Lisbon Region Research Articles

Viral pathogen surveillance in wastewater using metagenomic approaches: obstacles and prospects

Abstract Background Wastewater monitoring offers an important tool for pathogen detection and tracking within large populations at a minimized cost and labor. Untargeted metagenomic approaches for the detection and sequencing of viruses still face limitations. In this study we tested the application of the sequence-independent single-primer amplification (SISPA) protocol in conjunction with nanopore sequencing to the study of viromes in wastewater samples. Methods Influent wastewater was collected from four Wastewater Treatment Plants located in the Lisbon region and Alentejo, Portugal in 2019 and 2023. Samples were processed with different methods including filtration, flocculation, Nanotraps or absorvent tampons. We applied the SISPA protocol, that includes a random amplification step, followed by nanopore sequencing on flow cells R9.4.1. We used the CZ ID (https://czid.org) pipeline for metagenomic analysis and taxonomic reporting. Results A large heterogeneity was found between samples in sequencing output (ranging from 17 thousand to 12 million reads) and the proportion of sequence reads classified as viral (ranging from 0.06% to 4% per sample). Viral taxa with higher number of reads were Picornavirales, dsDNA and ssDNA phages, Mimiviridae and Circoviridae. Known viral pathogens included Rotavirus A, Orthopoxvirus, Human betaherpesvirus and Avian orthoavulavirus. Conclusions Metagenomic studies of environmental samples generally exhibit a low proportion of viral reads, even after viral enrichment. A substantial sequencing effort is thus required to achieve a comprehensive virome characterization. As alternative, a more targeted approach, e.g. to target families of viruses of interest, may be considered. Funding: Fundação para a Ciência e Tecnologia (FCT): GHTM - UID/04413/2020; LA-REAL - LA/P/0117/2020; https://doi.org/10.54499/CEECINST/00102/2018/CP1567/CT0040 to SGS. Research council of the Vrije Universiteit Brussel (OZR-VUB): OZR3863BOF to PL. Key messages • Enrichment for viruses in metagenomic approaches remain challenging in very complex samples as are influent wastewaters. • Virome characterization still necessitates high sequencing efforts but may be used as a complementary environmental survey tool integrated with more targeted approaches.

Pediatric tonsilitis: modern tactics against an old foe

Abstract Background Pediatric tonsillitis (PT) impacts public health due to its widespread incidence and the prevalent overprescription of antibiotics driven by concerns over Group A β-hemolytic streptococcus (SGA) complications. Rapid antigen diagnostic tests (RADT) serve as vital tools for promptly identifying SGA infections in PT cases. However, despite their widespread availability, healthcare professionals often underutilize RADT, leading to inappropriate antibiotic prescriptions. Clinical audits and feedback to professionals emerge as solutions to this issue. Methods An audit was conducted on clinical cases of PT during 2023 to evaluate the correct usage of RADT and subsequent antibiotic prescription across various primary care practices in Lisbon, Portugal. Afterwards, a pilot practice was selected to assess the feasibility and utility of an online tool designed specifically to report RADT results and create a real-time surveillance system of incidence of SGA with feedback to prescribing clinicians. Following the revision of the reporting tool after the pilot, its implementation was extended to multiple practices across the Lisbon region. Results From the 1050 clinical cases analyzed, 992 had an indication to do a RADT according to the Portuguese guidelines, however only 282 (28.4%) tests were done. Overall, only 19.6% of PT cases were considered fully compliant. During the pilot, the introduction of the online tool led to a 3.259 increase in reporting (from 0.574 RADT/day to 1.872 RADT/day) for the same time period between February and March. Conclusions The implementation of an online reporting tool represents a significant advancement in SGA surveillance efforts, detecting cases promptly for public health interventions. This initiative underscores the importance of continuous quality improvement in diagnostics and shows digital tools’ potential for better disease surveillance in clinical settings. Key messages • Underutilization of RADT in PT cases contributes to inappropriate antibiotic prescriptions, compromising patient care. • Introduction of an online reporting tool significantly enhances RADT usage, aiding prompt SGA detection for improved public health interventions.

Breastfeeding duration, children’s diet and physical activity in immigrant children living in Lisbon

Abstract Background In 2023, 25% of children born in the Lisbon metropolitan area were from foreign mothers. Children of immigrant parents often face an unbalanced diet and unhealthy lifestyle, preventing them from reaching their full potential. The aim of this study was to analyse the associations between migrant status and breastfeeding duration, fruit and vegetable consumption and physical activity in children living in the Lisbon metropolitan area, Portugal. Methods Cross-sequential cohort study in Lisbon Region. Between May 2022 and April 2024, 729 children (49.4% immigrants) born in 2018 and 2020 were enrolled in the study. Data were collected in a face-to-face interview with the parents using a structured questionnaire with information on children’s diet (fruit and vegetable consumption) and physical activity. We used X2, Mann-Whitney U and t-tests to compare immigrant and non-immigrant children. Adjusted odds ratios (aOR) with a 5% level were estimated by logistic regression. Results Immigrant children (49.4%) live in socio-economically disadvantaged families. Breastfeeding practices are more common among migrant mothers with a higher median duration of exclusive breastfeeding (6 versus 4 months, p < 0.001) and a higher median duration of breastfeeding (14 versus 8 months, p < 0.001). Parental migration background is associated with the frequency of fruit (p = 0.039) and vegetable (p < 0.01) consumption and with the practice of physical activity (p < 0.01). The odds of consuming three or more portions of fruit are 1.37 times higher for non-immigrant children, and the odds of consuming two portions of vegetables are higher for non-immigrants than immigrants (aOR=2.04, p < 0.01). Practicing sports is most frequent in non-immigrants (aOR =2.25; p < 0.01). Conclusions Migrant status was associated with a less healthy lifestyle in childhood for children living in the Lisbon metropolitan area. Key messages • Breastfeeding is an essential source of nutrition for children, especially in socio-economically disadvantaged families. • The migrant status is often associated with inequalities in childhood, challenging immigrant children to achieve their full potential.

Unlocking Tourism Diversity in Winter: Clusters of Tourists in Lisbon Based on Motivations, Profiles, and Behaviour

Recent trends in Lisbon's winter tourism indicate a shift towards off-peak travel, attracting diverse visitors with its rich cultural heritage, sustainable initiatives, and extended stay options for digital nomads. The city's culinary scene, arts, wellness activities, and tech-driven tourism options enhance its appeal. Aligned with these recent trends, tourism in Lisbon's region during the winter season presents a unique and dynamic landscape influenced by a wide range of motivations, tourist profiles, and travel behaviours. This study aims to define distinctive clusters of winter tourists in Lisbon by analysing these key variables, providing valuable insights specific to the winter travel context. Based on a compiled dataset from the winter season in Lisbon, this study delves into examining the factors driving tourist visits, encompassing socio-economic backgrounds, travel frequency, and age demographics. We aim to reveal the distinctive subgroups that define Lisbon's winter tourist population, employing data analysis techniques such as cluster analysis. From an academic perspective, this study offers a novel tourist segmentation model based on motivations, profiles, and behaviour. This model enriches the existing body of knowledge in tourism studies, providing a valuable reference for future research. For tourism agents in Lisbon, this study provides actionable insights to enhance strategic decision-making. By segmenting winter tourists, they can tailor marketing strategies and product development to cater to diverse tourist segments. Moreover, this approach can lead to economic benefits, optimising resource allocation, and revenue generation.

Exploring seismic fragility and strengthening of masonry built heritage in Lisbon (Portugal) via the Applied Element Method

Although mainland Portugal has been spared from large magnitude earthquakes in recent years, it faces a threat due to the presence of several active fault systems. In such a framework, Portuguese pre-code masonry construction is believed to be the most vulnerable in the existing building stock. Given the lack of information on earthquake damage to this stock, the use of detailed numerical models is a viable strategy to comprehend its seismic behavior. This paper provides an updated fragility characterization of Lisbon pre-code masonry buildings based on their seismic assessment through the Applied Element Method. To limit the computational time, a promising pushover strategy, known as Incremental Ground Acceleration, was adopted. After the characterization of the current fragility, two retrofit layouts based on piers strengthening were modeled and assessed for the building stock whose seismic capacity does not meet expected demand. The aim of the paper is to derive updated fragility curves for the Lisbon region to support risk analysis incorporating the latest hazard studies and to offer insights into potential retrofit interventions.

Architecture from an Alternative Power

In a revolution, governors can no longer govern, and the governed refuse to be so. In this sense, the experience of the Portuguese Local Support Service (Serviço de Apoio Ambulatório Local—SAAL) epitomizes the national revolution of 1974–5, allowing poor city workers to reclaim the right to housing and the city. This essay discusses the Catujal Workers Estate, built in this context, in Loures (Lisbon Region) with a plan by the brigade led by architect Francisco Pires Keil do Amaral. Most information is derived from the reports and drawings of the original SAAL intervention, with the aim of presenting an observation of this case and trying to highlight the process of cooperation that linked those designing the habitat with those who were to live in it.

Genomic insights into the expansion of carbapenem-resistant Klebsiella pneumoniae within Portuguese hospitals

Carbapenem-resistant Klebsiella pneumoniae (CR-KP) are a public health concern, causing infections with a high mortality rate, limited therapeutic options and challenging infection control strategies. In Portugal, the CR-KP rate has increased sharply, but the factors associated with this increase are poorly explored. In order to address this question, phylogenetic and resistome analysis were used to compare the draft genomes of 200 CR-KP isolates collected in 2017-2019 from five hospitals in the Lisbon region, Portugal. Most CR-KP belonged to sequence type (ST) 13 (29%), ST17 (15%), ST348 (13%), ST231 (12%) and ST147 (7%). Carbapenem resistance was conferred mostly by the presence of KPC-3 (74%) or OXA-181 (18%), which were associated with IncF/IncN and IncX plasmids, respectively. Almost all isolates were multi-drug resistant, harbouring resistance determinants to aminoglycosides, beta-lactams, trimethoprim, fosfomycin, quinolones and sulphonamides. In addition, 11% of isolates were resistant to colistin. Colonizing and infecting isolates were highly related, and most colonized patients (89%) reported a previous hospitalization. Moreover, among the 171 events of cross-dissemination identified by core genome multi-locus sequence typing data analysis (fewer than five allelic differences), 41 occurred between different hospitals and 130 occurred within the same hospital. The results suggest that CR-KP dissemination in the Lisbon region results from acquisition of carbapenemases in mobile genetic elements, influx of CR-KP into the hospitals by colonized ambulatory patients, and transmission of CR-KP within and between hospitals. Prudent use of carbapenems, patient screening at hospital entry, and improvement of infection control are needed to decrease the burden of CR-KP infection in Portugal.

Ophthalmology Census 2021: A Demographic Characterisation of Ophthalmologists in Portugal.

Human resources in ophthalmology have recently received particular attention, and it has been questioned whether there is a sufficient number of workers. The aim of this study was to analyze and characterize Portugal's ophthalmologist population. In this descriptive, cross-sectional study, an online questionnaire was sent to all ophthalmologists registered with the Portuguese College of Ophthalmology in December 2021. Information on the following variables was collected and analyzed: demographic factors, professional qualifications, professional activity, weekly professional activity and medium-term plans. Among the 910 registered ophthalmologists, a response rate of 64.7% was achieved. There were 0.9 ophthalmologists for every 10 000 inhabitants, 0.45:10 000 working in the public sector (0.35:10 000 full-time equivalent). Among the respondents, 57.6% were over 50 years old (59.6% male), 97.3% were Portuguese, 46.7% completed their residency in the Lisbon region, 27.3% complemented their programme with additional training, 9.5% had a PhD and approximately 58% lived and worked in large urban centres. Regarding professional activity, 58.5% of the respondents worked in the public sector (4.2% exclusively), while 67.9% worked in different economic sectors. The median number of weekly working hours reported was 45 hours, with those in the public sector reporting 35 hours. Private/social sector work and public sector work accounted for 12 926 hours/week and 10 808 hours/week, respectively. It was found that 31.4% of the respondents provided emergency medical services and that 52.8% performed surgical procedures more than once a week. Looking ahead, 38.7% of the ophthalmologists intended to reduce their workload within the next five years due to family reasons, fatigue and demotivation. The projected rate of retirement or cessation of activity in the next five years was estimated to be 1.7%, while an average of 20 new ophthalmologists are expected to enter the profession annually, resulting in a generational balance of 0.8%. While the number of ophthalmologists in Portugal meets the international recommendations, there is a shortage in the public sector and most ophthalmologists work in large urban centres. The number of ophthalmologists in Portugal is expected to be stable for the next five years.

Perceptions and Realities of Lisbon: An Examination of the Image of a Tourist Destination

Destination image is related to comprising cognitive, emotional, and conative components and includes an individual's thoughts, ideas, and perceptions of a place. Images consistently coincide with the internalisation of distinct perspectives, demonstrating that people have different perceptions of the destiny. Influences include media, authority figures, music, and movies. Although the experience may not match their initial expectations, these effects form their preconceived beliefs and expectations of a trip. Accordingly, it is important to explore the trustfulness of the positioning of tourist destinations to ascertain its alignment with the expectations of tourists. Given that, Lisbon has been regarded as one of the foremost European cities in recent years, owing to its high level of accessibility and its multifaceted sensory attributes, it was deemed pertinent to investigate the perceptions of the visitors towards the city. The present study used a mixed methods approach, incorporating a multimedia component that showcases various locations in the Lisbon region with open-ended questionnaires to gather the perspectives of the tourists and a closed-ended questionnaire that inquiries about the primary factors that attract visitors to Lisbon. This analysis employed graphical representations, including word clouds and graphics to explore the identified impressions. The research revealed a robust association between cultural, historical, and aesthetic variables and the choice of travel destination. Certain visual representations highlight the imperative of pursuing sustainable and responsible development to mitigate the potential for enduring degradation. This holds significance as certain images are linked to instances of environmental and social irresponsibility. The study also revealed that History and Heritage emerged as the most significant factors that attract individuals, followed by Cultural Attractions, Weather and Climate, Gastronomy, and Panoramic Views and Landscapes. A notable perception exists regarding the insufficiency of sustainability and eco-friendly practices, underscoring the necessity for targeted sustainability endeavours to promote responsible and sustainable development of tourism destinations. Indeed, additional research on the contrast of perception and reality at the location is needed to evaluate the picture provided to visitors. However, understanding tourist-relevant areas like Lisbon is a good foundation for advertising them, allowing various stakeholders to make authentic and valuable marketing decisions.

An Importance–Performance Analysis Approach to a Tourism Destination: the Case of Lisbon Metropolitan Area, Portugal

Pull factors, the attributes of a specific location, matter in tourism. These factors encompass the distinctive characteristics and alluring features that attract tourists to a destination, their importance and performance influencing the decision-making process and overall experience. A clear comprehension of this concept is crucial for destinations' economic vitality as they compete for tourists and strive for economic expansion and employment prospects. Indeed, an in-depth knowledge of these factors' importance and performance underscores the need for regions to adjust their approach to evolving tourist preferences. This adaptation is crucial to fostering responsible and sustainable tourism practices that safeguard cultural and natural resources. However, besides learning about the factors considered critical by tourists to visit a location, it is paramount to analyse how they evaluate the performance of each of these factors while staying there.This study focuses on the Lisbon Metropolitan Area (LMA), Portugal, and the findings will provide essential insights into destination competitiveness, sustainable tourism development, and the creation of unique travel experiences. As a destination that gained popularity, attracting tourists from all over the world, it is necessary to comprehend the specific factors that contribute to this vibrant region's allure and how it performs regarding them. The research will use the Importance-Performance Analysis to make data interpretation accessible and suggest relevant measures to improve competitiveness based on optimising the allocation of resources among the various factors/attributes analysed. The research incorporates numerous criteria categories, including historical significance, urban appeal, natural scenery, culinary experiences, cultural heritage, and aspects like streets' cleanliness, transport availability, or health emergency infrastructures. The study's conclusions will impact Lisbon region's (LMA) tourism and destination management. By understanding what factors are more important for tourists that visit the area and their evaluation of the performance of each of these factors, stakeholders can improve marketing, infrastructure, and the visitors' experience to promote sustainable development and maintain Lisbon's standing as a top tourist destination for rewarding and enlightening experiences. Relevant data is also provided to inform future tourism initiatives. This study adds to the academic discussion of location competitiveness and unique travel experiences.

Exploring refugees' health care access in times of COVID-19: a quantitative study in the Lisbon region, Portugal.

To address the health needs of refugees, health services must be culturally competent and facilitate this population's access to health care, especially in a context prone to the amplification of social inequities, such as the COVID-19 pandemic. However, few quantitative studies exist in the European Union, and to the extent of our knowledge, there are no published quantitative studies exploring refugees' access to health care during the pandemic in Portugal. The objective of this study is to describe the demographic and socioeconomic characteristics of refugees living in Lisbon and to explore their healthcare access patterns during the COVID-19 pandemic. We conducted a cross-sectional, descriptive, and quantitative study from May to November 2022. Using Levesque' s theory on health care access, we designed and applied a 38-item questionnaire through face-to-face interviews with refugees living in Lisbon for at least 12 months, and used descriptive statistics to characterize sociodemographic and healthcare access profiles during the pandemic. The mean age of the 36 recruited refugees was 35 years (SD = 10.24), the majority were male (56%), married (72%), had at least a secondary education (69%), were unemployed (77.8%), and had a median length of stay in Portugal of 17 months (IQR = 45). All were registered in a primary care center, and 94% used healthcare services during the pandemic. The majority never tested positive for the coronavirus (58%) and one out of the positive was admitted to hospital due to severe COVID-19. A total of 97% received COVID-19 vaccination, of which 69% had an incomplete schedule. A quarter of the participants did not have access to information about COVID-19 in a language they understood, and although 97% needed health care during the pandemic, more than half (63%) did not seek it because of structural and cultural barriers. Half of the respondents had difficulty getting medical advice by phone or email, and 39.4% could not afford a medical examination or treatment. Only 18.2% sought counseling services. A total of 58.8% of the participants felt like healthcare professionals did not always show respect towards their culture, and 64.7% reported that healthcare professionals did not always discuss treatment options with them. This study's findings highlight the need to endow inclusive communication, cultural competency, and patient involvement in health care, alongside improving the socioeconomic condition of refugees. Identified population characteristics and barriers to health care access by refugees in this study may inform future research on the health care needs of refugees in Portugal and ultimately assist in the devising of strategies to reduce inequalities in health care access.

Use and misuse of psychoactive medicines: a descriptive cross-sectional study in a densely populated region of Portugal.

Although psychoactive medicines (PMed) are needed in several psychiatric conditions, their use and misuse bear risks. We aimed at estimating the prevalence of PMed use and misuse. Data on all PMed prescribed in 2017 and dispensed in community pharmacies of the Lisbon and Tagus Valley region of Portugal (ARSLVT) were extracted from ARSLVT medicines' dispensing database. For 21 PMed among prescription opioids, benzodiazepines and z-drugs (BZDR), antidepressants (AD) and anticonvulsants (AC), we estimated the number of users of each PMed, and assessed PMed misuse by a set of proxy indicators for studying this practice: chronic use (use of ≥180 DDD during the study period) of PMed intended for short-term treatments, concomitant use of several PMed, in particular if involving long-term (≥ 30 days) opioid analgesic (OA) use, and doctor shopping (patients consulting several physicians in order to have access to a quantity higher than intended by each prescriber). Data were analysed using descriptive statistics and hypothesis testing, and multivariate logistic regression was used to explore potential factors affecting long-term concomitant treatment of chronic OA with other PMed. PMed use prevalence was 21.7%: 6.6% for OA, 12.7% for benzodiazepines (BZD), 5.3% for AD and 2.8% for AC. BZDR were mainly prescribed in primary care and OA in hospital outpatients. Chronic use of PMed was observed in 25%, especially with sertraline and buprenorphine for opioid use disorder (long-term treatment), and lorazepam (short-term treatment). About 56.6% of OA chronic users were long-term concurrent users with other PMed, mainly BZDR. Risk of abuse was low for BZDR, whilst four opioids had meaningful doctor shopping indicators - fentanyl, opioid use disorder buprenorphine, morphine and hydromorphone. BZD are the main PMed used in ARSLVT, often chronically, especially lorazepam. Prevalence of OA use is low, although with higher risk of misuse than BZDR. Concomitant use of several PMed is frequent.

Five years of reorganization in the family practice residency program in the Lisbon and Tagus Valley Region in Portugal

Resumo O internato médico em Medicina Geral e Familiar transformou-se entre 1981 e 2010 de um internato hospitalar de três anos para um internato baseado nos Cuidados de Saúde Primários de quatro anos. Em 2015 e 2019 o programa foi revisto e introduziram-se novos métodos de avaliação. A Coordenação de Internato Médico de Lisboa e Vale do Tejo gere a formação de 850 médicos internos, e, perante o aumento no número de médicos internos e com as alterações no programa, organizou a sua metodologia de trabalho à volta de 4 focos de intervenção: 1) Equipas Regionais; 2) Comunicação e decisão; 3) Colaboração interinstitucional; 4) Organização da equipa central em 5 pilares - a capacidade formativa, a formação de médicos internos, a avaliação contínua, a formação de médicos orientadores e a avaliação final. Entre 2019 e 2023 foi possível capacitar as equipas regionais, melhorar os processos de tomada de decisão, uniformizar o internato médico, e, a nível central, reforçar a quantidade e qualidade de vagas, aumentar a formação para médicos internos e orientadores, criar equipas de avaliação contínua e contribuir significativamente para o processo de avaliação final a nível nacional.

Persistence with medical glaucoma therapy in newly diagnosed patients.

Monotherapy, age, and side effects are significant risk factors for the discontinuation of antiglaucoma therapy. Long-term therapy persistence is crucial for slowing disease progression and preventing irreversible blindness. Therefore, it is essential to identify patients at higher risk of discontinuation. In this study, we aimed to evaluate the real-world persistence of antiglaucoma therapy in patients diagnosed with glaucoma in the primary healthcare units of the Lisbon and Tagus Valley regions. We conducted a retrospective longitudinal study by collecting data from the prescription records of new antiglaucoma drug users diagnosed with glaucoma between 2012 and 2013 in the Primary Health Care Units of the Lisbon and Tagus Valley Region. These patients were followed over 3 years. Therapy persistence was measured as the proportion of patients remaining on any antiglaucoma drug, regardless of any modifications or switching of drugs over time. Persistence was assessed at three time points: the end of the first, second, and third years of the observation period. A total of 2138 patients treated using new antiglaucoma drugs (867 [40.6%] male patients; 1271 [59.4%] female patients) were included in the study. Over the observation period, the overall persistence rate decreased from 91.9% (n = 1965) in the first year to 67.3% (n = 1439) in the third year. Older patients (≥ 65 years) showed higher persistence rates, although there was a decrease over the 3-year follow-up period (from 1481 [92.7%] to 1124 [70.4%]). Additionally, participants initially treated with monotherapy showed higher persistence rates, ranging from 92.4% (n = 1186) in the first year to 70.2% (n = 901) in the third year. The findings highlight the importance of patient follow-up over time, as almost one in three new antiglaucoma therapy users completely discontinued treatment, potentially risking disease progression. This could be mitigated with proper use of these drugs. Further studies should utilize recent health information systems to explore the impact of medication adherence and persistence on the functional and structural outcomes in patients with glaucoma.

Five years of reorganization in the family practice residency program in the Lisbon and Tagus Valley Region in Portugal

Resumen El internado médico en medicina general y de familia se transformó, entre 1981 y 2010, de un internado hospitalario de tres años a un internado basado en la atención primaria de cuatro años. En 2015 y 2019, el programa fue revisado y se introdujeron nuevos métodos de evaluación. La Coordinación del Internado Médico de Lisboa y Valle del Tajo gestiona la formación de 850 médicos internos y, ante el aumento en el número de médicos internos y las modificaciones en el programa, organizó su metodología de trabajo en torno a cuatro focos de intervención: 1) equipos regionales; 2) comunicación y toma de decisiones; 3) colaboración interinstitucional; 4) organización del equipo central, en cinco pilares: la capacidad formativa, la formación de médicos internos, la evaluación continua, la formación de médicos tutores y la evaluación final. Entre 2019 y 2023 se logró capacitar a los equipos regionales, mejorar los procesos de toma de decisiones, estandarizar el internado médico y, a nivel central, reforzar la cantidad y calidad de plazas, aumentar la formación para médicos internos y tutores, crear equipos de evaluación continua y contribuir de manera significativa al proceso de evaluación final a nivel nacional.

A contratualização com os cuidados de saúde primários na Administração Regional de Saúde de Lisboa e Vale do Tejo, até 2023

Abstract The article discusses contractualization in Primary Health Care (PHC), relating what has been contractualized and what has been achieved to answer the question: can contractualization contribute to guaranteeing equity and adequate access to PHC? A case study methodology was used, using data available on the SNS Transparency Portal and data used in external contractualization. Data was collected in December 2023. In the Lisbon and Tagus Valley Health Region, 29.6 percent of people were registered without a family doctor in 2023. One-year appointment usage rates fell progressively (-2.7%) between 2021 and 2023. As for cancer screening, in the case of colon and rectum screening, only 34.4% of those contractualized were performed in 2021 and 28.9% in 2022. Regarding the Overall Performance Index, the variation intervals between the negotiated proposals and those obtained were above 20 points. Drug therapy prescription in Diabetes Mellitus was analyzed, and no ACES achieved the expected values. We concluded that contractualization has not helped improve access and equity, as a gap between the situational or local strategic planning phases seems evident.

Covid-19 and the Portuguese accommodation sector

Abstract According to organisational theories, performance can be explained by threats and opportunities generated in the external environment and the interplay between the macro and the microenvironment. This logic holds for tourism companies. This study aims to analyse the impact of a macro-environmental factor, the COVID-19 pandemic, on the accommodation sector in Portugal, studying differences across regional destinations and industries. A descriptive approach was made using secondary data from INE (the Portuguese Statistics Institute) for 2019 and 2020. Three performance indicators were analysed: number of overnight stays, number of guests, and total income. Results suggest that the impact of COVID-19 was relatively higher in the regions of Lisbon and the Azores and on the industry of short-term rentals. The region of Alentejo and the industry of rural tourism/manor houses were the least affected. Implications are both theoretical and practical. Theoretically, this study highlights the interplay between the macro and the microenvironment, translating to future crises. For managers, our research also highlights specific characteristics of regional destinations and industries, which might have been a source of competitive advantage during the pandemic, translating into less unfavourable outcomes in this context.

Protocol for a cluster randomised trial of a goal-oriented care approach for multimorbidity patients supported by a digital platform

IntroductionHealth information systems represent an opportunity to improve the care provided to people with multimorbidity. There is a pressing need to assess their impact on clinical outcomes to validate this...

Promoting primary healthcare services resilience with chronic disease management digitalization: a foresight study in the Lisbon health region

Abstract Background Due to the pressure on health systems, the COVID-19 Pandemic forced administrators to rapidly harness and integrate existing technology to manage access of patients with chronic diseases to Primary Health Care (PHC) in Portugal. Studies show that one of the most important areas for improvement is the sustainability of artefacts after the implementation phase, which depends on the successful implementation of digital transformation. As such, this study aims to assess the impact and influence of digitalization of PHC to settle a set of actions to be taken so that implementation is carried out more effectively and to support evidence-based policy-making in a PHC Unit located in the peripheral area of Lisbon. Methods This study followed a collaborative foresight approach using a scenario development methodology proposed by Lapão and Thore, divided into three stages: understanding the context, developing scenarios, and their analysis. These steps were achieved by conducting focus groups using the thematic brainstorming approach to analyse strategic and operational scenarios within ten years (between 2022 and 2032). Results Considering the influence of digitalization of PHC in the next ten years, three relevant and plausible scenarios were developed: ‘Digital PHC and active patients’, ‘NHS transition’ and ‘Climate exigency’. Combining innovation skills to establish digital services with improved governance policies has shown significant benefits toward the goals of more patient-centred care. Conclusions The collaborative reflection process throughout the study made the different stakeholders identify and understand the impact of the essential measures to be taken in different scenarios, allowing the digitalization of PHCs to be implemented more effectively, enabling the sustainability of the National Health Service in the Lisbon region, which has only been discussed so far at a limited and theoretical level.

Cohesion policy and metropolitan governance: innovation in stakeholders collaboration practices in Lisbon

This study examines the impact of Cohesion Policy on metropolitan governance and stakeholders’ collaboration practices in the Lisbon region. The financial crisis and subsequent austerity policies have underscored the importance of institutional arrangements and governance processes, particularly at the local and regional levels. Focusing on the Lisbon metropolitan area, which faces fragmented institutional structures and governance challenges, this research highlights the role of Cohesion Policy through Integrated Territorial Investments (ITI) in fostering innovation and collaboration among stakeholders. The EVA (Green and Blue Corridor) project in the Lisbon Metropolitan Area exemplifies the role of EU funding in promoting cooperation and governance innovation. The introduction of ITI under the Cohesion Policy has facilitated the establishment of collaborative networks and innovative practices in the metropolitan area. These initiatives have broken down planning silos, promoting "soft spaces of governance" that encouraged knowledge exchange and institutional learning among territorial stakeholders. However, challenges persist in the absence of a coherent regional strategy and the prioritization of broad EU objectives over tailored regional needs. This hampers the potential for integrated and proactive territorial management. Nevertheless, Cohesion Policy has stimulated stakeholder collaboration and innovation in metropolitan governance, paving the way for sustainable and inclusive development in the Lisbon region.