABSTRACT OBJECTIVE: To describe the frequency of behavioral problems and the internal consistency of the parent version of the Strengths and Difficulties Questionnaire (SDQ-P) in Amazonian preschool children during the covid-19 pandemic. METHODS: Data from the Maternal and Child Health and Nutrition in Acre (MINA-Brazil) study, a population-based birth cohort in the Western Brazilian Amazon, were used. The SDQ-P was applied in 2021 at the five-year follow-up visit to parents or caregivers of 695 children (49.4% of which were girls). This instrument is a short behavioral screening questionnaire composed of 25 items reorganized into five subscales: emotional symptoms, conduct problems, hyperactivity/inattention, peer relationship problems, and prosocial behavior. Cases of behavioral problems were defined according to the original SDQ cut-offs based on United Kingdom norms. Moreover, cut off points were estimated based on the SDQ-P percentile results of our study sample. Internal consistency was assessed by calculating Cronbach's alpha coefficient and McDonald's omega for each scale. RESULTS: According to the cut-offs based on our studied population distribution, 10% of all children had high or very high total difficulty scores, whereas it was almost twice when the original SDQ cut-offs based on United Kingdom norms, were applied (18%). Differences were also observed in the other scales. Compared to girls, boys showed higher means of externalizing problem and lower means of prosocial behavior. The five-factor model showed a moderate internal consistency of the items for all scales (0.60 ≤ α ≤ 0.40), except for total difficulty scores, which it considered substantial (α > 0.61). CONCLUSIONS: Our results support the usefulness of SDQ in our study population and reinforce the need for strategies and policy development for mental health care in early life in the Amazon.

RESUMO OBJETIVO: Descrever a frequência de problemas de comportamento e a consistência interna da versão para os pais do Questionário de Capacidades e Dificuldades (SDQ-P) em crianças pré-escolares da Amazônia durante a pandemia de covid-19. MÉTODOS: Foram utilizados dados do estudo de saúde e nutrição Materno-Infantil no Acre (MINA-Brasil), uma coorte de nascimentos de base populacional na Amazônia Ocidental Brasileira. O SDQ-P foi aplicado aos pais e cuidadores em 2021 na visita de acompanhamento de cinco anos de 695 crianças (49,4% das quais eram meninas). Esse instrumento é um breve questionário de rastreamento comportamental composto por 25 itens reorganizados em cinco subescalas: sintomas emocionais, problemas de conduta, hiperatividade/desatenção, problemas de relacionamento com colegas e comportamento pró-social. Os casos de problemas de comportamento foram definidos de acordo com os pontos de corte originais do SDQ, baseados nas normas do Reino Unido. Além disso, os pontos de corte foram estimados com base nos percentis dos resultados do SDQ-P da amostra do nosso estudo. A consistência interna foi avaliada pelo cálculo do coeficiente alfa de Cronbach e ômega de McDonald para cada escala. RESULTADOS: De acordo com os pontos de corte baseados na distribuição da população estudada, 10% de todas as crianças apresentaram escores totais de dificuldade elevados ou muito elevados, o que quase dobrou quando os pontos de corte originais do SDQ, baseados nas normas do Reino Unido, foram utilizados (18%). Este estudo também encontrou diferenças nas demais escalas. Comparados às meninas, os meninos apresentaram maiores médias de problemas de externalização e menores médias de comportamento pró-social. O modelo de cinco fatores apresentou consistência interna dos itens moderada para todas as escalas (0,60 ≤ α ≤ 0,40), exceto para a escala de pontuação total de dificuldades, a qual foi considerada substancial (α > 0,61). CONCLUSÕES: Nossos resultados apoiam a utilidade do SDQ em nossa população de estudo e reforçam a necessidade de estratégias e desenvolvimento de políticas para o cuidado em saúde mental no início da vida na Amazônia.

Cohort profile: Health trajectories of Immigrant Children (CRIAS)-a prospective cohort study in the metropolitan area of Lisbon, Portugal.

PURPOSE: The CRIAS (Health trajectories of Immigrant Children in Amadora) cohort study was created to explore whether children exposed to a migratory process experience different health risks over time, including physical health, cognitive, socioemotional and behavioural challenges and different healthcare utilisation patterns. PARTICIPANTS: The original CRIAS was set up to include 604 children born in 2015, of whom 50% were immigrants, and their parents. Recruitment of 420 children took place between June 2019 and March 2020 at age 4/5 years, with follow-up carried out at age 5/6 years, at age 6/7 years currently under way. FINDINGS TO DATE: Baseline data at age 4/5 years (2019-2020) suggested immigrant children to be more likely to belong to families with less income, compared with non-immigrant children. Being a first-generation immigrant child increased the odds of emotional and behavioural difficulties (adjusted OR 2.2; 95% CI: 1.06 to 4.76); more immigrant children required monitoring of items in the psychomotor development test (38.5% vs 28.3%). The prevalence of primary care utilisation was slightly higher among immigrant children (78.0% vs 73.8%), yet they received less health monitoring assessments for age 4 years. Utilisation of the hospital emergency department was higher among immigrants (53.2% vs 40.6%). Age 5 years follow-up (2020-2021) confirmed more immigrant children requiring monitoring of psychomotor development, compared with non-immigrant children (33.9% vs 21.6%). Economic inequalities exacerbated by post-COVID-19 pandemic confinement with parents of immigrant children 3.2 times more likely to have their household income decreased. FUTURE PLANS: Further follow-up will take place at 8, 10, 12/13 and 15 years of age. Funds awarded by the National Science Foundation will allow 900 more children from four other Lisbon area municipalities to be included in the cohort (cohort-sequential design).

Factors associated with self-perceived health status in Portugal: Results from the National Health Survey 2014.

Background: Self-perceived health is an important indicator of illness and mortality. This study aims at identifying a wide range of factors that can influence self-perceived health status among a representative sample in Portugal. Methods: We used the 2014 National Health Survey (n = 17,057), whereby participants were required to assess their health status from "Very good," "Good," "Fair," "Poor" to "Very poor." We grouped the answers "Very good" and "Good," and "Poor" and "Very poor," respectively. Multinomial logistic regression was used to compare participants' characteristics across groups by computing odds ratio and corresponding 95% confidence intervals. Models included Socioeconomic/demographic characteristics, objective health status, healthcare use, functional disability, barriers to healthcare services utilization, lifestyle variables, mental health status, social support, and satisfaction with life as potential factors that can affect self-perceived health. Models were adjusted for sex, age, educational level, degree of urbanization, and presence of chronic diseases. Results: About 45% of participants reported good/very good, 39% reported fair, while ~16% reported poor/very poor health perception. Poor/very poor health was more reported by women when compared to men (19.1 vs. 11.4%, respectively, p < 0.001). A higher prevalence of poor/very poor health status was reported by participants living in thinly populated areas or among older populations. Lower educational levels, lower income, as well as unemployment, were found to increase the risk of reporting poor/very poor health status. Utilizing healthcare services more frequently, experiencing barriers to access healthcare services, having depressive symptoms or activity limitations, or lacking social support were found to be significantly associated with poor/very poor self-perceived health. Conclusion: Subjects living in Portugal tend to report less good/very good health status and more poor/very poor health when compared to the rest of Europe. This study stresses the importance of socioeconomic factors, chronic illness, barriers to access healthcare services, social isolation, and mental health status in influencing self-perceived health and highlights the urgent need for social-informed policies, strategies, and interventions to reduce health inequalities in Portugal.

Statistical models for analyzing count data: predictors of length of stay among HIV patients in Portugal using a multilevel model.

BACKGROUND: This study offers a comprehensive approach to precisely analyze the complexly distributed length of stay among HIV admissions in Portugal. OBJECTIVE: To provide an illustration of statistical techniques for analysing count data using longitudinal predictors of length of stay among HIV hospitalizations in Portugal. METHOD: Registered discharges in the Portuguese National Health Service (NHS) facilities Between January 2009 and December 2017, a total of 26,505 classified under Major Diagnostic Category (MDC) created for patients with HIV infection, with HIV/AIDS as a main or secondary cause of admission, were used to predict length of stay among HIV hospitalizations in Portugal. Several strategies were applied to select the best count fit model that includes the Poisson regression model, zero-inflated Poisson, the negative binomial regression model, and zero-inflated negative binomial regression model. A random hospital effects term has been incorporated into the negative binomial model to examine the dependence between observations within the same hospital. A multivariable analysis has been performed to assess the effect of covariates on length of stay. RESULTS: The median length of stay in our study was 11 days (interquartile range: 6-22). Statistical comparisons among the count models revealed that the random-effects negative binomial models provided the best fit with observed data. Admissions among males or admissions associated with TB infection, pneumocystis, cytomegalovirus, candidiasis, toxoplasmosis, or mycobacterium disease exhibit a highly significant increase in length of stay. Perfect trends were observed in which a higher number of diagnoses or procedures lead to significantly higher length of stay. The random-effects term included in our model and refers to unexplained factors specific to each hospital revealed obvious differences in quality among the hospitals included in our study. CONCLUSIONS: This study provides a comprehensive approach to address unique problems associated with the prediction of length of stay among HIV patients in Portugal.

Improving Underestimation of HIV Prevalence in Surveys Using Time-Location Sampling.

We sought to find a method that improves HIV estimates obtained through time-location sampling (TLS) used to recruit most-at-risk populations (MARPs). The calibration on residuals (CARES) method attributes weights to TLS sampled individuals depending on the percentile to which their logistic regression residues belong. Using a real country database, provided by EMIS-2010, with 9591 men who have sex with men (MSM) and an HIV prevalence of 12.1%, we simulated three populations (termed "pseudo-populations") with different levels of HIV. From each pseudo-population, 1000 TLS samples were drawn, and the HIV prevalence estimated by the TLS method and by the CARES method were recorded and compared with the HIV prevalence of the 9591 men. Results showed that the CARES method improves estimates given by the TLS method by getting closer to the real HIV prevalence.

COVID-19: What Is Next for Portugal?

Highly infectious with the possibility of causing severe respiratory complications, the novel COVID-19 began stretching health systems beyond their capacity all over the world and pushing them to breaking points. Giving the devastating effects caused by this infection, unprecedented measures have to be adopted in order to mitigate its impacts on the health system. This perspective aims to review the epidemic of COVID-19 in Portugal, possible areas of improvement, and potential interventions that can help to mitigate the effect of COVID-19 on the Portuguese health system.

Risk of Readmission Among HIV Patients in Public Portuguese Hospitals: Longitudinal Multilevel Population-Based Study.

Background: Thirty-day hospital readmission is receiving growing attention as an indicator of the quality of hospital care. Understanding factors associated with 30-day hospital readmission among HIV patients in Portugal is essential given the high burden cost of HIV hospitalizations in Portugal, a country suffering from financial constrains for almost 10 years. Objectives: We aimed to estimate the 30-day hospital readmission rates among HIV patients in Portugal and to identify its determinants using population-based data for Portuguese public hospitals. Study Design: A multilevel longitudinal population-based study. Methods: Between January 2009 and December 2014, a total of 37,134 registered discharges in the Portuguese National Health Service (NHS) facilities with HIV/AIDS as a main or secondary cause of admission were analyzed. Logistic regression was used to compare 30-day hospital readmission categories by computing odds ratio (OR) and corresponding 95% confidence intervals (95% CIs). A normal random effects model was used to determine unmeasured factors specific to each hospital. Results: A total of 4914 (13.2%, 95% CI: 12.9%-13.6%) hospitalizations had a subsequent 30-day readmission. Hospitalizations that included exit against medical opinion (OR = 1.18, 95% CI: 1.01-1.39), scheduled admissions (OR = 1.71, 95% CI: 1.58-1.85), and tuberculosis infection (OR = 1.20, 95% CI: 1.05-1.38) exhibited a higher risk of hospitalizations with subsequent 30-day readmission. In contrast, hospitalizations that included females (OR = 0.87, 95% CI: 0.81-0.94), a transfer to another facility (OR = 0.78, 95% CI: 0.67-0.91), and having a responsible financial institution (OR = 0.63, 95% CI: 0.55-0.72) exhibited a lower risk of hospitalizations with subsequent 30-day readmission. Hospitalizations associated with higher number of diagnosis, older ages, or hospitalizations during the economic crisis showed an increasing trend of 30-day readmission, whereas an opposite trend was observed for hospitalizations with higher number of procedures. Significant differences exist between hospital quality, adjusting for other factors. Conclusion: This study analyzes the indicators of 30-day hospital readmission among HIV patients in Portugal and provides useful information for enlightening policymakers and health care providers for developing health policies that can reduce costs associated with HIV hospitalizations.

Unmatched Case-Control Study on Late Presentation of HIV Infection in Santiago, Cape Verde (2004-2011).

Access to free antiretroviral therapy (ART) in Sub-Saharan Africa has been steadily increasing over the past decade. However, the success of large-scale ART programmes depends on timely diagnosis and early initiation of HIV care. This study characterizes late presenters to HIV care in Santiago (Cape Verde) between 2004 and 2011, and identifies factors associated with late presentation for care. We defined late presentation as persons presenting to HIV care with a CD4 count below 350 cells/mm³. An unmatched case-control study was conducted using socio-demographic and behavioural data of 368 individuals (191 cases and 177 controls) collected through an interviewer-administered questionnaire, comparing HIV patients late and early presented to care. Logistic regression was performed to estimate odds ratio and 95% confidence intervals. Results show that 51.9% were late presenters for HIV. No differences were found in gender distribution, marital status, or access to health services between cases and controls. Participants who undertook an HIV test by doctor indication were more likely to present late compared with those who tested for HIV by their own initiative. Also, individuals taking less time to initiate ART are more likely to present late. This study highlights the need to better understand reasons for late presentation to HIV care in Cape Verde. People in older age groups should be targeted in future approaches focused on late presenters to HIV care.

Hard-to-reach populations of men who have sex with men and sex workers: a systematic review on sampling methods.

BACKGROUND: In public health, hard-to-reach populations are often recruited by non-probabilistic sampling methods that produce biased results. In order to overcome this, several sampling methods have been improved and developed in the last years. The aim of this systematic review was to identify all current methods used to survey most-at-risk populations of men who have sex with men and sex workers. The review also aimed to assess if there were any relations between the study populations and the sampling methods used to recruit them. Lastly, we wanted to assess if the number of publications originated in middle and low human development (MLHD) countries had been increasing in the last years. METHODS: A systematic review was conducted using electronic databases and a total of 268 published studies were included in the analysis. RESULTS: In this review, 11 recruitment methods were identified. Semi-probabilistic methods were used most commonly to survey men who have sex with men, and the use of the Internet was the method that gathered more respondents. We found that female sex workers were more frequently recruited through non-probabilistic methods than men who have sex with men (odds = 2.2; p < 0.05; confidence interval (CI) [1.1-4.2]). In the last 6 years, the number of studies based in middle and low human development countries increased more than the number of studies based in very high and high human development countries (odds = 2.5; p < 0.05; CI [1.3-4.9]). CONCLUSIONS: This systematic literature review identified 11 methods used to sample men who have sex with men and female sex workers. There is an association between the type of sampling method and the population being studied. The number of studies based in middle and low human development countries has increased in the last 6 years of this study.