A Stratified Approach for Managing Patients With Low Back Pain in Primary Care (SPLIT Program): A Before-and-After Study.

PURPOSE: To determine the effects of stratified primary care for low back pain (SPLIT program) in decreasing back-related disability for patients with low back pain (LBP) in primary care. METHODS: We conducted a before-and-after study. We compared health-related outcomes for 2 sequential, independent cohorts of patients with LBP recruited at 7 primary care units in Portugal. The first prospective cohort study characterized usual care (UC) and collected data from February to September 2018. The second was performed when the SPLIT program was implemented and collected data from November 2018 to October 2021. Between cohorts, physical therapists were trained in the implementation of the SPLIT program, which used the STarT Back Screening Tool to categorize patients for matched treatment. We compared back-related disability (Roland-Morris Disability Questionnaire, 0-24 points), pain (Numeric Pain Rating Scale, 0-10 points), perceived effect of treatment (Global Perceived Effect Scale, -5 to +5 points), and health-related quality of life (EuroQoL 5 dimensions 3 levels index, 0-1 points). RESULTS: We enrolled a total of 447 patients: 115 in the UC cohort (mostly treated with pharmacologic treatment) and 332 in the SPLIT cohort (all referred for a physical therapy intervention program). Over the study period of 6 months, patients in the SPLIT program showed significantly greater improvements in back-related disability (ß, -2.94; 95% CI, -3.63 to -2.24; P ≤ .001), pain (ß, -0.88; 95% CI, -1.18 to -0.57; P ≤ .001), perceived effect of treatment (ß, 1.40; 95% CI, 0.97 to 1.82; P ≤ .001), and health-related quality of life (ß, 0.11; 95% CI, 0.08 to 0.14; P ≤ .001) compared with UC. CONCLUSIONS: Patients in the SPLIT program for LBP showed greater benefits regarding health-related outcomes than those receiving UC.

Is food insecurity related to health-care use, access and absenteeism?

OBJECTIVE: Food insecurity (FI) is defined as uncertain access to healthy food in quantity and quality. We hypothesize that FI may be associated with greater health-care use and absenteeism because it may amplify the effect of diseases; also, FI may be associated with reduced health-care access because it reflects economic vulnerability. The present study estimates the association between FI and health-care use and access, and absenteeism. DESIGN: Cross-sectional data collected in 2015-2016. Health-care use was measured as the number of consultations, taking any drug and having been hospitalized in the past year. Health-care access was measured by the suspension of medication and having fewer consultations due to financial constraints. Absenteeism was measured by the weeks of sickness leave. Binary variables were modelled as a function of FI using logistic regressions; continuous variables were modelled as a function of FI using negative binomial and zero-inflated negative binomial regressions. Covariates were included sequentially. SETTING: Portugal. PARTICIPANTS: Non-institutionalized adults from the EpiDoc3 cohort (n 5648). RESULTS: FI was significantly associated with health-care use before controlling for socio-economic conditions and quality of life. Moderate/severe FI was positively related to the suspension of medicines (adjusted OR = 4·68; 95 % CI 3·11, 6·82) and to having fewer consultations (adjusted OR = 3·98; 95 % CI 2·42, 6·37). FI and absenteeism were not significantly associated. CONCLUSIONS: Our results support the hypothesis that FI reflects precariousness, which hinders access to health care. The greater use of health care among food-insecure people is explained by their worse quality of life and lower socio-economic condition, so that the specific role of poor nutrition is unclear.

Linguistic and cultural adaptation of the EARP Questionnaire to European Portuguese.

OBJECTIVE: This study aims at the linguistic and cultural adaptation of the Early ARthritis for Psoriatic Patients (EARP) questionnaire into European Portuguese, for psoriatic patients attending dermatology medical examination. METHODS: Firstly, we performed a process of translation and back-translation of the English version of the EARP Questionnaire to European Portuguese, with interim and final harmonization. The resulting Portuguese version was approved by the EARP original author. Secondly, individual interviews were conducted to complete the linguistic and cultural adaptation of the initial translated Portuguese version, with the think-aloud and probe methods. At this stage, we conducted eight interviews, four with rheumatology and dermatology doctors (experts), and four with patients with psoriasis and psoriatic arthritis. Finally, the version resulting from the adaptation process was back-translated from Portuguese to English. RESULTS: Our results showed that EARP Questionnaire's items are easy to understand and do not raise comprehension concerns in experts or patients. Our findings suggested that items demanding health literacy from patients and that do not include a precise cue to signal the inflammatory nature of the joint pain may lead to confusion while answering, potentially leading to the patient's need for assistance. CONCLUSION: The Portuguese version of the EARP Questionnaire demonstrated adequate comprehension properties. Our findings support the use of this measure in clinical practice and future research, however, a validation study with Portuguese patients is needed.

A Video-Based Mobile App as a Health Literacy Tool for Older Adults Living at Home: Protocol for a Utility Study.

BACKGROUND: People aged ≥65 years are more likely to have health problems related to aging, polypharmacy, and low treatment adherence. Moreover, health literacy levels decrease with increasing age. OBJECTIVE: The aim of this study is to assess an app's utility in promoting health-related knowledge in people aged ≥65 years. METHODS: We developed a simple, intuitive, and video-based app (DigiAdherence) that presents a recipe, nutritional counseling, and content on physical activity, cognitive exercise, motivation to adhere to treatment, fall prevention, and health literacy. A convenience sample of 25 older adults attending the Personalized Health Care Unit of Portimão or the Family Health Unit of Portas do Arade (ACeS Algarve II - Barlavento, ARS Algarve, Portugal) will be recruited. Subjects must be aged ≥65 years, own a smartphone or tablet, be willing to participate, and consent to participate. Those who do not know how to use or do not have a smartphone/tablet will be excluded. Likewise, people with major cognitive or physical impairment as well as those living in a long-term care center will not be included in this study. Participants will have access to the app for 4 weeks and will be evaluated at 3 different timepoints (V0, before they start using the app; V1, after using it for 30 days; and V2, 60 days after stopping using it). After using the app for 30 days, using a 7-point Likert scale, participants will be asked to score the mobile tool's utility in encouraging them to take their medications correctly, improving quality of life, increasing their health-related knowledge, and preventing falls. They will also be asked to assess the app's ease of use and visual esthetics, their motivation to use the app, and their satisfaction with the app. Subjects will be assessed in a clinical interview with a semistructured questionnaire, including questions regarding user experience, satisfaction, the utility of the app, quality of life (EQ-5D-3L instrument), and treatment adherence (Morisky scale). The proportion of participants who considered the app useful for their health at V1 and V2 will be analyzed. Regarding quality of life and treatment adherence perceptions, comparisons will be made between V0 and V1, using the t test for dependent samples. The same comparisons will be made between V0 and V2. RESULTS: This study was funded in December 2019 and authorized by the Executive Board of ACeS Algarve II - Barlavento and by the Ethics Committee of NOVA Medical School (99/2019/CEFCM, June 2020). This protocol was also approved by the Ethics Committee for Health (16/2020, September 2020) and the Executive Board (December 2020) of the Regional Health Administration of the Algarve, IP (Instituto Público). Recruitment was completed in June 2021. CONCLUSIONS: Since the next generation of older adults may have higher digital literacy, information and communication technologies could potentially be used to deliver health-related content to improve lifestyles among older adults. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/29675.

Food Insecurity Is Associated with Low Adherence to the Mediterranean Diet and Adverse Health Conditions in Portuguese Adults.

BACKGROUND: Food insecurity is a limited or uncertain access to the adequate food and is a significant public health problem. We aimed to assess determinants of food insecurity and the corresponding health impact in Portugal, a southern European country that faced a severe economic crisis. METHODS: Data were derived from the Epidemiology of Chronic Diseases Cohort Study (EpiDoC), a population-based cohort of 10,661 individuals that were representative of the Portuguese adult population and followed since 2011. A cross-sectional analysis of the third wave of evaluation (EpiDoC 3) was performed between 2015 and 2016. Food insecurity was assessed with the household food insecurity psychometric scale. Socioeconomic, demographic, lifestyle, adherence to Mediterranean diet (MD), self-reported non-communicable disease, health-related quality of life (HRQoL) (EQ-5D-3L), physical function (HAQ score), and health resource consumption information was also collected. RESULTS: The estimated proportion of food insecurity was 19.3% among a total of 5,653 participants. Food insecure households had low adherence to the MD (OR = 0.44; 95% IC 0.31-0.62). In addition, diabetes (OR = 1.69; 95% IC 1.20-2.40), rheumatic disease (OR = 1.67; 95% IC 1.07-2.60), and depression symptoms (OR = 1.50; 95% IC 1.09-2.06) were independently associated with food insecurity. On average, food insecure households had a lower HRQoL (OR = 0.18; 95% IC 0.11-0.31) and a higher disability (OR = 2.59; 95% IC 2.04-3.29). A significantly higher proportion of food insecure households reported being hospitalized (OR = 1.57; 95% IC 1.18-2.07) and had more public hospital medical appointments (OR = 1.48; 95% IC 1.12-1.94) in the previous 12 months. CONCLUSION: We found that food insecurity is highly prevalent in Portugal. Food insecurity was associated with low adherence to the MD, non-communicable chronic diseases, lower quality of life, and higher health resource consumption. Therefore, this study provides valuable insight into the relationship between food security and the diet and health of the population during an economic crisis.

Food Insecurity in Older Adults: Results From the Epidemiology of Chronic Diseases Cohort Study 3.

Introduction: The public health problem of food insecurity also affects the elderly population. This study aimed to estimate the prevalence of household food insecurity and its associations with chronic disease and health-related quality of life characteristics in individuals ≥65 years of age living in the community in Portugal. Methods: The data were collected from the Epidemiology of Chronic Diseases Cohort Study 3 (EpiDoC3)-Promoting Food Security Study (2015-2016), which was the third evaluation wave of the EpiDoC and represented the Portuguese adult population. Food insecurity was assessed using a psychometric scale adapted from the Brazilian Food Insecurity Scale. The data on sociodemographic variables, chronic disease, and management of chronic disease were self-reported. Health-related quality of life were assessed using the European Quality of Life Survey (version validated for the Portuguese population). Logistic regression models were used to determine crude and adjusted odds ratios (for age group, gender, region, and education). The dependent variable was the perceived level of food security. Results: Among older adults, 23% were living in a food-insecure household. The odds of living in a food-insecure household were higher for individuals in the 70-74 years age group (odds ratio (OR) = 1.405, 95% confidence interval (CI) 1.392-1.417), females (OR = 1.545, 95% CI 1.534-1.556), those with less education (OR = 3.355, 95% CI 3.306-3.404), low income (OR = 4,150, 95% CI 4.091-4.210), and those reporting it was very difficult to live with the current income (OR = 16.665, 95% CI 16.482-16.851). The odds of having a chronic disease were also greater among individuals living in food-insecure households: diabetes mellitus (OR = 1.832, 95% CI 1.818-1.846), pulmonary diseases (OR = 1.628, 95% CI 1.606-1.651), cardiac disease (OR = 1.329, 95% CI 1.319-1.340), obesity (OR = 1.493, 95% CI 1.477-1.508), those who reduced their frequency of medical visits (OR = 4.381, 95% CI 4.334-4.428), and who stopped taking medication due to economic difficulties (OR = 5.477, 95% CI 5.422-5.532). Older adults in food-insecure households had lower health-related quality of life (OR = 0.212, 95% CI 0.210-0.214). Conclusions: Our findings indicated that food insecurity was significantly associated with economic factors, higher values for prevalence of chronic diseases, poor management of chronic diseases, and decreased health-related quality of life in older adults living in the community.

Anxiety and Depression in the Portuguese Older Adults: Prevalence and Associated Factors.

Anxiety and depression in the elderly individuals have been studied around the world, and some authors consider them among the most serious problems faced by modern societies. With recent economic crisis-very important in Southern European countries-isolation, loneliness, and exclusion of the active society, mental problems are probably raising and associated with distinct factors. In this cross-sectional analysis, nested in a longitudinal population-based cohort study, we analyze anxiety and depression prevalence, and their related factors, in a representative cohort of Portuguese seniors. We used data retrieved from second wave of follow-up of EpiDoC Cohort-EpiDoC 2 study, which is composed by 10,661 adults, representative of adult Portuguese population. This study included all ≥65 years old EpiDoC 2 study participants, who responded to Hospital Anxiety and Depression Scale (HADS), n = 1,680. Sociodemographic, lifestyles, self-reported non-communicable diseases, health-related quality of life (EQ-5D-3D), physical function (HAQ), and health resources consumption data were collected. Anxiety and depression were assessed with HADS. Anxiety and depression prevalence were estimated. Multivariable logistic regression was used to assess anxiety and depression score determinants. The estimated prevalence of anxiety among Portuguese elderly is 9.6% and depression is 11.8%. Seniors with anxiety and seniors with depression have a higher probability to self-report higher levels of physical disability (OR = 3.10; 96% CI 2.12-4.52; OR = 3.08, 95% CI 2.29-4.14, respectively) and lower levels of quality of life (OR = 0.03, 95% CI 0.01-0.09; OR = 0.03, 95% CI 0.01-0.06, respectively). Female gender (OR = 2.77, 95% CI 1.53-5.00), low educational level (OR = 2.30, 95% CI 1.22-4.36), allergic (OR = 2.02, 95% CI 1.14-3.55), and rheumatic disease (OR = 2.92, 95% CI 1.74-4.90) were significantly and independently associated with the presence of anxiety symptoms. Physical inactivity (OR = 1.64, 95% CI 1.11-2.42) and low educational level (OR = 2.40, 95% CI 1.41-4.09) were significantly and independently associated with depression symptoms. Subjects that reported to drink alcohol daily or occasionally were negatively associated with depression symptoms. Anxiety and depression are frequent among Portuguese elderly. These prevalence rates suggest that preventing mental illness in senior population is a crucial need. A well-designed prevention strategy might have an effective action in raising the well-being of elderly.

Home-Based Intervention Program to Reduce Food Insecurity in Elderly Populations Using a TV App: Study Protocol of the Randomized Controlled Trial Saúde.Come Senior.

BACKGROUND: The limited or uncertain access to adequate food in elderly people includes not only economic restrictions but also inability of food utilization due to functional or cognitive impairment, health problems, and illiteracy. OBJECTIVE: The aim of this work is to present the protocol of the randomized controlled trial Saúde.Come Senior, an educational and motivational television (TV)-based intervention to promote healthy lifestyles and decrease food insecurity in elderly people. METHODS: A randomized controlled study will be conducted in subjects aged 60 years and older with food insecurity, identified at 17 primary care centers in the Lisboa e Vale do Tejo health region in Lisbon, Portugal. The primary outcome will be the changes in participants' food insecurity score (evaluated by the Household Food Insecurity Scale) at 3 months. Change in other outcomes will be assessed (dietary habits, nutritional status, physical activity, health status, and clinical outcomes). Subjects will be followed over 6 months; the intervention will last 3 months. Data collection will be performed at 3 different time points (baseline, end of intervention at 3 months, and follow-up at 6 months). The intervention is based on an interactive TV app with an educational and motivational program specifically developed for the elderly that has weekly themes and includes daily content in video format: (1) nutrition and diet tips for healthy eating, (2) healthy, easy to cook and low-cost recipes, and (3) physical exercise programs. Furthermore, brief reminders on health behaviors will also be broadcasted through the TV app. The total duration of the study will be 6 months. The intervention is considered to be effective and meaningful if 50% of the individuals in the experimental group have a decrease of 1 point in the food insecurity score, all the remaining being unchanged. We expect to include and randomize 282 (141 experimental and 141 control) elderly with food insecurity. We will recruit a total of 1,128 subjects considering that 50% of the target individuals are food insecure (based on INFOFAMÍLIA Survey) (567) and about 50% of those will adhere to the study (282). RESULTS: The randomized controlled trial with the 12-week home-based intervention with a comprehensive program on healthy eating and physical activity delivery is planned to start recruiting participants at the end of 2017. CONCLUSIONS: This study will assess the efficacy of this innovative tool (Saúde.Come Senior) for disseminating relevant health information, modifying behaviors, and decreasing food insecurity in an easy, low-cost, and massive way.