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1.  Evaluating Drug Prices, Availability, Affordability, and Price Components: Implications for Access to Drugs in Malaysia 
PLoS Medicine  2007;4(3):e82.
Background
Malaysia's stable health care system is facing challenges with increasing medicine costs. To investigate these issues a survey was carried out to evaluate medicine prices, availability, affordability, and the structure of price components.
Methods and Findings
The methodology developed by the World Health Organization (WHO) and Health Action International (HAI) was used. Price and availability data for 48 medicines was collected from 20 public sector facilities, 32 private sector retail pharmacies and 20 dispensing doctors in four geographical regions of West Malaysia. Medicine prices were compared with international reference prices (IRPs) to obtain a median price ratio. The daily wage of the lowest paid unskilled government worker was used to gauge the affordability of medicines. Price component data were collected throughout the supply chain, and markups, taxes, and other distribution costs were identified. In private pharmacies, innovator brand (IB) prices were 16 times higher than the IRPs, while generics were 6.6 times higher. In dispensing doctor clinics, the figures were 15 times higher for innovator brands and 7.5 for generics. Dispensing doctors applied high markups of 50%–76% for IBs, and up to 316% for generics. Retail pharmacy markups were also high—25%–38% and 100%–140% for IBs and generics, respectively. In the public sector, where medicines are free, availability was low even for medicines on the National Essential Drugs List. For a month's treatment for peptic ulcer disease and hypertension people have to pay about a week's wages in the private sector.
Conclusions
The free market by definition does not control medicine prices, necessitating price monitoring and control mechanisms. Markups for generic products are greater than for IBs. Reducing the base price without controlling markups may increase profits for retailers and dispensing doctors without reducing the price paid by end users. To increase access and affordability, promotion of generic medicines and improved availability of medicines in the public sector are required.
Drug price and availability data were collected from West Malaysian public sector facilities, private sector retail pharmacies, and dispensing doctors. Mark-ups were higher on generic drugs than on innovator brands.
Editors' Summary
Background.
The World Health Organization has said that one-third of the people of the world cannot access the medicines they need. An important reason for this problem is that prices are often too high for people or government-funded health systems to afford. In developing countries, most people who need medicines have to pay for them out of their own pockets. Where the cost of drugs is covered by health systems, spending on medicines is a major part of the total healthcare budget. Governments use a variety of approaches to try to control the cost of drugs and make sure that essential medicines are affordable and not overpriced. According to the theory of “free market economics,” the costs of goods and services are determined by interactions between buyers and sellers and not by government intervention. However, free market economics does not work well at containing the costs of medicines, particularly new medicines, because new medicines are protected by patent law, which legally prevents others from making, using, or selling the medicine for a particular period of time. Therefore, without government intervention, there is nothing to help to push down prices.
Why Was This Study Done?
Malaysia is a middle-income country with a relatively effective public health system, but it is facing a rapid rise in drug costs. In Malaysia, medicine prices are determined by free-market economics, without any control by government. Government hospitals are expected to provide drugs free, but a substantial proportion of medicines are paid for by patients who buy them directly from private pharmacies or prescribing doctors. There is evidence that Malaysian patients have difficulties accessing the drugs they need and that cost is an important factor. Therefore, the researchers who wrote this paper wanted to examine the cost of different medicines in Malaysia, and their availability and affordability from different sources.
What Did the Researchers Do and Find?
In this research project, 48 drugs were studied, of which 28 were part of a “core list” identified by the World Health Organization as “essential drugs” on the basis of the global burden of disease. The remaining 20 reflected health care needs in Malaysia itself. The costs of each medicine were collected from government hospitals, private pharmacies, and dispensing doctors in four different regions of Malaysia. Data were collected for the “innovator brand” (made by the original patent holder) and for “generic” brands (an equivalent drug to the innovator brand, produced by a different company once the innovator brand no longer has an exclusive patent). The medicine prices were compared against international reference prices (IRP), which are the average prices offered by not-for-profit drug companies to developing countries. Finally, the researchers also compared the cost of the drugs with daily wages, in order to work out their “affordability.”
The researchers found that, irrespective of the source of medicines, prices were on average very much higher than the international reference price, ranging from 2.4 times the IRP for innovator brands accessed through public hospitals, to 16 times the IRP for innovator brands accessed through private pharmacies. The availability of medicines was also very poor, with only 25% of generic medicines available on average through the public sector. The affordability of many of the medicines studied was again very poor. For example, one month's supply of ranitidine (a drug for stomach ulcers) was equivalent to around three days' wages for a low-paid government worker, and one month's supply of fluoxetine (an antidepressant) would cost around 26 days' wages.
What Do These Findings Mean?
These results show that essential drugs are very expensive in Malaysia and are not universally available. Many people would not be able to pay for essential medicines. The cost of medicines in Malaysia seems to be much higher than in areas of India and Sri Lanka, although the researchers did not attempt to collect data in order to carry out an international comparison. It is possible that the high cost and low availability in Malaysia are the result of a lack of government regulation. Overall, the findings suggest that the government should set up mechanisms to prevent drug manufacturers from increasing prices too much and thus ensure greater access to essential medicines.
Additional Information.
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.0040082.
Read a related PLoS Medicine Perspective article by Suzanne Hill
Information is available from the World Health Organization on Improving Access to Medicines
Information on medicine prices is available from Health Action International
Wikipedia has an entry on Patent (a type of intellectual property that is normally used to prevent other companies from selling a newly invented medicine). (Wikipedia is an internet encyclopedia anyone can edit.)
The Drugs for Neglected Diseases Initiative is an international collaboration between public organizations that aims to develop drugs for people suffering from neglected diseases
doi:10.1371/journal.pmed.0040082
PMCID: PMC1831730  PMID: 17388660
2.  Evolution of Antiretroviral Drug Costs in Brazil in the Context of Free and Universal Access to AIDS Treatment  
PLoS Medicine  2007;4(11):e305.
Background
Little is known about the long-term drug costs associated with treating AIDS in developing countries. Brazil's AIDS treatment program has been cited widely as the developing world's largest and most successful AIDS treatment program. The program guarantees free access to highly active antiretroviral therapy (HAART) for all people living with HIV/AIDS in need of treatment. Brazil produces non-patented generic antiretroviral drugs (ARVs), procures many patented ARVs with negotiated price reductions, and recently issued a compulsory license to import one patented ARV. In this study, we investigate the drivers of recent ARV cost trends in Brazil through analysis of drug-specific prices and expenditures between 2001 and 2005.
Methods and Findings
We compared Brazil's ARV prices to those in other low- and middle-income countries. We analyzed trends in drug expenditures for HAART in Brazil from 2001 to 2005 on the basis of cost data disaggregated by each ARV purchased by the Brazilian program. We decomposed the overall changes in expenditures to compare the relative impacts of changes in drug prices and drug purchase quantities. We also estimated the excess costs attributable to the difference between prices for generics in Brazil and the lowest global prices for these drugs. Finally, we estimated the savings attributable to Brazil's reduced prices for patented drugs. Negotiated drug prices in Brazil are lowest for patented ARVs for which generic competition is emerging. In recent years, the prices for efavirenz and lopinavir–ritonavir (lopinavir/r) have been lower in Brazil than in other middle-income countries. In contrast, the price of tenofovir is US$200 higher per patient per year than that reported in other middle-income countries. Despite precipitous price declines for four patented ARVs, total Brazilian drug expenditures doubled, to reach US$414 million in 2005. We find that the major driver of cost increases was increased purchase quantities of six specific drugs: patented lopinavir/r, efavirenz, tenofovir, atazanavir, enfuvirtide, and a locally produced generic, fixed-dose combination of zidovudine and lamivudine (AZT/3TC). Because prices declined for many of the patented drugs that constitute the largest share of drug costs, nearly the entire increase in overall drug expenditures between 2001 and 2005 is attributable to increases in drug quantities. Had all drug quantities been held constant from 2001 until 2005 (or for those drugs entering treatment guidelines after 2001, held constant between the year of introduction and 2005), total costs would have increased by only an estimated US$7 million. We estimate that in the absence of price declines for patented drugs, Brazil would have spent a cumulative total of US$2 billion on drugs for HAART between 2001 and 2005, implying a savings of US$1.2 billion from price declines. Finally, in comparing Brazilian prices for locally produced generic ARVs to the lowest international prices meeting global pharmaceutical quality standards, we find that current prices for Brazil's locally produced generics are generally much higher than corresponding global prices, and note that these prices have risen in Brazil while declining globally. We estimate the excess costs of Brazil's locally produced generics totaled US$110 million from 2001 to 2005.
Conclusions
Despite Brazil's more costly generic ARVs, the net result of ARV price changes has been a cost savings of approximately US$1 billion since 2001. HAART costs have nevertheless risen steeply as Brazil has scaled up treatment. These trends may foreshadow future AIDS treatment cost trends in other developing countries as more people start treatment, AIDS patients live longer and move from first-line to second and third-line treatment, AIDS treatment becomes more complex, generic competition emerges, and newer patented drugs become available. The specific application of the Brazilian model to other countries will depend, however, on the strength of their health systems, intellectual property regulations, epidemiological profiles, AIDS treatment guidelines, and differing capacities to produce drugs locally.
Amy Nunn and colleagues analyze the cost of antiretroviral drugs in Brazil between 2001 and 2005 and discuss the implications for HIV treatment in other developing countries.
Editors' Summary
Background.
Acquired immunodeficiency syndrome (AIDS) has killed 29 million people since the first case occurred in 1981 and an estimated 40 million people live with HIV/AIDS today. AIDS is caused by the human immunodeficiency virus (HIV), which destroys the immune system. Infected individuals are consequently very susceptible to other infections. Early in the AIDS epidemic, most HIV-positive individuals died within a few years of becoming infected. Then, in 1996, highly active antiretroviral therapy (HAART)—a cocktail of antiretroviral drugs (ARVs)—was developed. For people who could afford HAART (which holds HIV infections in check), AIDS became a chronic disease. People who start HAART must keep taking it or their illness will progress.
Unfortunately, few people in low- and middle-income countries could afford these expensive drugs. In 2001, ARV prices fell in developing countries as AIDS activists and developing country governments challenged pharmaceutical companies about ARV prices, pharmaceutical companies set tiered prices for the low- and middle-income countries and more generic (inexpensive copies of brand-named drugs) ARVs became available. In 2003, the lack of access to HIV/AIDS treatment was declared a global health emergency. Governments, international organizations, and funding bodies began to set targets and provide funds to increase access to HAART in developing countries. By 2007, over 2 million people in low- and middle-income countries had access to HAART, but another 5 million remain in urgent need of drugs for treatment.
Why Was This Study Done?
In 1995, many countries in the world signed the World Trade Organization (WTO) Trade-Related Aspects of Intellectual Property (TRIPS) agreement, which requires countries to acknowledge intellectual property rights for many products, including pharmaceuticals. In 1996, Brazil became the first developing country to commit to and implement policies to provide free and universal access to HAART. Since then, Brazil's successful AIDS treatment program has become a model for the developing world, and 180,000 Brazilians were receiving HAART at the end of 2006. However, as a WTO member that signed on to the TRIPS agreement, Brazil was required to recognize the intellectual property rights of pharmaceutical companies' patented ARVs. As Brazil scaled up treatment in the late 1990s, the cost of treating AIDS patients rose quickly and the country took controversial public policy steps to reduce the cost of providing HAART to people living with HIV/AIDS. Brazil produces several non-patented ARVs locally, and since 2001 has challenged multinational pharmaceutical companies about the prices of patented ARVs. To induce price reductions for patented ARVs, Brazil has threatened to issue compulsory licenses (which under WTO terms allow countries facing a health emergency to produce patented drugs without consent of the company holding the patent). Brazil also recently issued a compulsory license for one ARV.
Although world leaders have set a target of universal access to HAART by 2010, little is known about the long-term costs of AIDS treatment in developing countries. In this study, the researchers have investigated how and why the costs of ARVs changed in Brazil between 2001 and 2005 and discuss the relevance of the Brazilian model for AIDS treatment for other resource-limited settings.
What Did the Researchers Do and Find?
The researchers analyzed the prices for each ARV recommended in Brazil's therapeutic guidelines for adults and estimated the changes in purchase quantities for each between 2001 and 2005. These changes likely stem from the growing number of options in Brazil's treatment guidelines, the steadily rising number of patients commencing treatment, and patients' shifts to second- and third-line treatments when their HIV infection became resistant to first-line drugs or they developed side effects. The researchers report that the generic drugs produced in Brazil were generally more expensive than similar drugs made elsewhere, but Brazil's negotiated drug prices for many patented ARVs were lower than elsewhere. Overall, total annual drug expenditure on ARVs doubled between 2001 and 2005, reaching US$414 million in 2005. Because many drug prices fell sharply as a result of declining patented drug prices over the study period, this increase was mainly attributable to increases in drug quantities purchased. If these quantities had stayed constant, the total annual cost would have increased by only $7 million, to $211 million. Conversely, without the decrease in the price of patented drugs, Brazil would have spent $952 million annually by 2005. If Brazil had enjoyed the lowest global prices for generic medicines, the total costs per year in 2005 would have been $367 million, or nearly $50 million less than the costs Brazil actually realized.
What Do These Findings Mean?
These findings tease out the many factors—clinical, commercial, and political—that affected the total costs of the Brazilian AIDS treatment program between 2001 and 2005.
Brazil's ability to produce generic drugs facilitated Brazil's price negotiations for patented drugs. Although Brazil saved approximately US$1 billion over the study period as a result of declining prices for patented medicines, the cost of producing generic drugs locally has risen while the prices for generic drugs have fallen elsewhere. Brazil's recent decision to import a generic ARV using a compulsory license suggests that the Brazilian model for AIDS treatment continues to evolve.
Questions remain about the precise causes of year-to-year cost trends in Brazil because, for example, the researchers did not have full data on when patients switched from first-line to second- or third-line drugs. The observed steep rise in costs from 2004 to 2005 in particular warrants further analysis. In addition, the findings may not be generalizable to countries with different policies on HIV/AIDS treatment, different access to generic drugs, or different bargaining power with multinational drug companies. Nevertheless, the trends this study highlights provide important information about how AIDS treatment costs are likely to evolve in other developing countries as efforts are made to provide universal access to life-saving ARVs.
Additional Information.
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.0040305.
Information from the US National Institute of Allergy and Infectious Diseases on HIV infection and AIDS
Information from the US Centers for Disease Control and Prevention on global HIV/AIDS topics (in English and Spanish)
HIV InSite, comprehensive and up-to-date information on all aspects of HIV/AIDS from the University of California San Francisco
Information from Avert, an international AIDS charity, on HIV and AIDS in Brazil and on HIV/AIDS treatment and care, including universal access to ARVs
Progress towards universal access to HIV/AIDS treatment, the latest report from the World Health Organization (available in several languages)
The National STD and AIDS Program of Brazil
doi:10.1371/journal.pmed.0040305
PMCID: PMC2071936  PMID: 18001145
3.  Trends in Compulsory Licensing of Pharmaceuticals Since the Doha Declaration: A Database Analysis 
PLoS Medicine  2012;9(1):e1001154.
Reed Beall and Randall Kuhn describe their findings from an analysis of use of compulsory licenses for pharmaceutical products by World Trade Organization members since 1995.
Background
It is now a decade since the World Trade Organization (WTO) adopted the “Declaration on the TRIPS Agreement and Public Health” at its 4th Ministerial Conference in Doha. Many anticipated that these actions would lead nations to claim compulsory licenses (CLs) for pharmaceutical products with greater regularity. A CL is the use of a patented innovation that has been licensed by a state without the permission of the patent title holder. Skeptics doubted that many CLs would occur, given political pressure against CL activity and continued health system weakness in poor countries. The subsequent decade has seen little systematic assessment of the Doha Declaration's impact.
Methods and Findings
We assembled a database of all episodes in which a CL was publically entertained or announced by a WTO member state since 1995. Broad searches of CL activity were conducted using media, academic, and legal databases, yielding 34 potential CL episodes in 26 countries. Country- and product-specific searches were used to verify government participation, resulting in a final database of 24 verified CLs in 17 nations. We coded CL episodes in terms of outcome, national income, and disease group over three distinct periods of CL activity. Most CL episodes occurred between 2003 and 2005, involved drugs for HIV/AIDS, and occurred in upper-middle-income countries (UMICs). Aside from HIV/AIDS, few CL episodes involved communicable disease, and none occurred in least-developed or low-income countries.
Conclusions
Given skepticism about the Doha Declaration's likely impact, we note the relatively high occurrence of CLs, yet CL activity has diminished markedly since 2006. While UMICs have high CL activity and strong incentives to use CLs compared to other countries, we note considerable countervailing pressures against CL use even in UMICs. We conclude that there is a low probability of continued CL activity. We highlight the need for further systematic evaluation of global health governance actions.
Please see later in the article for the Editors' Summary
Editors' Summary
Background
The development of a new drug is a time-consuming and expensive process. To stimulate investment in drug development, the creators of new drugs (including the pharmaceutical companies that undertake the development and testing that is needed before any drug can be used in patients) can apply for “intellectual property rights” (a patent). Intellectual property rights protect the investments made by companies during drug development by preventing other companies from making the new drug for a fixed period of time and by providing a means by which creators of new drugs can negotiate payment from other companies for the use of their creation. Until recently, the extent and enforcement of intellectual property rights varied widely around the world. Then, in 1995, the World Trade Organization (WTO) was established. By providing a set of ground rules for trade among nations, the WTO aims to ensure that trade flows as smoothly, predictably, and freely as possible around the world. One of the founding documents of the WTO is the Agreement on Trade-Related Aspects of Intellectual Property Rights (TRIPS Agreement), which attempts to bring the protection of intellectual property rights (including patents) under common international rules.
Why Was This Study Done?
Unfortunately, patent protection for drugs (pharmaceuticals) means that many medicines are too expensive for use in developing countries. While maintaining incentives for drug development, the TRIPS Agreement allows governments to license the use of patented inventions to someone else without the consent of the patent owner. Such “compulsory licensing” normally occurs only after negotiations for a voluntary license have failed, and the patent owner still receives an appropriate payment. It soon became clear that some governments were unsure of their right to use compulsory licensing and other flexibilities in the TRIPS Agreement, a situation likely to affect public health in poor countries by hindering universal access to medicines. Consequently, the WTO issued the “Declaration on the TRIPS Agreement and Public Health” at its 4th Ministerial Conference in Doha in November 2001. Reaction to the Doha Declaration, which reaffirms that the “TRIPS Agreement does not and should not prevent members from taking measures to protect public health,” has been mixed. Some experts predicted that it would increase compulsory licensing of pharmaceuticals, but others suggested that political pressure against compulsory licensing and health system weaknesses in poor countries would limit claims for compulsory licenses. In this database analysis, the researchers systematically assess the impact of the Doha Declaration on the compulsory licensing of pharmaceuticals.
What Did the Researchers Do and Find?
By systematically searching media archives for reports of WTO member states considering or announcing compulsory licensing of pharmaceuticals, the researchers identified 24 verified compulsory licensing episodes in 17 nations that occurred between January 1995 and June 2011. Half of these episodes ended with an announcement of a compulsory license, and the majority ended in a price reduction for a specific pharmaceutical product for the potential issuing nation through a compulsory license, a voluntary license, or a negotiated discount. Sixteen of the compulsory licensing episodes involved drugs for HIV/AIDS, four involved drugs for other communicable diseases, and four involved drugs for non-communicable diseases such as cancer. More than half the compulsory licensing episodes occurred in upper-middle-income countries (including Brazil and Thailand). Finally, most compulsory licensing episodes occurred between 2003 and 2005. There was a smaller peak of activity in the months leading up to the Doha conference, but after 2006 activity declined substantially.
What Do These Findings Mean?
Given these findings, the researchers suggest that the Doha Declaration is unlikely to have an important long-term impact on the use of compulsory licensing or on access to pharmaceuticals for communicable diseases other than HIV/AIDS in developing and low-income countries. Most notably, the researchers found no evidence of a spike in compulsory licensing episodes immediately after the Doha Declaration, and they note that the lagged spike that occurred between 2003 and 2005 could have resulted in large part from the global antiretroviral advocacy campaign. Moreover, compulsory licensing activity has diminished greatly since 2006. Thus, the researchers conclude, health advocates who pushed for the Doha Declaration reforms have had little success in engaging trade as a positive, proactive force for addressing health gaps.
Additional Information
Please access these websites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001154.
The World Trade Organization provides information on intellectual property rights, on the TRIPS Agreement, on TRIPS and pharmaceutical patents, and on compulsory licensing of pharmaceuticals and TRIPS (in English, French, and Spanish); the Doha Declaration on the TRIPS Agreement and Public Health is also available
The World Health Organization provides information on the Doha Declaration on the TRIPS Agreement and Public Health and an analysis of the implications of the Doha Declaration
Wikipedia has pages on intellectual property rights, on the TRIPS Agreement, and on the Doha Declaration (note: Wikipedia is a free online encyclopedia that anyone can edit; available in several languages)
doi:10.1371/journal.pmed.1001154
PMCID: PMC3254665  PMID: 22253577
4.  Reinterpreting Ethnic Patterns among White and African American Men Who Inject Heroin: A Social Science of Medicine Approach 
PLoS Medicine  2006;3(10):e452.
Background
Street-based heroin injectors represent an especially vulnerable population group subject to negative health outcomes and social stigma. Effective clinical treatment and public health intervention for this population requires an understanding of their cultural environment and experiences. Social science theory and methods offer tools to understand the reasons for economic and ethnic disparities that cause individual suffering and stress at the institutional level.
Methods and Findings
We used a cross-methodological approach that incorporated quantitative, clinical, and ethnographic data collected by two contemporaneous long-term San Francisco studies, one epidemiological and one ethnographic, to explore the impact of ethnicity on street-based heroin-injecting men 45 years of age or older who were self-identified as either African American or white. We triangulated our ethnographic findings by statistically examining 14 relevant epidemiological variables stratified by median age and ethnicity. We observed significant differences in social practices between self-identified African Americans and whites in our ethnographic social network sample with respect to patterns of (1) drug consumption; (2) income generation; (3) social and institutional relationships; and (4) personal health and hygiene. African Americans and whites tended to experience different structural relationships to their shared condition of addiction and poverty. Specifically, this generation of San Francisco injectors grew up as the children of poor rural to urban immigrants in an era (the late 1960s through 1970s) when industrial jobs disappeared and heroin became fashionable. This was also when violent segregated inner city youth gangs proliferated and the federal government initiated its “War on Drugs.” African Americans had earlier and more negative contact with law enforcement but maintained long-term ties with their extended families. Most of the whites were expelled from their families when they began engaging in drug-related crime. These historical-structural conditions generated distinct presentations of self. Whites styled themselves as outcasts, defeated by addiction. They professed to be injecting heroin to stave off “dopesickness” rather than to seek pleasure. African Americans, in contrast, cast their physical addiction as an oppositional pursuit of autonomy and pleasure. They considered themselves to be professional outlaws and rejected any appearance of abjection. Many, but not all, of these ethnographic findings were corroborated by our epidemiological data, highlighting the variability of behaviors within ethnic categories.
Conclusions
Bringing quantitative and qualitative methodologies and perspectives into a collaborative dialog among cross-disciplinary researchers highlights the fact that clinical practice must go beyond simple racial or cultural categories. A clinical social science approach provides insights into how sociocultural processes are mediated by historically rooted and institutionally enforced power relations. Recognizing the logical underpinnings of ethnically specific behavioral patterns of street-based injectors is the foundation for cultural competence and for successful clinical relationships. It reduces the risk of suboptimal medical care for an exceptionally vulnerable and challenging patient population. Social science approaches can also help explain larger-scale patterns of health disparities; inform new approaches to structural and institutional-level public health initiatives; and enable clinicians to take more leadership in changing public policies that have negative health consequences.
Bourgois and colleagues found that the African American and white men in their study had a different pattern of drug use and risk behaviors, adopted different strategies for survival, and had different personal histories.
Editors' Summary
Background.
There are stark differences in the health of different ethnic groups in America. For example, the life expectancy for white men is 75.4 years, but it is only 69.2 years for African-American men. The reasons behind these disparities are unclear, though there are several possible explanations. Perhaps, for example, different ethnic groups are treated differently by health professionals (with some groups receiving poorer quality health care). Or maybe the health disparities are due to differences across ethnic groups in income level (we know that richer people are healthier). These disparities are likely to persist unless we gain a better understanding of how they arise.
Why Was This Study Done?
The researchers wanted to study the health of a very vulnerable community of people: heroin users living on the streets in the San Francisco Bay Area. The health status of this community is extremely poor, and its members are highly stigmatized—including by health professionals themselves. The researchers wanted to know whether African American men and white men who live on the streets have a different pattern of drug use, whether they adopt varying strategies for survival, and whether they have different personal histories. Knowledge of such differences would help the health community to provide more tailored and culturally appropriate interventions. Physicians, nurses, and social workers often treat street-based drug users, especially in emergency rooms and free clinics. These health professionals regularly report that their interactions with street-based drug users are frustrating and confrontational. The researchers hoped that their study would help these professionals to have a better understanding of the cultural backgrounds and motivations of their drug-using patients.
What Did the Researchers Do and Find?
Over the course of six years, the researchers directly observed about 70 men living on the streets who injected heroin as they went about their usual lives (this type of research is called “participant observation”). The researchers specifically looked to see whether there were differences between the white and African American men. All the men gave their consent to be studied in this way and to be photographed. The researchers also studied a database of interviews with almost 7,000 injection drug users conducted over five years, drawing out the data on differences between white and African men. The researchers found that the white men were more likely to supplement their heroin use with inexpensive fortified wine, while African American men were more likely to supplement heroin with crack. Most of the white men were expelled from their families when they began engaging in drug-related crime, and these men tended to consider themselves as destitute outcasts. African American men had earlier and more negative contact with law enforcement but maintained long-term ties with their extended families, and these men tended to consider themselves as professional outlaws. The white men persevered less in attempting to find a vein in which to inject heroin, and so were more likely to inject the drug directly under the skin—this meant that they were more likely to suffer from skin abscesses. The white men generated most of their income from panhandling (begging for money), while the African American men generated most of their income through petty crime and/or through offering services such as washing car windows at gas stations.
What Do These Findings Mean?
Among street-based heroin users, there are important differences between white men and African American men in the type of drugs used, the method of drug use, their social backgrounds, the way in which they identify themselves, and the health risks that they take. By understanding these differences, health professionals should be better placed to provide tailored and appropriate care when these men present to clinics and emergency rooms. As the researchers say, “understanding of different ethnic populations of drug injectors may reduce difficult clinical interactions and resultant physician frustration while improving patient access and adherence to care.” One limitation of this study is that the researchers studied one specific community in one particular area of the US—so we should not assume that their findings would apply to street-based heroin users elsewhere.
Additional Information.
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.0030452.
The US Centers for Disease Control (CDC) has a web page on HIV prevention among injection drug users
The World Health Organization has collected documents on reducing the risk of HIV in injection drug users and on harm reduction approaches
The International Harm Reduction Association has information relevant to a global audience on reducing drug-related harm among individuals and communities
US-focused information on harm reduction is available via the websites of the Harm Reduction Coalition and the Chicago Recovery Alliance
Canada-focused information can be found at the Street Works Web site
The Harm Reduction Journal publishes open-access articles
The CDC has a web page on eliminating racial and ethnic health disparities
The Drug Policy Alliance has a web page on drug policy in the United States
doi:10.1371/journal.pmed.0030452
PMCID: PMC1621100  PMID: 17076569
5.  Representation and Misrepresentation of Scientific Evidence in Contemporary Tobacco Regulation: A Review of Tobacco Industry Submissions to the UK Government Consultation on Standardised Packaging 
PLoS Medicine  2014;11(3):e1001629.
Selda Ulucanlar and colleagues analyze submissions by two tobacco companies to the UK government consultation on standardized packaging.
Please see later in the article for the Editors' Summary
Background
Standardised packaging (SP) of tobacco products is an innovative tobacco control measure opposed by transnational tobacco companies (TTCs) whose responses to the UK government's public consultation on SP argued that evidence was inadequate to support implementing the measure. The government's initial decision, announced 11 months after the consultation closed, was to wait for ‘more evidence’, but four months later a second ‘independent review’ was launched. In view of the centrality of evidence to debates over SP and TTCs' history of denying harms and manufacturing uncertainty about scientific evidence, we analysed their submissions to examine how they used evidence to oppose SP.
Methods and Findings
We purposively selected and analysed two TTC submissions using a verification-oriented cross-documentary method to ascertain how published studies were used and interpretive analysis with a constructivist grounded theory approach to examine the conceptual significance of TTC critiques. The companies' overall argument was that the SP evidence base was seriously flawed and did not warrant the introduction of SP. However, this argument was underpinned by three complementary techniques that misrepresented the evidence base. First, published studies were repeatedly misquoted, distorting the main messages. Second, ‘mimicked scientific critique’ was used to undermine evidence; this form of critique insisted on methodological perfection, rejected methodological pluralism, adopted a litigation (not scientific) model, and was not rigorous. Third, TTCs engaged in ‘evidential landscaping’, promoting a parallel evidence base to deflect attention from SP and excluding company-held evidence relevant to SP. The study's sample was limited to sub-sections of two out of four submissions, but leaked industry documents suggest at least one other company used a similar approach.
Conclusions
The TTCs' claim that SP will not lead to public health benefits is largely without foundation. The tools of Better Regulation, particularly stakeholder consultation, provide an opportunity for highly resourced corporations to slow, weaken, or prevent public health policies.
Please see later in the article for the Editors' Summary
Editors' Summary
Background
Every year, about 6 million people die from tobacco-related diseases and, if current trends continue, annual tobacco-related deaths will increase to more than 8 million by 2030. To reduce this loss of life, national and international bodies have drawn up various conventions and directives designed to implement tobacco control measures such as the adoption of taxation policies aimed at reducing tobacco consumption and bans on tobacco advertising, promotion, and sponsorship. One innovative but largely unused tobacco control measure is standardised packaging of tobacco products. Standardised packaging aims to prevent the use of packaging as a marketing tool by removing all brand imagery and text (other than name) and by introducing packs of a standard shape and colour that include prominent pictorial health warnings. Standardised packaging was first suggested as a tobacco control measure in 1986 but has been consistently opposed by the tobacco industry.
Why Was This Study Done?
The UK is currently considering standardised packaging of tobacco products. In the UK, Better Regulation guidance obliges officials to seek the views of stakeholders, including corporations, on the government's cost and benefit estimates of regulatory measures such as standardised packaging and on the evidence underlying these estimates. In response to a public consultation about standardised packaging in July 2013, which considered submissions from several transnational tobacco companies (TTCs), the UK government announced that it would wait for the results of the standardised packaging legislation that Australia adopted in December 2012 before making its final decision about this tobacco control measure. Parliamentary debates and media statements have suggested that doubt over the adequacy of the evidence was the main reason for this ‘wait and see’ decision. Notably, TTCs have a history of manufacturing uncertainty about the scientific evidence related to the harms of tobacco. Given the centrality of evidence to the debate about standardised packaging, in this study, the researchers analyse submissions made by two TTCs, British American Tobacco (BAT) and Japan Tobacco International (JTI), to the first UK consultation on standardised packaging (a second review is currently underway and will report shortly) to examine how TTCs used evidence to oppose standardised packaging.
What Did the Researchers Do and Find?
The researchers analysed sub-sections of two of the four TTC submissions (those submitted by BAT and JTI) made to the public consultation using verification-oriented cross-documentary analysis, which compared references made to published sources with the original sources to ascertain how these sources had been used, and interpretative analysis to examine the conceptual significance of TTC critiques of the evidence on standardised packaging. The researchers report that the companies' overall argument was that the evidence base in support of standardised packaging was seriously flawed and did not warrant the introduction of such packaging. The researchers identified three ways in which the TTC reports misrepresented the evidence base. First, the TTCs misquoted published studies, thereby distorting the main messages of these studies. For example, the TTCs sometimes omitted important qualifying information when quoting from published studies. Second, the TTCs undermined evidence by employing experts to review published studies for methodological rigor and value in ways that did not conform to normal scientific critique approaches (‘mimicked scientific critique’). So, for example, the experts considered each piece of evidence in isolation for its ability to support standardised packaging rather than considering the cumulative weight of the evidence. Finally, the TTCs engaged in ‘evidential landscaping’. That is, they promoted research that deflected attention from standardised packaging (for example, research into social explanations of smoking behaviour) and omitted internal industry research on the role of packaging in marketing.
What Do These Findings Mean?
These findings suggest that the TTC critique of the evidence in favour of standardised packaging that was presented to the UK public consultation on this tobacco control measure is highly misleading. However, because the researchers' analysis only considered subsections of the submissions from two TTCs, these findings may not be applicable to the other submissions or to other TTCs. Moreover, their analysis only considered the efforts made by TTCs to influence public health policy and not the effectiveness of these efforts. Nevertheless, these findings suggest that the claim of TTCs that standardised packaging will not lead to public health benefits is largely without foundation. More generally, these findings highlight the possibility that the tools of Better Regulation, particularly stakeholder consultation, provide an opportunity for wealthy corporations to slow, weaken, or prevent the implementation of public health policies.
Additional Information
Please access these websites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001629.
The World Health Organization provides information about the dangers of tobacco (in several languages) and an article about first experiences with Australia's tobacco plain packaging law; for information about the tobacco industry's influence on policy, see the 2009 World Health Organization report ‘Tobacco industry interference with tobacco control’
A UK parliamentary briefing on standardised packaging of tobacco products, a press release about the consultation, and a summary report of the consultation are available; the ideas behind the UK's Better Regulation guidance are described in a leaflet produced by the Better Regulation Task Force
Cancer Research UK (CRUK) has a web page with information on standardised packaging and includes videos
Wikipedia has a page on standardised packaging of tobacco products (note: Wikipedia is a free online encyclopaedia that anyone can edit; available in several languages)
The UK Centre for Tobacco Control Studies is a network of UK universities that undertakes original research, policy development, advocacy, and teaching and training in the field of tobacco control
TobaccoTactics.org, an online resource managed by the University of Bath, provides up-to-date information on the tobacco industry and the tactics it uses to influence tobacco regulation
SmokeFree, a website provided by the UK National Health Service, offers advice on quitting smoking and includes personal stories from people who have stopped smoking
Smokefree.gov, from the US National Cancer Institute, offers online tools and resources to help people quit smoking
doi:10.1371/journal.pmed.1001629
PMCID: PMC3965396  PMID: 24667150
6.  Proceedings of the 3rd IPLeiria’s International Health Congress 
Tomás, Catarina Cardoso | Oliveira, Emanuel | Sousa, D. | Uba-Chupel, M. | Furtado, G. | Rocha, C. | Teixeira, A. | Ferreira, P. | Alves, Celeste | Gisin, Stefan | Catarino, Elisabete | Carvalho, Nelma | Coucelo, Tiago | Bonfim, Luís | Silva, Carina | Franco, Débora | González, Jesús Alcoba | Jardim, Helena G. | Silva, Rita | Baixinho, Cristina L. | Presado, Mª Helena | Marques, Mª Fátima | Cardoso, Mário E. | Cunha, Marina | Mendes, Joana | Xavier, Ana | Galhardo, Ana | Couto, Margarida | Frade, João G. | Nunes, Carla | Mesquita, João R. | Nascimento, Maria S. | Gonçalves, Guilherme | Castro, Conceição | Mártires, Alice | Monteiro, Mª João | Rainho, Conceição | Caballero, Francisco P. | Monago, Fatima M. | Guerrero, Jose T. | Monago, Rocio M. | Trigo, Africa P. | Gutierrez, Milagros L. | Milanés, Gemma M. | Reina, Mercedes G. | Villanueva, Ana G. | Piñero, Ana S. | Aliseda, Isabel R. | Ramirez, Francisco B. | Ribeiro, Andrea | Quelhas, Ana | Manso, Conceição | Caballero, Francisco P. | Guerrero, Jose T. | Monago, Fatima M. | Santos, Rafael B. | Jimenez, Nuria R. | Nuñez, Cristina G. | Gomez, Inmaculada R. | Fernandez, Mª Jose L. | Marquez, Laura A. | Moreno, Ana L. | Huertas, Mª Jesus Tena | Ramirez, Francisco B. | Seabra, Daniel | Salvador, Mª Céu | Braga, Luciene | Parreira, Pedro | Salgueiro-Oliveira, Anabela | Arreguy-Sena, Cristina | Oliveira, Bibiana F. | Henriques, Mª Adriana | Santos, Joana | Lebre, Sara | Marques, Alda | Festas, Clarinda | Rodrigues, Sandra | Ribeiro, Andrea | Lumini, José | Figueiredo, Ana G. | Hernandez-Martinez, Francisco J. | Campi, Liliana | Quintana-Montesdeoca, Mª Pino | Jimenez-Diaz, Juan F. | Rodriguez-De-Vera, Bienvenida C. | Parente, Alexandra | Mata, Mª Augusta | Pereira, Ana Mª | Fernandes, Adília | Brás, Manuel | Pinto, Mª Rosário | Parreira, Pedro | Basto, Marta L. | Rei, Ana C. | Mónico, Lisete M. | Sousa, Gilberta | Morna, Clementina | Freitas, Otília | Freitas, Gregório | Jardim, Ana | Vasconcelos, Rita | Horta, Lina G. | Rosa, Roger S. | Kranz, Luís F. | Nugem, Rita C. | Siqueira, Mariana S. | Bordin, Ronaldo | Kniess, Rosiane | Lacerda, Josimari T. | Guedes, Joana | Machado, Idalina | Almeida, Sidalina | Zilhão, Adriano | Alves, Helder | Ribeiro, Óscar | Amaral, Ana P. | Santos, Ana | Monteiro, Joana | Rocha, Mª Clara | Cruz, Rui | Amaral, Ana P. | Lourenço, Marina | Rocha, Mª Clara | Cruz, Rui | Antunes, Sandra | Mendonça, Verónica | Andrade, Isabel | Osório, Nádia | Valado, Ana | Caseiro, Armando | Gabriel, António | Martins, Anabela C. | Mendes, Fernando | Cabral, Lídia | Ferreira, Manuela | Gonçalves, Amadeu | Luz, Tatiana D. | Luz, Leonardo | Martins, Raul | Morgado, Alice | Vale-Dias, Maria L. | Porta-Nova, Rui | Fleig, Tânia C. | Reuter, Éboni M. | Froemming, Miriam B. | Guerreiro, Sabrina L. | Carvalho, Lisiane L. | Guedelha, Daniel | Coelho, P. | Pereira, A. | Calha, António | Cordeiro, Raul | Gonçalves, Ana | Certo, Ana | Galvão, Ana | Mata, Mª Augusta | Welter, Aline | Pereira, Elayne | Ribeiro, Sandra | Kretzer, Marcia | Jiménez-Díaz, Juan-Fernando | Jiménez-Rodríguez, Carla | Hernández-Martínez, Francisco-José | Rodríguez-De-Vera, Bienvenida-Del-Carmen | Marques-Rodrigues, Alexandre | Coelho, Patrícia | Bernardes, Tiago | Pereira, Alexandre | Sousa, Patrícia | Filho, João G. | Nazario, Nazare | Kretzer, Marcia | Amaral, Odete | Garrido, António | Veiga, Nélio | Nunes, Carla | Pedro, Ana R. | Pereira, Carlos | Almeia, António | Fernandes, Helder M. | Vasconcelos, Carlos | Sousa, Nelson | Reis, Victor M. | Monteiro, M. João | Mendes, Romeu | Pinto, Isabel C. | Pires, Tânia | Gama, João | Preto, Vera | Silva, Norberto | Magalhães, Carlos | Martins, Matilde | Duarte, Mafalda | Paúl, Constança | Martín, Ignácio | Pinheiro, Arminda A. | Xavier, Sandra | Azevedo, Julieta | Bento, Elisabete | Marques, Cristiana | Marques, Mariana | Macedo, António | Pereira, Ana T. | Almeida, José P. | Almeida, António | Alves, Josiane | Sousa, Nelson | Saavedra, Francisco | Mendes, Romeu | Maia, Ana S. | Oliveira, Michelle T. | Sousa, Anderson R. | Ferreira, Paulo P. | Lopes, Luci S. | Santiago, Eujcely C. | Monteiro, Sílvia | Jesus, Ângelo | Colaço, Armanda | Carvalho, António | Silva, Rita P. | Cruz, Agostinho | Ferreira, Ana | Marques, Catarina | Figueiredo, João P. | Paixão, Susana | Ferreira, Ana | Lopes, Carla | Moreira, Fernando | Figueiredo, João P. | Ferreira, Ana | Ribeiro, Diana | Moreira, Fernando | Figueiredo, João P. | Paixão, Susana | Fernandes, Telma | Amado, Diogo | Leal, Jéssica | Azevedo, Marcelo | Ramalho, Sónia | Mangas, Catarina | Ribeiro, Jaime | Gonçalves, Rita | Nunes, Amélia F | Tuna, Ana R. | Martins, Carlos R. | Forte, Henriqueta D. | Costa, Cláudia | Tenedório, José A. | Santana, Paula | Andrade, J. A. | Pinto, J. L. | Campofiorito, C. | Nunes, S. | Carmo, A. | Kaliniczenco, A. | Alves, B. | Mendes, F. | Jesus, C. | Fonseca, F. | Gehrke, F. | Albuquerque, Carlos | Batista, Rita | Cunha, Madalena | Madureira, António | Ribeiro, Olivério | Martins, Rosa | Madeira, Teresa | Peixoto-Plácido, Catarina | Santos, Nuno | Santos, Osvaldo | Bergland, Astrid | Bye, Asta | Lopes, Carla | Alarcão, Violeta | Goulão, Beatriz | Mendonça, Nuno | Nicola, Paulo | Clara, João G. | Gomes, João | Querido, Ana | Tomás, Catarina | Carvalho, Daniel | Cordeiro, Marina | Rosa, Marlene C. | Marques, Alda | Brandão, Daniela | Ribeiro, Óscar | Araújo, Lia | Paúl, Constança | Minghelli, Beatriz | Richaud, Sylvina | Mendes, Ana L. | Marta-Simões, Joana | Trindade, Inês A. | Ferreira, Cláudia | Carvalho, Teresa | Cunha, Marina | Pinto-Gouveia, José | Fernandes, Morgana C. | Rosa, Roger S. | Nugem, Rita C. | Kranz, Luís F. | Siqueira, Mariana S. | Bordin, Ronaldo | Martins, Anabela C. | Medeiros, Anabela | Pimentel, Rafaela | Fernandes, Andreia | Mendonça, Carlos | Andrade, Isabel | Andrade, Susana | Menezes, Ruth L. | Bravo, Rafael | Miranda, Marta | Ugartemendia, Lierni | Tena, José Mª | Pérez-Caballero, Francisco L. | Fuentes-Broto, Lorena | Rodríguez, Ana B. | Carmen, Barriga | Carneiro, M. A. | Domingues, J. N. | Paixão, S. | Figueiredo, J. | Nascimento, V. B. | Jesus, C. | Mendes, F | Gehrke, F. | Alves, B. | Azzalis, L. | Fonseca, F. | Martins, Ana R. | Nunes, Amélia | Jorge, Arminda | Veiga, Nélio | Amorim, Ana | Silva, André | Martinho, Liliana | Monteiro, Luís | Silva, Rafael | Coelho, Carina | Amaral, Odete | Coelho, Inês | Pereira, Carlos | Correia, André | Rodrigues, Diana | Marante, Nídia | Silva, Pedro | Carvalho, Sara | Araujo, André Rts | Ribeiro, Maximiano | Coutinho, Paula | Ventura, Sandra | Roque, Fátima | Calvo, Cristina | Reses, Manoela | Conde, Jorge | Ferreira, Ana | Figueiredo, João | Silva, David | Seiça, Luís | Soares, Raquel | Mourão, Ricardo | Kraus, Teresa | Abreu, Ana C. | Padilha, José M. | Alves, Júlia M. | Sousa, Paulino | Oliveira, Manuel | Sousa, Joana | Novais, Sónia | Mendes, Felismina | Pinto, Joana | Cruz, Joana | Marques, Alda | Duarte, Hugo | Dixe, Maria Dos Anjos | Sousa, Pedro | Cruz, Inês | Bastos, Fernanda | Pereira, Filipe | Carvalho, Francisco L. | Oliveira, Teresa T. | Raposo, Vítor R. | Rainho, Conceição | Ribeiro, José C. | Barroso, Isabel | Rodrigues, Vítor | Neves, Carmo | Oliveira, Teresa C. | Oliveira, Bárbara | Morais, Mª Carminda | Baylina, Pilar | Rodrigues, Rogério | Azeredo, Zaida | Vicente, Corália | Dias, Hélia | Sim-Sim, Margarida | Parreira, Pedro | Salgueiro-Oliveira, Anabela | Castilho, Amélia | Melo, Rosa | Graveto, João | Gomes, José | Vaquinhas, Marina | Carvalho, Carla | Mónico, Lisete | Brito, Nuno | Sarroeira, Cassilda | Amendoeira, José | Cunha, Fátima | Cândido, Anabela | Fernandes, Patrícia | Silva, Helena R. | Silva, Elsa | Barroso, Isabel | Lapa, Leila | Antunes, Cristina | Gonçalves, Ana | Galvão, Ana | Gomes, Mª José | Escanciano, Susana R. | Freitas, Maria | Parreira, Pedro | Marôco, João | Fernandes, Ana R. | Cabral, Cremilde | Alves, Samuel | Sousa, Pedro | Ferreira, António | Príncipe, Fernanda | Seppänen, Ulla-Maija | Ferreira, Margarida | Carvalhais, Maribel | Silva, Marilene | Ferreira, Manuela | Silva, Joana | Neves, Jéssica | Costa, Diana | Santos, Bruno | Duarte, Soraia | Marques, Sílvia | Ramalho, Sónia | Mendes, Isabel | Louro, Clarisse | Menino, Eva | Dixe, Maria | Dias, Sara S. | Cordeiro, Marina | Tomás, Catarina | Querido, Ana | Carvalho, Daniel | Gomes, João | Valim, Frederico C. | Costa, Joyce O. | Bernardes, Lúcia G. | Prebianchi, Helena | Rosa, Marlene Cristina | Gonçalves, Narcisa | Martins, Maria M. | Kurcgant, Paulina | Vieira, André | Bento, Sandrina | Deodato, Sérgio | Rabiais, Isabel | Reis, Laura | Torres, Ana | Soares, Sérgio | Ferreira, Margarida | Graça, Pedro | Leitão, Céu | Abreu, Renato | Bellém, Fernando | Almeida, Ana | Ribeiro-Varandas, Edna | Tavares, Ana | Frade, João G. | Henriques, Carolina | Menino, Eva | Louro, Clarisse | Jordão, Célia | Neco, Sofia | Morais, Carminda | Ferreira, Pedro | Silva, Carla R. | Brito, Alice | Silva, Antónia | Duarte, Hugo | Dixe, Maria Dos Anjos | Sousa, Pedro | Postolache, Gabriela | Oliveira, Raul | Moreira, Isabel | Pedro, Luísa | Vicente, Sónia | Domingos, Samuel | Postolache, Octavian | Silva, Darlen | Filho, João G. | Nazario, Nazare | Kretzer, Marcia | Schneider, Dulcineia | Marques, Fátima M. | Parreira, Pedro | Carvalho, Carla | Mónico, Lisete M. | Pinto, Carlos | Vicente, Sara | Breda, São João | Gomes, José H. | Melo, Rosa | Parreira, Pedro | Salgueiro, Anabela | Graveto, João | Vaquinhas, Marina | Castilho, Amélia | Jesus, Ângelo | Duarte, Nuno | Lopes, José C. | Nunes, Hélder | Cruz, Agostinho | Salgueiro-Oliveira, Anabela | Parreira, Pedro | Basto, Marta L. | Braga, Luciene M. | Ferreira, António | Araújo, Beatriz | Alves, José M. | Ferreira, Margarida | Carvalhais, Maribel | Silva, Marilene | Novais, Sónia | Sousa, Ana S. | Ferrito, Cândida | Ferreira, Pedro L. | Rodrigues, Alexandre | Ferreira, Margarida | Oliveira, Isabel | Ferreira, Manuela | Neves, Jéssica | Costa, Diana | Duarte, Soraia | Silva, Joana | Santos, Bruno | Martins, Cristina | Macedo, Ana P. | Araújo, Odete | Augusto, Cláudia | Braga, Fátima | Gomes, Lisa | Silva, Maria A. | Rosário, Rafaela | Pimenta, Luís | Carreira, Diana | Teles, Patrícia | Barros, Teresa | Tomás, Catarina | Querido, Ana | Carvalho, Daniel | Gomes, João | Cordeiro, Marina | Carvalho, Daniel | Querido, Ana | Tomás, Catarina | Gomes, João | Cordeiro, Marina | Jácome, Cristina | Marques, Alda | Capelas, Sylvie | Hall, Andreia | Alves, Dina | Lousada, Marisa | Loureiro, Mª Helena | Camarneiro, Ana | Silva, Margarida | Mendes, Aida | Pedreiro, Ana | G.Silva, Anne | Coelho, Elza S. | Melo, Flávio | Ribeiro, Fernando | Torres, Rui | Costa, Rui | Pinho, Tânia | Jácome, Cristina | Marques, Alda | Cruz, Bárbara | Seabra, Daniel | Carreiras, Diogo | Ventura, Maria | Cruz, x | Brooks, Dina | Marques, Alda | Pinto, M Rosário | Parreira, Pedro | Lima-Basto, Marta | Neves, Miguel | Mónico, Lisete M. | Bizarro, Carla | Cunha, Marina | Galhardo, Ana | Margarida, Couto | Amorim, Ana P. | Silva, Eduardo | Cruz, Susana | Padilha, José M. | Valente, Jorge | Guerrero, José T. | Caballero, Francisco P. | Santos, Rafael B. | Gonzalez, Estefania P. | Monago, Fátima M. | Ugalde, Lierni U. | Vélez, Marta M. | Tena, Maria J. | Guerrero, José T. | Bravo, Rafael | Pérez-Caballero, Francisco L. | Becerra, Isabel A. | Agudelo, Mª Elizabeth | Acedo, Guadalupe | Bajo, Roberto | Malheiro, Isabel | Gaspar, Filomena | Barros, Luísa | Furtado, Guilherme | Uba-Chupel, Mateus | Marques, Mariana | Rama, Luís | Braga, Margarida | Ferreira, José P. | Teixeira, Ana Mª | Cruz, João | Barbosa, Tiago | Simões, Ângela | Coelho, Luís | Rodrigues, Alexandre | Jiménez-Díaz, Juan-Fernando | Martinez-Hernandez, Francisco | Rodriguez-De-Vera, Bienvenida | Ferreira, Pedro | Rodrigues, Alexandrina | Ramalho, André | Petrica, João | Mendes, Pedro | Serrano, João | Santo, Inês | Rosado, António | Mendonça, Paula | Freitas, Kátia | Ferreira, Dora | Brito, António | Fernandes, Renato | Gomes, Sofia | Moreira, Fernando | Pinho, Cláudia | Oliveira, Rita | Oliveira, Ana I. | Mendonça, Paula | Casimiro, Ana P. | Martins, Patrícia | Silva, Iryna | Evangelista, Diana | Leitão, Catarina | Velosa, Fábia | Carecho, Nélio | Coelho, Luís | Menino, Eva | Dixe, Anjos | Catarino, Helena | Soares, Fátima | Gama, Ester | Gordo, Clementina | Moreira, Eliana | Midões, Cristiana | Santos, Marlene | Machado, Sara | Oliveira, Vânia P. | Santos, Marlene | Querido, Ana | Dixe, Anjos | Marques, Rita | Charepe, Zaida | Antunes, Ana | Santos, Sofia | Rosa, Marlene C. | Rosa, Marlene C. | Marques, Silvana F. | Minghelli, Beatriz | CaroMinghelli, Eulália | Luís, Mª José | Brandão, Teresa | Mendes, Pedro | Marinho, Daniel | Petrica, João | Monteiro, Diogo | Paulo, Rui | Serrano, João | Santo, Inês | Monteiro, Lina | Ramalho, Fátima | Santos-Rocha, Rita | Morgado, Sónia | Bento, Teresa | Sousa, Gilberta | Freitas, Otília | Silva, Isabel | Freitas, Gregório | Morna, Clementina | Vasconcelos, Rita | Azevedo, Tatiana | Soares, Salete | Pisco, Jacinta | Ferreira, Paulo P. | Olszewer, Efrain O. | Oliveira, Michelle T. | Sousa, Anderson R. | Maia, Ana S. | Oliveira, Sebastião T. | Santos, Erica | Oliveira, Ana I. | Maia, Carla | Moreira, Fernando | Santos, Joana | Mendes, Maria F. | Oliveira, Rita F. | Pinho, Cláudia | Barreira, Eduarda | Pereira, Ana | Vaz, Josiana A. | Novo, André | Silva, Luís D. | Maia, Bruno | Ferreira, Eduardo | Pires, Filipa | Andrade, Renato | Camarinha, Luís | Silva, Luís D. | Maia, Bruno | Ferreira, Eduardo | Pires, Filipa | Andrade, Renato | Camarinha, Luís | César, Ana F. | Poço, Mariana | Ventura, David | Loura, Raquel | Gomes, Pedro | Gomes, Catarina | Silva, Cláudia | Melo, Elsa | Lindo, João | Domingos, Joana | Mendes, Zaida | Poeta, Susana | Carvalho, Tiago | Tomás, Catarina | Catarino, Helena | Dixe, Mª Anjos | Ramalho, André | Rosado, António | Mendes, Pedro | Paulo, Rui | Garcia, Inês | Petrica, João | Rodrigues, Sandra | Meneses, Rui | Afonso, Carlos | Faria, Luís | Seixas, Adérito | Cordeiro, Marina | Granjo, Paulo | Gomes, José C. | Souza, Nelba R. | Furtado, Guilherme E. | Rocha, Saulo V. | Silva, Paula | Carvalho, Joana | Morais, Marina Ana | Santos, Sofia | Lebre, Paula | Antunes, Ana | Calha, António | Xavier, Ana | Cunha, Marina | Pinto-Gouveia, José | Alencar, Liana | Cunha, Madalena | Madureira, António | Cardoso, Ilda | Galhardo, Ana | Daniel, Fernanda | Rodrigues, Vítor | Luz, Leonardo | Luz, Tatiana | Ramos, Maurício R. | Medeiros, Dayse C. | Carmo, Bruno M. | Seabra, André | Padez, Cristina | Silva, Manuel C. | Rodrigues, António | Coelho, Patrícia | Coelho, Alexandre | Caminha, Madson | Matheus, Filipe | Mendes, Elenice | Correia, Jony | Kretzer, Marcia | Hernandez-Martinez, Francisco J. | Jimenez-Diaz, Juan F. | Rodriguez-De-Vera, Bienvendida C. | Jimenez-Rodriguez, Carla | Armas-Gonzalez, Yadira | Rodrigues, Cátia | Pedroso, Rosa | Apolinário-Hagen, Jennifer | Vehreschild, Viktor | Veloso, Milene | Magalhães, Celina | Cabral, Isabel | Ferraz, Maira | Nave, Filipe | Costa, Emília | Matos, Filomena | Pacheco, José | Dias, António | Pereira, Carlos | Duarte, João | Cunha, Madalena | Silva, Daniel | Mónico, Lisete M. | Alferes, Valentim R. | Brêda, Mª São João | Carvalho, Carla | Parreira, Pedro M. | Morais, Mª Carminda | Ferreira, Pedro | Pimenta, Rui | Boavida, José | Pinto, Isabel C. | Pires, Tânia | Silva, Catarina | Ribeiro, Maria | Viega-Branco, Maria | Pereira, Filomena | Pereira, Ana Mª | Almeida, Fabrícia M. | Estevez, Gustavo L. | Ribeiro, Sandra | Kretzer, Marcia R. | João, Paulo V. | Nogueira, Paulo | Novais, Sandra | Pereira, Ana | Carneiro, Lara | Mota, Maria | Cruz, Rui | Santiago, Luiz | Fontes-Ribeiro, Carlos | Furtado, Guilherme | Rocha, Saulo V. | Coutinho, André P. | Neto, João S. | Vasconcelos, Lélia R. | Souza, Nelba R. | Dantas, Estélio | Dinis, Alexandra | Carvalho, Sérgio | Castilho, Paula | Pinto-Gouveia, José | Sarreira-Santos, Alexandra | Figueiredo, Amélia | Medeiros-Garcia, Lurdes | Seabra, Paulo | Rodrigues, Rosa | Morais, Mª Carminda | Fernandes, Paula O. | Santiago, Conceição | Figueiredo, Mª Henriqueta | Basto, Marta L. | Guimarães, Teresa | Coelho, André | Graça, Anabela | Silva, Ana M. | Fonseca, Ana R. | Vale-Dias, Luz | Minas, Bárbara | Franco-Borges, Graciete | Simões, Cristina | Santos, Sofia | Serra, Ana | Matos, Maria | Jesus, Luís | Tavares, Ana S. | Almeida, Ana | Leitão, Céu | Varandas, Edna | Abreu, Renato | Bellém, Fernando | Trindade, Inês A. | Ferreira, Cláudia | Pinto-Gouveia, José | Marta-Simões, Joana | Amaral, Odete | Miranda, Cristiana | Guimarães, Pedro | Gonçalves, Rodrigo | Veiga, Nélio | Pereira, Carlos | Fleig, Tânia C. | San-Martin, Elisabete A. | Goulart, Cássia L. | Schneiders, Paloma B. | Miranda, Natacha F. | Carvalho, Lisiane L. | Silva, Andrea G. | Topa, Joana | Nogueira, Conceição | Neves, Sofia | Ventura, Rita | Nazaré, Cristina | Brandão, Daniela | Freitas, Alberto | Ribeiro, Óscar | Paúl, Constança | Mercê, Cristiana | Branco, Marco | Almeida, Pedro | Nascimento, Daniela | Pereira, Juliana | Catela, David | Rafael, Helga | Reis, Alcinda C. | Mendes, Ana | Valente, Ana R. | Lousada, Marisa | Sousa, Diana | Baltazar, Ana L. | Loureiro, Mª Helena | Oliveira, Ana | Aparício, José | Marques, Alda | Marques, Alda | Oliveira, Ana | Neves, Joana | Ayoub, Rodrigo | Sousa, Luís | Marques-Vieira, Cristina | Severino, Sandy | José, Helena | Cadorio, Inês | Lousada, Marisa | Cunha, Marina | Andrade, Diogo | Galhardo, Ana | Couto, Margarida | Mendes, Fernando | Domingues, Cátia | Schukg, Susann | Abrantes, Ana M. | Gonçalves, Ana C. | Sales, Tiago | Teixo, Ricardo | Silva, Rita | Estrela, Jéssica | Laranjo, Mafalda | Casalta-Lopes, João | Rocha, Clara | Simões, Paulo C. | Sarmento-Ribeiro, Ana B. | Botelho, Mª Filomena | Rosa, Manuel S. | Fonseca, Virgínia | Colaço, Diogo | Neves, Vanessa | Jesus, Carlos | Hesse, Camilla | Rocha, Clara | Osório, Nádia | Valado, Ana | Caseiro, Armando | Gabriel, António | Svensson, Lola | Mendes, Fernando | Siba, Wafa A. | Pereira, Cristina | Tomaz, Jorge | Carvalho, Teresa | Pinto-Gouveia, José | Cunha, Marina | Duarte, Diana | Lopes, Nuno V. | Fonseca-Pinto, Rui | Duarte, Diana | Lopes, Nuno V. | Fonseca-Pinto, Rui | Martins, Anabela C. | Brandão, Piedade | Martins, Laura | Cardoso, Margarida | Morais, Nuno | Cruz, Joana | Alves, Nuno | Faria, Paula | Mateus, Artur | Morouço, Pedro | Alves, Nuno | Ferreira, Nelson | Mateus, Artur | Faria, Paula | Morouço, Pedro | Malheiro, Isabel | Gaspar, Filomena | Barros, Luísa | Parreira, Pedro | Cardoso, Andreia | Mónico, Lisete | Carvalho, Carla | Lopes, Albino | Salgueiro-Oliveira, Anabela | Seixas, Adérito | Soares, Valter | Dias, Tiago | Vardasca, Ricardo | Gabriel, Joaquim | Rodrigues, Sandra | Paredes, Hugo | Reis, Arsénio | Marinho, Sara | Filipe, Vítor | Lains, Jorge | Barroso, João | Da Motta, Carolina | Carvalho, Célia B. | Pinto-Gouveia, José | Peixoto, Ermelindo | Gomes, Ana A. | Costa, Vanessa | Couto, Diana | Marques, Daniel R. | Leitão, José A. | Tavares, José | Azevedo, Maria H. | Silva, Carlos F. | Freitas, João | Parreira, Pedro | Marôco, João | Garcia-Gordillo, Miguel A. | Collado-Mateo, Daniel | Chen, Gang | Iezzi, Angelo | Sala, José A. | Parraça, José A. | Gusi, Narcis | Sousa, Jani | Marques, Mariana | Jardim, Jacinto | Pereira, Anabela | Simões, Sónia | Cunha, Marina | Sardo, Pedro | Guedes, Jenifer | Lindo, João | Machado, Paulo | Melo, Elsa | Carvalho, Célia B. | Benevides, Joana | Sousa, Marina | Cabral, Joana | Da Motta, Carolina | Pereira, Ana T. | Xavier, Sandra | Azevedo, Julieta | Bento, Elisabete | Marques, Cristiana | Carvalho, Rosa | Marques, Mariana | Macedo, António | Silva, Ana M. | Alves, Juliana | Gomes, Ana A. | Marques, Daniel R. | Azevedo, Mª Helena | Silva, Carlos | Mendes, Ana | Lee, Huei D. | Spolaôr, Newton | Oliva, Jefferson T. | Chung, Wu F. | Fonseca-Pinto, Rui | Bairros, Keila | Silva, Cláudia D. | Souza, Clóvis A. | Schroeder, Silvana S. | Araújo, Elsa | Monteiro, Helena | Costa, Ricardo | Dias, Sara S. | Torgal, Jorge | Henriques, Carolina G. | Santos, Luísa | Caceiro, Elisa F. | Ramalho, Sónia A. | Oliveira, Rita | Afreixo, Vera | Santos, João | Mota, Priscilla | Cruz, Agostinho | Pimentel, Francisco | Marques, Rita | Dixe, Mª Anjos | Querido, Ana | Sousa, Patrícia | Benevides, Joana | Da Motta, Carolina | Sousa, Marina | Caldeira, Suzana N. | Carvalho, Célia B. | Querido, Ana | Tomás, Catarina | Carvalho, Daniel | Gomes, João | Cordeiro, Marina | Costa, Joyce O. | Valim, Frederico C. | Ribeiro, Lígia C. | Charepe, Zaida | Querido, Ana | Figueiredo, Mª Henriqueta | Aquino, Priscila S. | Ribeiro, Samila G. | Pinheiro, Ana B. | Lessa, Paula A. | Oliveira, Mirna F. | Brito, Luísa S. | Pinto, Ítalo N. | Furtado, Alessandra S. | Castro, Régia B. | Aquino, Caroline Q. | Martins, Eveliny S. | Pinheiro, Ana B | Aquino, Priscila S. | Oliveira, Lara L. | Pinheiro, Patrícia C. | Sousa, Caroline R. | Freitas, Vívien A. | Silva, Tatiane M. | Lima, Adman S. | Aquino, Caroline Q. | Andrade, Karizia V. | Oliveira, Camila A. | Vidal, Eglidia F. | Ganho-Ávila, Ana | Moura-Ramos, Mariana | Gonçalves, Óscar | Almeida, Jorge | Silva, Armando | Brito, Irma | Amado, João | Rodrigo, António | Santos, Sofia | Gomes, Fernando | Rosa, Marlene C. | Marques, Silvana F. | Luís, Sara | Cavalheiro, Luís | Ferreira, Pedro | Gonçalves, Rui | Lopes, Rui S. | Cavalheiro, Luís | Ferreira, Pedro | Gonçalves, Rui | Fiorin, Bruno H. | Santos, Marina S. | Oliveira, Edmar S. | Moreira, Rita L. | Oliveira, Elizabete A. | Filho, Braulio L. | Palmeira, Lara | Garcia, Teresa | Pinto-Gouveia, José | Cunha, Marina | Cardoso, Sara | Palmeira, Lara | Cunha, Marina | Pinto-Gouveia, José | Marta-Simões, Joana | Mendes, Ana L. | Trindade, Inês A. | Oliveira, Sara | Ferreira, Cláudia | Mendes, Ana L. | Marta-Simões, Joana | Trindade, Inês A. | Ferreira, Cláudia | Nave, Filipe | Campos, Mariana | Gaudêncio, Iris | Martins, Fernando | Ferreira, Lino | Lopes, Nuno | Fonseca-Pinto, Rui | Rodrigues, Rogério | Azeredo, Zaida | Vicente, Corália | Silva, Joana | Sousa, Patrícia | Marques, Rita | Mendes, Isabel | Rodrigues, Rogério | Azeredo, Zaida | Vicente, Corália | Vardasca, Ricardo | Marques, Ana R. | Seixas, Adérito | Carvalho, Rui | Gabriel, Joaquim | Ferreira, Paulo P. | Oliveira, Michelle T. | Sousa, Anderson R. | Maia, Ana S. | Oliveira, Sebastião T. | Costa, Pablo O. | Silva, Maiza M. | Arreguy-Sena, Cristina | Alvarenga-Martins, Nathália | Pinto, Paulo F. | Oliveira, Denize C. | Parreira, Pedro D. | Gomes, Antônio T. | Braga, Luciene M. | Araújo, Odete | Lage, Isabel | Cabrita, José | Teixeira, Laetitia | Marques, Rita | Dixe, Mª Anjos | Querido, Ana | Sousa, Patrícia | Silva, Sara | Cordeiro, Eugénio | Pimentel, João | Ferro-Lebres, Vera | Souza, Juliana A. | Tavares, Mariline | Dixe, Mª Anjos | Sousa, Pedro | Passadouro, Rui | Peralta, Teresa | Ferreira, Carlos | Lourenço, Georgina | Serrano, João | Petrica, João | Paulo, Rui | Honório, Samuel | Mendes, Pedro | Simões, Alexandra | Carvalho, Lucinda | Pereira, Alexandre | Silva, Sara | Sousa, Paulino | Padilha, José M. | Figueiredo, Daniela | Valente, Carolina | Marques, Alda | Ribas, Patrícia | Sousa, Joana | Brandão, Frederico | Sousa, Cesar | Martins, Matilde | Sousa, Patrícia | Marques, Rita | Mendes, Francisco | Fernandes, Rosina | Martins, Emília | Magalhães, Cátia | Araújo, Patrícia | Grande, Carla | Mata, Mª Augusta | Vieitez, Juan G. | Bianchini, Bruna | Nazario, Nazare | Filho, João G. | Kretzer, Marcia | Costa, Tânia | Almeida, Armando | Baffour, Gabriel | Almeida, Armando | Costa, Tânia | Baffour, Gabriel | Azeredo, Zaida | Laranjeira, Carlos | Guerra, Magda | Barbeiro, Ana P. | Ferreira, Regina | Lopes, Sara | Nunes, Liliana | Mendes, Ana | Martins, Julian | Schneider, Dulcineia | Kretzer, Marcia | Magajewski, Flávio | Soares, Célia | Marques, António | Batista, Marco | Castuera, Ruth J. | Mesquita, Helena | Faustino, António | Santos, Jorge | Honório, Samuel | Vizzotto, Betina P. | Frigo, Leticia | Pivetta, Hedioneia F. | Sardo, Dolores | Martins, Cristina | Abreu, Wilson | Figueiredo, Mª Céu | Batista, Marco | Jimenez-Castuera, Ruth | Petrica, João | Serrano, João | Honório, Samuel | Paulo, Rui | Mendes, Pedro | Sousa, Patrícia | Marques, Rita | Faustino, António | Silveira, Paulo | Serrano, João | Paulo, Rui | Mendes, Pedro | Honório, Samuel | Oliveira, Catarina | Bastos, Fernanda | Cruz, Inês | Rodriguez, Cláudia K. | Kretzer, Márcia R. | Nazário, Nazaré O. | Cruz, Pedro | Vaz, Daniela C. | Ruben, Rui B. | Avelelas, Francisco | Silva, Susana | Campos, Mª Jorge | Almeida, Maria | Gonçalves, Liliana | Antunes, Lígia | Sardo, Pedro | Guedes, Jenifer | Simões, João | Machado, Paulo | Melo, Elsa | Cardoso, Susana | Santos, Osvaldo | Nunes, Carla | Loureiro, Isabel | Santos, Flávia | Alves, Gilberto | Soar, Cláudia | Marsi, Teresa O. | Silva, Ernestina | Pedrosa, Dora | Leça, Andrea | Silva, Daniel | Galvão, Ana | Gomes, Maria | Fernandes, Paula | Noné, Ana | Combadão, Jaime | Ramalhete, Cátia | Figueiredo, Paulo | Caeiro, Patrícia | Fontana, Karine C. | Lacerda, Josimari T. | Machado, Patrícia O. | Borges, Raphaelle | Barbosa, Flávio | Sá, Dayse | Brunhoso, Germana | Aparício, Graça | Carvalho, Amâncio | Garcia, Ana P. | Fernandes, Paula O. | Santos, Adriana | Veiga, Nélio | Brás, Carina | Carvalho, Inês | Batalha, Joana | Glória, Margarida | Bexiga, Filipa | Coelho, Inês | Amaral, Odete | Pereira, Carlos | Pinho, Cláudia | Paraíso, Nilson | Oliveira, Ana I. | Lima, Cristóvão F. | Dias, Alberto P. | Silva, Pedro | Espada, Mário | Marques, Mário | Pereira, Ana | Pereira, Ana Mª | Veiga-Branco, Mª | Pereira, Filomena | Ribeiro, Maria | Lima, Vera | Oliveira, Ana I. | Pinho, Cláudia | Cruz, Graça | Oliveira, Rita F. | Barreiros, Luísa | Moreira, Fernando | Camarneiro, Ana | Loureiro, Mª Helena | Silva, Margarida | Duarte, Catarina | Jesus, Ângelo | Cruz, Agostinho | Mota, Maria | Novais, Sandra | Nogueira, Paulo | Pereira, Ana | Carneiro, Lara | João, Paulo V. | Lima, Teresa Maneca | Salgueiro-Oliveira, Anabela | Vaquinhas, Marina | Parreira, Pedro | Melo, Rosa | Graveto, João | Castilho, Amélia | Gomes, José H. | Medina, María S. | Blanco, Valeriana G. | Santos, Osvaldo | Lopes, Elisa | Virgolino, Ana | Dinis, Alexandra | Ambrósio, Sara | Almeida, Inês | Marques, Tatiana | Heitor, Mª João | Garcia-Gordillo, Miguel A. | Collado-Mateo, Daniel | Olivares, Pedro R. | Parraça, José A. | Sala, José A. | Castilho, Amélia | Graveto, João | Parreira, Pedro | Oliveira, Anabela | Gomes, José H. | Melo, Rosa | Vaquinhas, Marina | Cheio, Mónica | Cruz, Agostinho | Pereira, Olívia R. | Pinto, Sara | Oliveira, Adriana | Manso, M. Conceição | Sousa, Carla | Vinha, Ana F. | Machado, Mª Manuela | Vieira, Margarida | Fernandes, Beatriz | Tomás, Teresa | Quirino, Diogo | Desouzart, Gustavo | Matos, Rui | Bordini, Magali | Mouroço, Pedro | Matos, Ana R. | Serapioni, Mauro | Guimarães, Teresa | Fonseca, Virgínia | Costa, André | Ribeiro, João | Lobato, João | Martin, Inmaculada Z. | Björklund, Anita | Tavares, Aida I. | Ferreira, Pedro | Passadouro, Rui | Morgado, Sónia | Tavares, Nuno | Valente, João | Martins, Anabela C. | Araújo, Patrícia | Fernandes, Rosina | Mendes, Francisco | Magalhães, Cátia | Martins, Emília | Mendes, Pedro | Paulo, Rui | Faustino, António | Mesquita, Helena | Honório, Samuel | Batista, Marco | Lacerda, Josimari T. | Ortiga, Angela B. | Calvo, Mª Cristina | Natal, Sônia | Pereira, Marta | Ferreira, Manuela | Prata, Ana R. | Nelas, Paula | Duarte, João | Carneiro, Juliana | Oliveira, Ana I. | Pinho, Cláudia | Couto, Cristina | Oliveira, Rita F. | Moreira, Fernando | Maia, Ana S. | Oliveira, Michelle T. | Sousa, Anderson R. | Ferreira, Paulo P. | Souza, Géssica M. | Almada, Lívia F. | Conceição, Milena A. | Santiago, Eujcely C. | Rodrigues, Sandra | Domingues, Gabriela | Ferreira, Irina | Faria, Luís | Seixas, Adérito | Costa, Ana R. | Jesus, Ângelo | Cardoso, Américo | Meireles, Alexandra | Colaço, Armanda | Cruz, Agostinho | Vieira, Viviane L. | Vincha, Kellem R. | Cervato-Mancuso, Ana Mª | Faria, Melissa | Reis, Cláudia | Cova, Marco P. | Ascenso, Rita T. | Almeida, Henrique A. | Oliveira, Eunice G. | Santana, Miguel | Pereira, Rafael | Oliveira, Eunice G. | Almeida, Henrique A. | Ascenso, Rita T. | Jesus, Rita | Tapadas, Rodrigo | Tim-Tim, Carolina | Cezanne, Catarina | Lagoa, Matilde | Dias, Sara S. | Torgal, Jorge | Lopes, João | Almeida, Henrique | Amado, Sandra | Carrão, Luís | Cunha, Madalena | Saboga-Nunes, Luís | Albuquerque, Carlos | Ribeiro, Olivério | Oliveira, Suzete | Morais, Mª Carminda | Martins, Emília | Mendes, Francisco | Fernandes, Rosina | Magalhães, Cátia | Araújo, Patrícia | Pedro, Ana R. | Amaral, Odete | Escoval, Ana | Assunção, Victor | Luís, Henrique | Luís, Luís | Apolinário-Hagen, Jennifer | Vehreschild, Viktor | Fotschl, Ulrike | Lirk, Gerald | Martins, Anabela C. | Andrade, Isabel | Mendes, Fernando | Mendonça, Verónica | Antunes, Sandra | Andrade, Isabel | Osório, Nádia | Valado, Ana | Caseiro, Armando | Gabriel, António | Martins, Anabela C. | Mendes, Fernando | Silva, Paula A. | Mónico, Lisete M. | Parreira, Pedro M. | Carvalho, Carla | Carvalho, Carla | Parreira, Pedro M. | Mónico, Lisete M. | Ruivo, Joana | Silva, Vânia | Sousa, Paulino | Padilha, José M. | Ferraz, Vera | Aparício, Graça | Duarte, João | Vasconcelos, Carlos | Almeida, António | Neves, Joel | Correia, Telma | Amorim, Helena | Mendes, Romeu | Saboga-Nunes, Luís | Cunha, Madalena | Albuquerque, Carlos | Pereira, Elsa S. | Santos, Leonino S. | Reis, Ana S. | Silva, Helena R. | Rombo, João | Fernandes, Jorge C. | Fernandes, Patrícia | Ribeiro, Jaime | Mangas, Catarina | Freire, Ana | Silva, Sara | Francisco, Irene | Oliveira, Ana | Catarino, Helena | Dixe, Mª Anjos | Louro, Mª Clarisse | Lopes, Saudade | Dixe, Anjos | Dixe, Mª Anjos | Menino, Eva | Catarino, Helena | Soares, Fátima | Oliveira, Ana P. | Gordo, Sara | Kraus, Teresa | Tomás, Catarina | Queirós, Paulo | Rodrigues, Teresa | Sousa, Pedro | Frade, João G. | Lobão, Catarina | Moura, Cynthia B. | Dreyer, Laysa C. | Meneghetti, Vanize | Cabral, Priscila P. | Pinto, Francisca | Sousa, Paulino | Esteves, Mª Raquel | Galvão, Sofia | Tytgat, Ite | Andrade, Isabel | Osório, Nádia | Valado, Ana | Caseiro, Armando | Gabriel, António | Martins, Anabela C. | Mendes, Fernando | Casas-Novas, Mónica | Bernardo, Helena | Andrade, Isabel | Sousa, Gracinda | Sousa, Ana P. | Rocha, Clara | Belo, Pedro | Osório, Nádia | Valado, Ana | Caseiro, Armando | Gabriel, António | Martins, Anabela C. | Mendes, Fernando | Martins, Fátima | Pulido-Fuentes, Montserrat | Barroso, Isabel | Cabral, Gil | Monteiro, M. João | Rainho, Conceição | Prado, Alessandro | Carvalho, Yara M. | Campos, Maria | Moreira, Liliana | Ferreira, José | Teixeira, Ana | Rama, Luís | Campos, Maria | Moreira, Liliana | Ferreira, José | Teixeira, Ana | Rama, Luís
BMC Health Services Research  2016;16(Suppl 3):200.
Table of contents
S1 Health literacy and health education in adolescence
Catarina Cardoso Tomás
S2 The effect of a walking program on the quality of life and well-being of people with schizophrenia
Emanuel Oliveira, D. Sousa, M. Uba-Chupel, G. Furtado, C. Rocha, A. Teixeira, P. Ferreira
S3 Diagnosis and innovative treatments - the way to a better medical practice
Celeste Alves
S4 Simulation-based learning and how it is a high contribution
Stefan Gisin
S5 Formative research about acceptability, utilization and promotion of a home fortification programme with micronutrient powders (MNP) in the Autonomous Region of Príncipe, São Tomé and Príncipe
Elisabete Catarino, Nelma Carvalho, Tiago Coucelo, Luís Bonfim, Carina Silva
S6 Safety culture of the patient: a reflexion about the therapeutic approach on the patient with vocal pathology
Débora Franco
S7 About wine, fortune cookies and patient experience
Jesús Alcoba González
O1 The psychological impact on the emergency crews after the disaster event on February 20, 2010
Helena G. Jardim, Rita Silva
O2 Musculoskeletal disorders in midwives
Cristina L. Baixinho, Mª Helena Presado, Mª Fátima Marques, Mário E. Cardoso
O3 Negative childhood experiences and fears of compassion: Implications for psychological difficulties in adolescence
Marina Cunha, Joana Mendes, Ana Xavier, Ana Galhardo, Margarida Couto
O4 Optimal age to give the first dose of measles vaccine in Portugal
João G. Frade, Carla Nunes, João R. Mesquita, Maria S. Nascimento, Guilherme Gonçalves
O5 Functional assessment of elderly in primary care
Conceição Castro, Alice Mártires, Mª João Monteiro, Conceição Rainho
O6 Smoking and coronary events in a population of Spanish health-care centre: An observational study
Francisco P. Caballero, Fatima M. Monago, Jose T. Guerrero, Rocio M. Monago, Africa P. Trigo, Milagros L. Gutierrez, Gemma M. Milanés, Mercedes G. Reina, Ana G. Villanueva, Ana S. Piñero, Isabel R. Aliseda, Francisco B. Ramirez
O7 Prevalence of musculoskeletal injuries in Portuguese musicians
Andrea Ribeiro, Ana Quelhas, Conceição Manso
O8 Hip fractures, psychotropic drug consumption and comorbidity in patients of a primary care practice in Spain
Francisco P. Caballero, Jose T. Guerrero, Fatima M. Monago, Rafael B. Santos, Nuria R. Jimenez, Cristina G. Nuñez, Inmaculada R. Gomez, Mª Jose L. Fernandez, Laura A. Marquez, Ana L. Moreno, Mª Jesus Tena Huertas, Francisco B. Ramirez
O9 The role of self-criticism and shame in social anxiety in a clinical SAD sample
Daniel Seabra, Mª Céu Salvador
O10 Obstruction and infiltration: a proposal of a quality indicator
Luciene Braga, Pedro Parreira, Anabela Salgueiro-Oliveira, Cristina Arreguy-Sena, Bibiana F. Oliveira, Mª Adriana Henriques
O11 Balance and anxiety and depression symptoms in old age people
Joana Santos, Sara Lebre, Alda Marques
O12 Prevalence of postural changes and risk factors in school children and adolescents in a northern region (Porto)
Clarinda Festas, Sandra Rodrigues, Andrea Ribeiro, José Lumini
O13 Ischemic stroke vs. haemorrhagic stroke survival rate
Ana G. Figueiredo
O14 Chronobiological factors as responsible for the appearance of locomotor pathology in adolescents
Francisco J. Hernandez-Martinez, Liliana Campi, Mª Pino Quintana-Montesdeoca, Juan F. Jimenez-Diaz, Bienvenida C. Rodriguez-De-Vera
O15 Risk of malnutrition in the elderly of Bragança
Alexandra Parente, Mª Augusta Mata, Ana Mª Pereira, Adília Fernandes, Manuel Brás
O16 A Lifestyle Educational Programme for primary care diabetic patients: the design of a complex nursing intervention
Mª Rosário Pinto, Pedro Parreira, Marta L. Basto, Ana C. Rei, Lisete M. Mónico
O17 Medication adherence in elderly people
Gilberta Sousa, Clementina Morna, Otília Freitas, Gregório Freitas, Ana Jardim, Rita Vasconcelos
O18 Hospitalization for cervical cancer of residents in the metropolitan region of Porto Alegre, Southern Brazil, 2012 to 2014
Lina G. Horta, Roger S. Rosa, Luís F. Kranz, Rita C. Nugem, Mariana S. Siqueira, Ronaldo Bordin
O19 Oncologic assistance of high complexity: evaluation of regulating accesses
Rosiane Kniess, Josimari T. Lacerda
O20 Perceived barriers for using health care services by the older population as seen by the social sector: findings from the Vila Nova de Gaia Gerontological Plan
Joana Guedes, Idalina Machado, Sidalina Almeida, Adriano Zilhão, Helder Alves, Óscar Ribeiro
O21 Sleep difficulties and depressive symptoms in college students
Ana P. Amaral, Ana Santos, Joana Monteiro, Mª Clara Rocha, Rui Cruz
O22 Psychopathological symptoms and medication use in higher education
Ana P. Amaral, Marina Lourenço, Mª Clara Rocha, Rui Cruz
O23 Sexually transmitted diseases in higher education institutions
Sandra Antunes, Verónica Mendonça, Isabel Andrade, Nádia Osório, Ana Valado, Armando Caseiro, António Gabriel, Anabela C. Martins, Fernando Mendes
O24 Alcohol consumption and suicide ideation in higher education students
Lídia Cabral, Manuela Ferreira, Amadeu Gonçalves
O25 Quality of life in university students
Tatiana D. Luz, Leonardo Luz, Raul Martins
O26 Male and female adolescent antisocial behaviour: characterizing vulnerabilities in a Portuguese sample
Alice Morgado, Maria L. Vale-Dias
O27 Risk factors for mental health in higher education students of health sciences
Rui Porta-Nova
O28 International classification of functioning disability and health as reflexive reasoning in primary attention in health
Tânia C. Fleig, Éboni M. Reuter, Miriam B. Froemming, Sabrina L. Guerreiro, Lisiane L. Carvalho
O29 Risk factors and cardiovascular disease in Portalegre
Daniel Guedelha, P. Coelho, A. Pereira
O30 Health status of the elderly population living in Portalegre historic city centre: A longitudinal study
António Calha, Raul Cordeiro
O31 Student’s sleep in higher education: sleep quality among students of the IPB
Ana Gonçalves, Ana Certo, Ana Galvão, Mª Augusta Mata
O32 Trend in mortality from cervical cancer in the metropolitan area of Florianópolis, state of Santa Catarina, Brazil, 2000 to 2013
Aline Welter, Elayne Pereira, Sandra Ribeiro, Marcia Kretzer
O33 Adherence to treatment in the elderly in an urban environment in Spain
Juan-Fernando Jiménez-Díaz, Carla Jiménez-Rodríguez, Francisco-José Hernández-Martínez, Bienvenida-Del-Carmen Rodríguez-De-Vera, Alexandre Marques-Rodrigues
O34 Beira Baixa Blood Pressure Study (Study PABB)
Patrícia Coelho, Tiago Bernardes, Alexandre Pereira
O35 Trends in cervical cancer mortality statistics in Santa Catarina State, Brazil, by age group and macro-region, from 2000 to 2013
Patrícia Sousa, João G. Filho, Nazare Nazario, Marcia Kretzer
O36 Sleep problems among Portuguese adolescents: a public health issue
Odete Amaral, António Garrido, Nélio Veiga, Carla Nunes, Ana R. Pedro, Carlos Pereira
O37 Association between body fat and health-related quality of life in patients with type 2 diabetes
António Almeia, Helder M. Fernandes, Carlos Vasconcelos, Nelson Sousa, Victor M. Reis, M. João Monteiro, Romeu Mendes
O38 Therapy adherence and polypharmacy in non-institutionalized elderly from Amares county, Portugal
Isabel C. Pinto, Tânia Pires, João Gama
O39 Prevalence of surgical site infection in adults at a hospital unit in the North of Portugal
Vera Preto, Norberto Silva, Carlos Magalhães, Matilde Martins
O40 Frailty phenotype in old age: implications to intervention
Mafalda Duarte, Constança Paúl, Ignácio Martín
O41 Portuguese women: sexual symptoms in perimenopause
Arminda A. Pinheiro
O42 Predictive ability of the Perinatal Depression Screening and Prevention Tool – preliminary results of the categorical approach
Sandra Xavier, Julieta Azevedo, Elisabete Bento, Cristiana Marques, Mariana Marques, António Macedo, Ana T. Pereira
O43 Aging and muscle strength in patients with type 2 diabetes: cross sectional analysis
José P. Almeida, António Almeida, Josiane Alves, Nelson Sousa, Francisco Saavedra, Romeu Mendes
O44 Accessibility of the elderly in the prevention of hypertension in a family health unit
Ana S. Maia, Michelle T. Oliveira, Anderson R. Sousa, Paulo P. Ferreira, Luci S. Lopes, Eujcely C. Santiago
O45 Community Health screenings and self-reported chronic diseases
Sílvia Monteiro, Ângelo Jesus, Armanda Colaço, António Carvalho, Rita P. Silva, Agostinho Cruz
O46 Evaluation of indoor air quality in Kindergartens
Ana Ferreira, Catarina Marques, João P. Figueiredo, Susana Paixão
O47 Atmospheric exposure to chemical agents under the occupational activity of pathology technicians
Ana Ferreira, Carla Lopes, Fernando Moreira, João P. Figueiredo
O48 Occupational exposure to air pollutants in night entertainment venues workers
Ana Ferreira, Diana Ribeiro, Fernando Moreira, João P. Figueiredo, Susana Paixão
O49 Beliefs and attitudes of young people towards breastfeeding
Telma Fernandes, Diogo Amado, Jéssica Leal, Marcelo Azevedo, Sónia Ramalho
O50 Profiling informal caregivers: surveying needs in the care of the elderly
Catarina Mangas, Jaime Ribeiro, Rita Gonçalves
O51 Visual health in teenagers
Amélia F Nunes, Ana R. Tuna, Carlos R. Martins, Henriqueta D. Forte
O52 Amenable mortality and the geographic accessibility to healthcare in Portugal
Cláudia Costa, José A. Tenedório, Paula Santana
O53 Bacterial contamination of door handles in a São Paulo See Metropolitan Cathedral public restrooms in Brazil
J. A. Andrade, J. L. Pinto, C. Campofiorito, S. Nunes, A. Carmo, A. Kaliniczenco, B. Alves, F. Mendes, C. Jesus, F. Fonseca, F. Gehrke
O54 Adherence of patients to rehabilitation programmes
Carlos Albuquerque, Rita Batista, Madalena Cunha, António Madureira, Olivério Ribeiro, Rosa Martins
O55 Prevalence of malnutrition among Portuguese elderly living in nursing homes: preliminary results of the PEN-3S project
Teresa Madeira, Catarina Peixoto-Plácido, Nuno Santos, Osvaldo Santos, Astrid Bergland, Asta Bye, Carla Lopes, Violeta Alarcão, Beatriz Goulão, Nuno Mendonça, Paulo Nicola, João G. Clara
O56 Relation between emotional intelligence and mental illness in health students
João Gomes, Ana Querido, Catarina Tomás, Daniel Carvalho, Marina Cordeiro
P1 Fall risk factors in people older than 50 years old – a pilot report
Marlene C. Rosa, Alda Marques
P2 What about the Portuguese oldest old? A global overview using census data
Daniela Brandão, Óscar Ribeiro, Lia Araújo, Constança Paúl
P3 Prevalence of injuries in senior amateur volleyball athletes in Alentejo and Algarve clubs, Portugal: factors associated
Beatriz Minghelli, Sylvina Richaud
P4 Shame feelings and quality of life: the role of acceptance and decentring
Ana L. Mendes, Joana Marta-Simões, Inês A. Trindade, Cláudia Ferreira
P5 Assessment of social support during deployment in portuguese colonial war veterans
Teresa Carvalho, Marina Cunha, José Pinto-Gouveia
P6 Hospitalization for acute viral bronchiolitis of residents in the metropolitan region of Porto Alegre, Southern Brazil, 2012 to 2014
Morgana C. Fernandes, Roger S. Rosa, Rita C. Nugem, Luís F. Kranz, Mariana S. Siqueira, Ronaldo Bordin
P7 Falls-risk screening – an opportunity for preventing falls in the elderly from Nordeste
Anabela C. Martins, Anabela Medeiros, Rafaela Pimentel, Andreia Fernandes, Carlos Mendonça, Isabel Andrade, Susana Andrade, Ruth L. Menezes
P8 Aging provokes chronodisruption in mature people in temperature circadian rhythm
Rafael Bravo, Marta Miranda, Lierni Ugartemendia, José Mª Tena, Francisco L. Pérez-Caballero, Lorena Fuentes-Broto, Ana B. Rodríguez, Barriga Carmen
P9 The influence of climate and pollution factors in dengue cases of great ABC region, São Paulo
M. A. Carneiro, J. N. Domingues, S. Paixão, J. Figueiredo, V. B. Nascimento, C. Jesus, F Mendes, F. Gehrke, B. Alves, L. Azzalis, F. Fonseca
P10 Visual function and impact of visual therapy in children with learning disabilities: a pilot study
Ana R. Martins, Amélia Nunes, Arminda Jorge
P11 Edentulism and the need of oral rehabilitation among institutionalized elderly
Nélio Veiga, Ana Amorim, André Silva, Liliana Martinho, Luís Monteiro, Rafael Silva, Carina Coelho, Odete Amaral, Inês Coelho, Carlos Pereira, André Correia
P12 Therapy adherence of outpatients in the pharmacy services of a hospital unit
Diana Rodrigues, Nídia Marante, Pedro Silva, Sara Carvalho, André Rts Araujo, Maximiano Ribeiro, Paula Coutinho, Sandra Ventura, Fátima Roque
P13 Universal access and comprehensive care of oral health: an availability study
Cristina Calvo, Manoela Reses
P14 Is the respiratory function of children a predictor of air quality? Coimbra as a case study
Jorge Conde, Ana Ferreira, João Figueiredo
P15 Meaning-in-life of college students
David Silva, Luís Seiça, Raquel Soares, Ricardo Mourão, Teresa Kraus
O57 Training needs for nurses in palliative care
Ana C. Abreu, José M. Padilha, Júlia M. Alves
O58 Impact of computerized information systems in the global nurses’ workload: nurses’ perceptions and real-time
Paulino Sousa, Manuel Oliveira, Joana Sousa
O59 The perspective of health care professionals on self-care in hereditary neurodegenerative disease: a qualitative study
Sónia Novais, Felismina Mendes
O60 Contribution for health-related physical fitness reference values in healthy adolescents
Joana Pinto, Joana Cruz, Alda Marques
School of Health Sciences, University of Aveiro, 3810-193 Aveiro, Portugal
O61 Perception of learning, satisfaction and self-efficacy of nursing students about High-Fidelity Simulation
Hugo Duarte, Maria Dos Anjos Dixe, Pedro Sousa
O62 Analysis of statements of diagnosis about health deviation in self-care requisites customized in a Nursing Practice Support System (SAPE®): Management of therapeutic regimen
Inês Cruz, Fernanda Bastos, Filipe Pereira
O63 Hybrid management and hospital governance: doctors and nurses as managers
Francisco L. Carvalho, Teresa T. Oliveira, Vítor R. Raposo
O64 Time management in health professionals
Conceição Rainho, José C. Ribeiro, Isabel Barroso, Vítor Rodrigues
O65 Financial rewards and wellbeing in primary health care
Carmo Neves, Teresa C. Oliveira
O66 Patient safety promotion in the operating room
Bárbara Oliveira, Mª Carminda Morais, Pilar Baylina
O67 Difficulties and needs of pre-graduate nursing students in the area of Geriatrics/Gerontology
Rogério Rodrigues, Zaida Azeredo, Corália Vicente
O68 Teaching and learning sexuality in nursing education
Hélia Dias, Margarida Sim-Sim
O69 Entrepreneurial Motivations Questionnaire: AFC and CFA in academy
Pedro Parreira, Anabela Salgueiro-Oliveira, Amélia Castilho, Rosa Melo, João Graveto, José Gomes, Marina Vaquinhas, Carla Carvalho, Lisete Mónico, Nuno Brito
O70 Nursing intervention to patient with Permanent Pacemakers and Implantable Cardioverter Defibrillators: a qualitative analysis
Cassilda Sarroeira, José Amendoeira, Fátima Cunha, Anabela Cândido, Patrícia Fernandes, Helena R. Silva, Elsa Silva
O71 Alcohol consumption among nursing students: where does education fail?
Isabel Barroso, Leila Lapa, Cristina Antunes
O72 Labour stress in nursing
Ana Gonçalves, Ana Galvão, Mª José Gomes, Susana R. Escanciano
O73 The influence of safe staff nursing in patient satisfaction with nursing care
Maria Freitas, Pedro Parreira, João Marôco
O74 Intention to use eHealth strategies with nursing students
Ana R. Fernandes, Cremilde Cabral, Samuel Alves, Pedro Sousa
O75 Community Based Mental Health: contributions of an interdisciplinary international program for students in higher health education
António Ferreira, Fernanda Príncipe, Ulla-Maija Seppänen, Margarida Ferreira, Maribel Carvalhais, Marilene Silva
O76 Study of satisfaction at work of graduates in nursing: 2002-2014
Manuela Ferreira, Joana Silva, Jéssica Neves, Diana Costa, Bruno Santos, Soraia Duarte
O77 Health professionals’ attitudes towards breastfeeding
Sílvia Marques, Sónia Ramalho, Isabel Mendes
O78 Continuity of nursing care to person with type 2 diabetes
Clarisse Louro, Eva Menino, Maria Dixe, Sara S. Dias
O79 Stigma toward mental illness among future health professionals
Marina Cordeiro, Catarina Tomás, Ana Querido, Daniel Carvalho, João Gomes
O80 Working with fears and anxieties of medical students in search of a humanized care
Frederico C. Valim, Joyce O. Costa, Lúcia G. Bernardes
P16 Surgical paediatrics patients’ psycho prophylaxis at a teaching hospital
Helena Prebianchi
P17 Patient-perceived outcomes in physiotherapy – a pilot study
Marlene Cristina Rosa
P18 Building competencies for managers in nursing
Narcisa Gonçalves, Maria M. Martins, Paulina Kurcgant
P19 Theoretical basis underlying physiotherapy practice in stroke rehabilitation
André Vieira
P20 When the life-cycle ends: the nurse’s confrontation with death
Sandrina Bento, Sérgio Deodato, Isabel Rabiais
P21 Nursing students’ opinion about the supervision relationship during their first clinical experience
Laura Reis
P22 Nursing Relational Laboratory: Pedagogical, dialogic and critical project
Ana Torres, Sérgio Soares, Margarida Ferreira, Pedro Graça
P23 Job satisfaction of bioscientists at a Lisbon hospital
Céu Leitão, Renato Abreu, Fernando Bellém, Ana Almeida, Edna Ribeiro-Varandas, Ana Tavares
P24 Sociodemographic and professional profile of nurses and its relation with the importance of family in nursing practices
João G. Frade, Carolina Henriques, Eva Menino, Clarisse Louro, Célia Jordão
P25 Professional satisfaction of rehabilitation nurses
Sofia Neco, Carminda Morais, Pedro Ferreira
P26 The person living with a stoma: the formalization of knowledge in nursing
Carla R. Silva, Alice Brito, Antónia Silva
P27 Validation of the Portuguese versions of the nursing students’ perceptions of learning and learner satisfaction with simulation tool
Hugo Duarte, Maria Dos Anjos Dixe, Pedro Sousa
P28 Physiotherapists’ perceived knowledge on technologies for electronic health records for physiotherapy
Gabriela Postolache, Raul Oliveira, Isabel Moreira, Luísa Pedro, Sónia Vicente, Samuel Domingos, Octavian Postolache
P29 Quality of life and physical activity of medicine undergraduate students in the University of Southern Santa Catarina, Brazil
Darlen Silva, João G. Filho, Nazare Nazario, Marcia Kretzer, Dulcineia Schneider
P30 The curricular skills for decision making education in a Nursing Degree
Fátima M. Marques
P31 Effect of nurses’ mobilization in satisfaction at work and turnover: An empirical study in the hospital setting
Pedro Parreira, Carla Carvalho, Lisete M. Mónico, Carlos Pinto, Sara Vicente, São João Breda
P32 Entrepreneurial skills of students of polytechnic higher education in Portugal: Business influences
José H. Gomes, Rosa Melo, Pedro Parreira, Anabela Salgueiro, João Graveto, Marina Vaquinhas, Amélia Castilho
P33 Design and assessment of e-learning modules for Pharmacology
Ângelo Jesus, Nuno Duarte, José C. Lopes, Hélder Nunes, Agostinho Cruz
P34 Perspective of nurses involved in an action-research study on the changes observed in care provision: results from a focus group
Anabela Salgueiro-Oliveira, Pedro Parreira, Marta L. Basto, Luciene M. Braga
P35 Use of peer feedback by nursing students during clinical training: teacher’s perception
António Ferreira, Beatriz Araújo, José M. Alves, Margarida Ferreira, Maribel Carvalhais, Marilene Silva, Sónia Novais
P36 What’s new on endotracheal suctioning recommendations
Ana S. Sousa, Cândida Ferrito
P37 Assessment of the nurses satisfaction on the Central Region of Portugal
Pedro L. Ferreira, Alexandre Rodrigues, Margarida Ferreira, Isabel Oliveira
P38 Study of graduate’s satisfaction with the school of nursing
Manuela Ferreira, Jéssica Neves, Diana Costa, Soraia Duarte, Joana Silva, Bruno Santos
P39 Partnership between the school of nursing and the hospital: Supervisors´ perspectives
Cristina Martins, Ana P. Macedo, Odete Araújo, Cláudia Augusto, Fátima Braga, Lisa Gomes, Maria A. Silva, Rafaela Rosário
P40 Coping strategies of college students
Luís Pimenta, Diana Carreira, Patrícia Teles, Teresa Barros
P41 Emotional intelligence and mental health stigma in health students
Catarina Tomás, Ana Querido, Daniel Carvalho, João Gomes, Marina Cordeiro
P42 Stigma of mental health assessment: Comparison between health courses
Daniel Carvalho, Ana Querido, Catarina Tomás, João Gomes, Marina Cordeiro
O81 Short- and long-term effects of pulmonary rehabilitation in mild COPD
Cristina Jácome, Alda Marques
O82 Phonological awareness programme for preschool children
Sylvie Capelas, Andreia Hall, Dina Alves, Marisa Lousada
O83 REforma ATIVA: An efficient health promotion program to be implemented during retirement
Mª Helena Loureiro, Ana Camarneiro, Margarida Silva, Aida Mendes, Ana Pedreiro
O84 Intervention for men who batter women, a case report
Anne G.Silva, Elza S. Coelho
O85 Immediate effects of Bowen Therapy on muscle tone and flexibility
Flávio Melo, Fernando Ribeiro, Rui Torres, Rui Costa
O86 Predictive equation for incremental shuttle walk test in adolescents
Tânia Pinho, Cristina Jácome, Alda Marques
O87 Life satisfaction and psychopathology in institutionalized elderly people: The results of an adapted Mindfulness-Based Stress Reduction program
Bárbara Cruz, Daniel Seabra, Diogo Carreira, Maria Ventura
O88 Outcome changes in COPD rehabilitation: exploring the relationship between physical activity and health-related outcomes
Joana Cruz, Dina Brooks, Alda Marques
O89 Assessing the effectiveness of a Complex Nursing Intervention
M Rosário Pinto, Pedro Parreira, Marta Lima-Basto, Miguel Neves, Lisete M. Mónico
O90 Psychotherapeutic intervention in addiction disorders: Change in psychopathological symptoms and emotional states
Carla Bizarro, Marina Cunha, Ana Galhardo, Couto Margarida, Ana P. Amorim, Eduardo Silva
O91 Economic impact of a nursing intervention program to promote self-management in COPD
Susana Cruz, José M. Padilha, Jorge Valente
O92 Multimodal acute pain management during uterine artery embolization in treatment of uterine myomas
José T. Guerrero, Francisco P. Caballero, Rafael B. Santos, Estefania P. Gonzalez, Fátima M. Monago, Lierni U. Ugalde, Marta M. Vélez, Maria J. Tena
O93 Fluid administration strategies in major surgery: Goal-directed therapy
José T. Guerrero, Rafael Bravo, Francisco L. Pérez-Caballero, Isabel A. Becerra, Mª Elizabeth Agudelo, Guadalupe Acedo, Roberto Bajo
O94 Development and implementation of a self-management educational programme using lay-led’s in adolescents Spina Bifida: A pilot study
Isabel Malheiro, Filomena Gaspar, Luísa Barros
O95 Influence of chair-based yoga exercises on salivary anti-microbial proteins in institutionalized frail-elderly women: a preliminary study
Guilherme Furtado, Mateus Uba-Chupel, Mariana Marques, Luís Rama, Margarida Braga, José P. Ferreira, Ana Mª Teixeira
O96 High intensity interval training vs moderate intensity continuous training impact on diabetes 2
João Cruz, Tiago Barbosa, Ângela Simões, Luís Coelho
O97 Family caregiver of people with pressure ulcer: Nursing intervention plan
Alexandre Rodrigues, Juan-Fernando Jiménez-Díaz, Francisco Martinez-Hernández, Bienvenida Rodriguez-De-Vera, Pedro Ferreira, Alexandrina Rodrigues
O98 Chronic effects of exercise on motor memory consolidation in elderly people
André Ramalho, João Petrica, Pedro Mendes, João Serrano, Inês Santo, António Rosado
O99 Impression cytology of the ocular surface: Collection technique and sample processing
Paula Mendonça, Kátia Freitas
O100 Does sport practice affect the reaction time in neuromuscular activity?
Dora Ferreira, António Brito, Renato Fernandes
O101 Efficiency of the enteral administration of fibbers in the treatment of chronic obstipation
Sofia Gomes, Fernando Moreira, Cláudia Pinho, Rita Oliveira, Ana I. Oliveira
O102 Fast decalcifier in compact bone and spongy bone
Paula Mendonça, Ana P. Casimiro, Patrícia Martins, Iryna Silva
O103 Health promotion in the elderly – Intervention project in dementia
Diana Evangelista
O104 Prevention of musculoskeletal disorders through an exercise protocol held in labour context
Catarina Leitão, Fábia Velosa, Nélio Carecho, Luís Coelho
O105 Knowledge of teachers and other education agents on diabetes type 1: Effectiveness of an intervention program
Eva Menino, Anjos Dixe, Helena Catarino, Fátima Soares, Ester Gama, Clementina Gordo
O106 Treatment of diabetic peripheral neuropathic pain: a systematic review of clinical trials of phase II and III
Eliana Moreira, Cristiana Midões, Marlene Santos
O107 New drugs for osteoporosis treatment: Systematic review of clinical trials of phase II and III
Sara Machado, Vânia P. Oliveira, Marlene Santos
O108 Promoting hope at the end of life: Effectiveness of an Intervention Programme
Ana Querido, Anjos Dixe, Rita Marques, Zaida Charepe
P43 Psychomotor therapy effects on adaptive behaviour and motor proficiency of adults with intellectual disability
Ana Antunes, Sofia Santos
P44 The effect of exercise therapy in multiple sclerosis – a single study case
Marlene C. Rosa
P45 Physical condition and self-efficacy in people with fall risk – a preliminary study
Marlene C. Rosa, Silvana F. Marques
P46 Shock waves: their effectiveness in improving the symptoms of calcifying tendinitis of the shoulder
Beatriz Minghelli, Eulália Caro
P47 Pacifier – construction and pilot application of a parenting intervention for parents of babies until six months in primary health care
Mª José Luís, Teresa Brandão
P48 The influence of Motor Imagery in fine motor skills of individuals with disabilities
Pedro Mendes, Daniel Marinho, João Petrica, Diogo Monteiro, Rui Paulo, João Serrano, Inês Santo
P49 Evaluation of the effects of a walking programme on the fall risk factors in older people – a longitudinal pilot study
Lina Monteiro, Fátima Ramalho, Rita Santos-Rocha, Sónia Morgado, Teresa Bento
P50 Nursing intervention programme in lifestyles of adolescents
Gilberta Sousa, Otília Freitas, Isabel Silva, Gregório Freitas, Clementina Morna, Rita Vasconcelos
P51 The person submitted to hip replacement rehabilitation, at home
Tatiana Azevedo, Salete Soares, Jacinta Pisco
P52 Effects of Melatonin use in the treatment of neurovegetative diseases
Paulo P. Ferreira, Efrain O. Olszewer, Michelle T. Oliveira, Anderson R. Sousa, Ana S. Maia, Sebastião T. Oliveira
P53 Review of Phytotherapy and other natural substances in alcohol abuse and alcoholism
Erica Santos, Ana I. Oliveira, Carla Maia, Fernando Moreira, Joana Santos, Maria F. Mendes, Rita F. Oliveira, Cláudia Pinho
P54 Dietary programme impact on biochemical markers in diabetics: systematic review
Eduarda Barreira, Ana Pereira, Josiana A. Vaz, André Novo
P55 Biological approaches to knee osteoarthritis: platelet-rich plasma and hyaluronic acid
Luís D. Silva, Bruno Maia, Eduardo Ferreira, Filipa Pires, Renato Andrade, Luís Camarinha
P56 Platelet-rich plasma and hyaluronic acid intra-articular injections for the treatment of ankle osteoarthritis
Luís D. Silva, Bruno Maia, Eduardo Ferreira, Filipa Pires, Renato Andrade, Luís Camarinha
P57 The impact of preventive measures in the incidence of diabetic foot ulcers: a systematic review
Ana F. César, Mariana Poço, David Ventura, Raquel Loura, Pedro Gomes, Catarina Gomes, Cláudia Silva, Elsa Melo, João Lindo
P58 Dating violence among young adolescents
Joana Domingos, Zaida Mendes, Susana Poeta, Tiago Carvalho, Catarina Tomás, Helena Catarino, Mª Anjos Dixe
P59 Physical activity and motor memory in pedal dexterity
André Ramalho, António Rosado, Pedro Mendes, Rui Paulo, Inês Garcia, João Petrica
P60 The effects of whole body vibration on the electromyographic activity of thigh muscles
Sandra Rodrigues, Rui Meneses, Carlos Afonso, Luís Faria, Adérito Seixas
P61 Mental health promotion in the workplace
Marina Cordeiro, Paulo Granjo, José C. Gomes
P62 Influence of physical exercise on the self-perception of body image in elderly women: A systematic review of qualitative studies
Nelba R. Souza, Guilherme E. Furtado, Saulo V. Rocha, Paula Silva, Joana Carvalho
O109 Psychometric properties of the Portuguese version of the Éxamen Geronto-Psychomoteur (P-EGP)
Marina Ana Morais, Sofia Santos, Paula Lebre, Ana Antunes
O110 Symptoms of depression in the elderly population of Portugal, Spain and Italy
António Calha
O111 Emotion regulation strategies and psychopathology symptoms: A comparison between adolescents with and without deliberate self-harm
Ana Xavier, Marina Cunha, José Pinto-Gouveia
O112 Prevalence of physical disability in people with leprosy
Liana Alencar, Madalena Cunha, António Madureira
O113 Quality of life and self-esteem in type 1 and type 2 diabetes mellitus patients
Ilda Cardoso, Ana Galhardo, Fernanda Daniel, Vítor Rodrigues
O114 Cross-cultural comparison of gross motor coordination in children from Brazil and Portugal
Leonardo Luz, Tatiana Luz, Maurício R. Ramos, Dayse C. Medeiros, Bruno M. Carmo, André Seabra, Cristina Padez, Manuel C. Silva
O115 Electrocardiographic differences between African and Caucasian people
António Rodrigues, Patrícia Coelho, Alexandre Coelho
O116 Factors associated with domestic, sexual and other types of violence in the city of Palhoça - Brazil
Madson Caminha, Filipe Matheus, Elenice Mendes, Jony Correia, Marcia Kretzer
O117 Tinnitus prevalence study of users of a hospital of public management - Spain
Francisco J. Hernandez-Martinez, Juan F. Jimenez-Diaz, Bienvendida C. Rodriguez-De-Vera, Carla Jimenez-Rodriguez, Yadira Armas-Gonzalez
O118 Difficulties experienced by parents of children with diabetes mellitus of preschool age in therapeutic and nutritional management
Cátia Rodrigues, Rosa Pedroso
O119 E-mental health - “nice to have” or “must have”? Exploring the attitudes towards e-mental health in the general population
Jennifer Apolinário-Hagen, Viktor Vehreschild
O120 Violence against children and adolescents and the role of health professionals: Knowing how to identify and care
Milene Veloso, Celina Magalhães, Isabel Cabral, Maira Ferraz
O121 Marital violence. A study in the Algarve population
Filipe Nave, Emília Costa, Filomena Matos, José Pacheco
O122 Clinical factors and adherence to treatment in ischemic heart disease
António Dias, Carlos Pereira, João Duarte, Madalena Cunha, Daniel Silva
O123 Can religiosity improve optimism in participants in states of illness, when controlling for life satisfaction?
Lisete M. Mónico, Valentim R. Alferes, Mª São João Brêda, Carla Carvalho, Pedro M. Parreira
O124 Empowerment, knowledge and quality of life of people with diabetes type 2 in the Alto Minho Health Local Unit
Mª Carminda Morais, Pedro Ferreira, Rui Pimenta, José Boavida
O125 Antihypertensive therapy adherence among hypertensive patients from Bragança county, Portugal
Isabel C. Pinto, Tânia Pires, Catarina Silva
O126 Subjective perception of sexual achievement - An exploratory study on people with overweight
Maria Ribeiro, Maria Viega-Branco, Filomena Pereira, Ana Mª Pereira
O127 Physical activity level and associated factors in hypertensive individuals registered in the family health strategy of a basic health unit from the city of Palhoça, Santa Catarina, Brazil
Fabrícia M. Almeida, Gustavo L. Estevez, Sandra Ribeiro, Marcia R. Kretzer
O128 Perception of functional fitness and health in non-institutionalised elderly from rural areas
Paulo V. João, Paulo Nogueira, Sandra Novais, Ana Pereira, Lara Carneiro, Maria Mota
O129 Medication adherence in patients with type 2 diabetes mellitus treated at primary health care in Coimbra
Rui Cruz, Luiz Santiago, Carlos Fontes-Ribeiro
O130 Multivariate association between body mass index and multi-comorbidities in elderly people living in low socio-economic status context
Guilherme Furtado, Saulo V. Rocha, André P. Coutinho, João S. Neto, Lélia R. Vasconcelos, Nelba R. Souza, Estélio Dantas
O131 Metacognition, rumination and experiential avoidance in Borderline Personality Disorder
Alexandra Dinis, Sérgio Carvalho, Paula Castilho, José Pinto-Gouveia
O132 Health issues in a vulnerable population: nursing consultation in a public bathhouse in Lisbon
Alexandra Sarreira-Santos, Amélia Figueiredo, Lurdes Medeiros-Garcia, Paulo Seabra
O133 The perception of quality of life in people with multiple sclerosis accompanied in External Consultation of the Local Health Unit of Alto Minho
Rosa Rodrigues, Mª Carminda Morais, Paula O. Fernandes
O134 Representation of interaction established between immigrant women and nurse during pregnancy to postpartum, from the perspective of immigrant women
Conceição Santiago, Mª Henriqueta Figueiredo, Marta L. Basto
O135 Illness perceptions and medication adherence in hypertension
Teresa Guimarães, André Coelho, Anabela Graça, Ana M. Silva, Ana R. Fonseca
O136 A Portuguese study on adults’ intimate partner violence, interpersonal trust and hope
Luz Vale-Dias, Bárbara Minas, Graciete Franco-Borges
P63 QOL’ predictors of people with intellectual disability and general population
Cristina Simões, Sofia Santos
P64 Content validation of the Communication Disability Profile (CDP) - Portuguese Version
Ana Serra, Maria Matos, Luís Jesus
P65 Study of biochemical and haematological changes in football players
Ana S. Tavares, Ana Almeida, Céu Leitão, Edna Varandas, Renato Abreu, Fernando Bellém
P66 Body image dissatisfaction in inflammatory bowel disease: exploring the role of chronic illness-related shame
Inês A. Trindade, Cláudia Ferreira, José Pinto-Gouveia, Joana Marta-Simões
P67 Obesity and sleep in the adult population - a systematic review
Odete Amaral, Cristiana Miranda, Pedro Guimarães, Rodrigo Gonçalves, Nélio Veiga, Carlos Pereira
P68 Frequency of daytime sleepiness and obstructive sleep apnea risk in COPD patients
Tânia C. Fleig, Elisabete A. San-Martin, Cássia L. Goulart, Paloma B. Schneiders, Natacha F. Miranda, Lisiane L. Carvalho, Andrea G. Silva
P69 Working with immigrant-origin clients: discourses and practices of health professionals
Joana Topa, Conceição Nogueira, Sofia Neves
P70 Systemic Lupus Erythematosus – what are audiovestibular changes?
Rita Ventura, Cristina Nazaré
P71 Mental disorders in the oldest old: findings from the Portuguese national hospitalization database
Daniela Brandão, Alberto Freitas, Óscar Ribeiro, Constança Paúl
P72 Recurrence analysis in postural control in children with cerebral palsy
Cristiana Mercê, Marco Branco, Pedro Almeida, Daniela Nascimento, Juliana Pereira, David Catela
P73 The experience of self-care in the elderly with COPD: contributions to reflect proximity care
Helga Rafael
P74 Culturally competent nurses: managing unpredictability in clinical practice with immigrants
Alcinda C. Reis
O137 Paediatric speech and language screening: An instrument for health professionals
Ana Mendes, Ana R. Valente, Marisa Lousada
O138 Anthropometric and nutritional assessment in bodybuilders
Diana Sousa, Ana L. Baltazar, Mª Helena Loureiro
O139 Computerized adventitious respiratory sounds in children with lower respiratory tract infections
Ana Oliveira, José Aparício, Alda Marques
O140 Role of computerized respiratory sounds as a marker in LRTI
Alda Marques, Ana Oliveira, Joana Neves, Rodrigo Ayoub
O141 Confirmatory factor analysis of the Personal Wellbeing Index in people with chronic kidney disease
Luís Sousa, Cristina Marques-Vieira, Sandy Severino, Helena José
O142 Phonological awareness skills in school aged children
Inês Cadorio, Marisa Lousada
O143 Assessment of early memories of warmth and safeness in interaction with peers: its relationship with psychopathology in adolescence
Marina Cunha, Diogo Andrade, Ana Galhardo, Margarida Couto
O144 The molecular effects induced by single shot irradiation on a diffuse large B cell lymphoma cell line
Fernando Mendes, Cátia Domingues, Susann Schukg, Ana M. Abrantes, Ana C. Gonçalves, Tiago Sales, Ricardo Teixo, Rita Silva, Jéssica Estrela, Mafalda Laranjo, João Casalta-Lopes, Clara Rocha, Paulo C. Simões, Ana B. Sarmento-Ribeiro, Mª Filomena Botelho, Manuel S. Rosa
O145 Morpho-functional characterization of cardiac chambers by Transthoracic Echocardiography, in young athletes of gymnastics competition
Virgínia Fonseca, Diogo Colaço, Vanessa Neves
O146 Prevalence of the antibodies of the new histo-blood system – FORS system
Carlos Jesus, Camilla Hesse, Clara Rocha, Nádia Osório, Ana Valado, Armando Caseiro, António Gabriel, Lola Svensson, Fernando Mendes, Wafa A. Siba, Cristina Pereira, Jorge Tomaz
O147 Assessment of the war-related perceived threat in Portuguese Colonial War Veterans
Teresa Carvalho, José Pinto-Gouveia, Marina Cunha
O148 Pulse transit time estimation for continuous blood pressure measurement: A comparative study
Diana Duarte, Nuno V. Lopes, Rui Fonseca-Pinto
O149 Blood pressure assessment during standard clinical manoeuvres: A non-invasive PPT based approach
Diana Duarte, Nuno V. Lopes, Rui Fonseca-Pinto
O150 Development and initial validation of the Activities and Participation Profile related to Mobility (APPM)
Anabela C. Martins
O151 MEASYCare-2010 Standard–A geriatric evaluation system in primary health care: Reliability and validity of the latest version in Portugal
Piedade Brandão, Laura Martins, Margarida Cardoso
O152 Interrater and intrarater reliability and agreement of the range of shoulder flexion in the standing upright position through photographic assessment
Nuno Morais, Joana Cruz
O153 Three-dimensional biofabrication techniques for tissue regeneration
Nuno Alves, Paula Faria, Artur Mateus, Pedro Morouço
O154 A new computer tool for biofabrication applied to tissue engineering
Nuno Alves, Nelson Ferreira, Artur Mateus, Paula Faria, Pedro Morouço
O155 Development and psychometric qualities of a scale to measure the functional independence of adolescents with motor impairment
Isabel Malheiro, Filomena Gaspar, Luísa Barros
O156 Organizational Trust in Health services: Exploratory and Confirmatory factor analysis of the Organizational Trust Inventory- Short Form (OTI-SF)
Pedro Parreira, Andreia Cardoso, Lisete Mónico, Carla Carvalho, Albino Lopes, Anabela Salgueiro-Oliveira
O157 Thermal symmetry: An indicator of occupational task asymmetries in physiotherapy
Adérito Seixas, Valter Soares, Tiago Dias, Ricardo Vardasca, Joaquim Gabriel, Sandra Rodrigues
O158 A study of ICT active monitoring adoption in stroke rehabilitation
Hugo Paredes, Arsénio Reis, Sara Marinho, Vítor Filipe, João Barroso
O159 Paranoia Checklist (Portuguese Version): Preliminary studies in a mixed sample of patients and healthy controls
Carolina Da Motta, Célia B. Carvalho, José Pinto-Gouveia, Ermelindo Peixoto
O160 Reliability and validity of the Composite Scale on Morningness: European Portuguese version, in adolescents and young adults
Ana A. Gomes, Vanessa Costa, Diana Couto, Daniel R. Marques, José A. Leitão, José Tavares, Maria H. Azevedo, Carlos F. Silva
O161 Evaluation scale of patient satisfaction with nursing care: Psychometric properties evaluation
João Freitas, Pedro Parreira, João Marôco
O162 Impact of fibromyalgia on quality of life: Comparing results from generic instruments and FIQR
Miguel A. Garcia-Gordillo, Daniel Collado-Mateo, Gang Chen, Angelo Iezzi, José A. Sala, José A. Parraça, Narcis Gusi
O163 Preliminary study of the adaptation and validation of the Rating Scale of Resilient Self: Resilience, self-harm and suicidal ideation in adolescents
Jani Sousa, Mariana Marques, Jacinto Jardim, Anabela Pereira, Sónia Simões, Marina Cunha
O164 Development of the first pressure ulcer in inpatient setting: Focus on length of stay
Pedro Sardo, Jenifer Guedes, João Lindo, Paulo Machado, Elsa Melo
O165 Forms of Self-Criticizing and Self-Reassuring Scale: Adaptation and early findings in a sample of Portuguese children
Célia B. Carvalho, Joana Benevides, Marina Sousa, Joana Cabral, Carolina Da Motta
O166 Predictive ability of the Perinatal Depression Screening and Prevention Tool – Preliminary results of the dimensional approach
Ana T. Pereira, Sandra Xavier, Julieta Azevedo, Elisabete Bento, Cristiana Marques, Rosa Carvalho, Mariana Marques, António Macedo
O167 Psychometric properties of the BaSIQS-Basic Scale on insomnia symptoms and quality of sleep, in adults and in the elderly
Ana M. Silva, Juliana Alves, Ana A. Gomes, Daniel R. Marques, Mª Helena Azevedo, Carlos Silva
O168 Enlightening the human decision in health: The skin melanocytic classification challenge
Ana Mendes, Huei D. Lee, Newton Spolaôr, Jefferson T. Oliva, Wu F. Chung, Rui Fonseca-Pinto
O169 Test-retest reliability household life study and health questionnaire Pomerode (SHIP-BRAZIL)
Keila Bairros, Cláudia D. Silva, Clóvis A. Souza, Silvana S. Schroeder
O170 Characterization of sun exposure behaviours among medical students from Nova Medical School
Elsa Araújo, Helena Monteiro, Ricardo Costa, Sara S. Dias, Jorge Torgal
O171 Spirituality in pregnant women
Carolina G. Henriques, Luísa Santos, Elisa F. Caceiro, Sónia A. Ramalho
O172 Polypharmacy in older patients with cancer
Rita Oliveira, Vera Afreixo, João Santos, Priscilla Mota, Agostinho Cruz, Francisco Pimentel
O173 Quality of life of caregivers of people with advanced chronic disease: Translation and validation of the quality of life in life threatening illness - family carer version (QOLLTI-C-PT)
Rita Marques, Mª Anjos Dixe, Ana Querido, Patrícia Sousa
O174 The psychometric properties of the brief Other as Shamer Scale for Children (OAS-C): preliminary validation studies in a sample of Portuguese children
Joana Benevides, Carolina Da Motta, Marina Sousa, Suzana N. Caldeira, Célia B. Carvalho
O175 Measuring emotional intelligence in health care students – Revalidation of WLEIS-P
Ana Querido, Catarina Tomás, Daniel Carvalho, João Gomes, Marina Cordeiro
O176 Health indicators in prenatal assistance: The impact of computerization and of under-production in basic health centres
Joyce O. Costa, Frederico C. Valim, Lígia C. Ribeiro
O177 Hope genogram: Assessment of resources and interaction patterns in the family of the child with cerebral palsy
Zaida Charepe, Ana Querido, Mª Henriqueta Figueiredo
O178 The influence of childbirth type in postpartum quality of life
Priscila S. Aquino, Samila G. Ribeiro, Ana B. Pinheiro, Paula A. Lessa, Mirna F. Oliveira, Luísa S. Brito, Ítalo N. Pinto, Alessandra S. Furtado, Régia B. Castro, Caroline Q. Aquino, Eveliny S. Martins
O179 Women’s beliefs about pap smear test and cervical cancer: influence of social determinants
Ana B Pinheiro, Priscila S. Aquino, Lara L. Oliveira, Patrícia C. Pinheiro, Caroline R. Sousa, Vívien A. Freitas, Tatiane M. Silva, Adman S. Lima, Caroline Q. Aquino, Karizia V. Andrade, Camila A. Oliveira, Eglidia F. Vidal
O180 Validity of the Portuguese version of the ASI-3: Is anxiety sensitivity a unidimensional or multidimensional construct?
Ana Ganho-Ávila, Mariana Moura-Ramos, Óscar Gonçalves, Jorge Almeida
O181 Lifestyles of higher education students: the influence of self-esteem and psychological well-being
Armando Silva, Irma Brito, João Amado
P75 Assessing the quality of life of persons with significant intellectual disability: Portuguese version of Escala de San Martín
António Rodrigo, Sofia Santos, Fernando Gomes
P76 Childhood obesity and breastfeeding - A systematic review
Marlene C. Rosa, Silvana F. Marques
P77 Cross-cultural adaptation of the Foot and Ankle Ability Measure (FAAM) for the Portuguese population
Sara Luís, Luís Cavalheiro, Pedro Ferreira, Rui Gonçalves
P78 Cross-cultural adaptation of the Patient-Rated Wrist Evaluation score (PRWE) for the Portuguese population
Rui S. Lopes, Luís Cavalheiro, Pedro Ferreira, Rui Gonçalves
P79 Cross-cultural adaptation of the Myocardial Infraction Dimensional Assessment Scale (MIDAS) for Brazilian Portuguese language
Bruno H. Fiorin, Marina S. Santos, Edmar S. Oliveira, Rita L. Moreira, Elizabete A. Oliveira, Braulio L. Filho
P80 The revised Portuguese version of the Three-Factor Eating Questionnaire: A confirmatory factor analysis
Lara Palmeira, Teresa Garcia, José Pinto-Gouveia, Marina Cunha
P81 Assessing weight-related psychological inflexibility: An exploratory factor analysis of the AAQW’s Portuguese version
Sara Cardoso, Lara Palmeira, Marina Cunha; José Pinto-Gouveia
P82 Validation of the Body Appreciation Scale-2 for Portuguese women
Joana Marta-Simões, Ana L. Mendes, Inês A. Trindade, Sara Oliveira, Cláudia Ferreira
P83 The Portuguese validation of the Dietary Intent Scale
Ana L. Mendes, Joana Marta-Simões, Inês A. Trindade, Cláudia Ferreira
P84 Construction and validation of the Inventory of Marital Violence (IVC)
Filipe Nave
P85 Portable continuous blood pressure monitor system
Mariana Campos, Iris Gaudêncio, Fernando Martins, Lino Ferreira, Nuno Lopes, Rui Fonseca-Pinto
P86 Construction and validation of the Scale of Perception of the Difficulties in Caring for the Elderly (SPDCE)
Rogério Rodrigues, Zaida Azeredo, Corália Vicente
P87 Development and validation of a comfort rating scale for the elderly hospitalized with chronic illness
Joana Silva, Patrícia Sousa, Rita Marques
P88 Construction and validation of the Postpartum Paternal Quality of Life Questionnaire (PP-QOL)
Isabel Mendes, Rogério Rodrigues, Zaida Azeredo, Corália Vicente
P89 Infrared thermal imaging: A tool for assessing diabetic foot ulcers
Ricardo Vardasca, Ana R. Marques, Adérito Seixas, Rui Carvalho, Joaquim Gabriel
P90 Pressure ulcers in an intensive care unit: An experience report
Paulo P. Ferreira, Michelle T. Oliveira, Anderson R. Sousa, Ana S. Maia, Sebastião T. Oliveira, Pablo O. Costa, Maiza M. Silva
P91 Validation of figures used in evocations: instrument to capture representations
Cristina Arreguy-Sena, Nathália Alvarenga-Martins, Paulo F. Pinto, Denize C. Oliveira, Pedro D. Parreira, Antônio T. Gomes, Luciene M. Braga
P92 Telephone assistance to decrease burden in informal caregivers of stroke older people: Monitoring and diagnostic evaluation
Odete Araújo, Isabel Lage, José Cabrita, Laetitia Teixeira
P93 Hope of informal caregivers of people with chronic and advanced disease
Rita Marques, Mª Anjos Dixe, Ana Querido, Patrícia Sousa
P94 Functionality and quality information from the Portuguese National Epidemiological Surveillance System
Sara Silva, Eugénio Cordeiro, João Pimentel
P95 Resting metabolic rate objectively measured vs. Harris and Benedict formula
Vera Ferro-Lebres, Juliana A. Souza, Mariline Tavares
O182 Characteristics of non-urgent patients: Cross-sectional study of an emergency department
Mª Anjos Dixe, Pedro Sousa, Rui Passadouro, Teresa Peralta, Carlos Ferreira, Georgina Lourenço
O183 Physical fitness and health in children of the 1st Cycle of Education
João Serrano, João Petrica, Rui Paulo, Samuel Honório, Pedro Mendes
O184 The impact of physical activity on sleep quality, in children
Alexandra Simões, Lucinda Carvalho, Alexandre Pereira
O185 What is the potential for using Information and Communication Technologies in Arterial Hypertension self-management?
Sara Silva, Paulino Sousa, José M. Padilha
O186 Exploring psychosocial factors associated with risk of falling in older patients undergoing haemodialysis
Daniela Figueiredo, Carolina Valente, Alda Marques
O187 Development of pressure ulcers on the face in patients undergoing non-invasive ventilation
Patrícia Ribas, Joana Sousa, Frederico Brandão, Cesar Sousa, Matilde Martins
O188 The elder hospitalized: Limiting factors of comfort
Patrícia Sousa, Rita Marques
O189 Physical activity and health state self-perception by Portuguese adults
Francisco Mendes, Rosina Fernandes, Emília Martins, Cátia Magalhães, Patrícia Araújo
O190 Satisfaction with social support in the elderly of the district of Bragança
Carla Grande, Mª Augusta Mata, Juan G. Vieitez
O191 Prevalence of death by traumatic brain injury and associated factors in intensive care unit of a general hospital, Brazil
Bruna Bianchini, Nazare Nazario, João G. Filho, Marcia Kretzer
O192 Relation between family caregivers burden and health status of elderly dependents
Tânia Costa, Armando Almeida, Gabriel Baffour
O193 Phenomena sensitive to nursing care in day centre
Armando Almeida, Tânia Costa, Gabriel Baffour
O194 Frailty: what do the elderly think?
Zaida Azeredo, Carlos Laranjeira, Magda Guerra, Ana P. Barbeiro
O195 The therapeutic self-care as a nursing-sensitive outcome: A correlational study
Regina Ferreira
O196 Phonetic-phonological acquisition for the European Portuguese from 18 months to 6 years and 12 months
Sara Lopes, Liliana Nunes, Ana Mendes
O197 Quality of life of patients undergoing liver transplant surgery
Julian Martins, Dulcineia Schneider, Marcia Kretzer, Flávio Magajewski
O198 Professional competences in health: views of older people from different European Countries
Célia Soares, António Marques
O199 Life satisfaction of working adults due to the number of hours of weekly exercise
Marco Batista, Ruth J. Castuera, Helena Mesquita, António Faustino, Jorge Santos, Samuel Honório
O200 Therapeutic itinerary of women with breast cancer in Santa Maria City/RS
Betina P. Vizzotto, Leticia Frigo, Hedioneia F. Pivetta
O201 The breastfeeding prevalence at 4 months: Maternal experience as a determining factor
Dolores Sardo
O202 The impact of the transition to parenthood in health and well-being
Cristina Martins, Wilson Abreu, Mª Céu Figueiredo
P96 Self-determined motivation and well-being in Portuguese active adults of both genders
Marco Batista, Ruth Jimenez-Castuera, João Petrica, João Serrano, Samuel Honório, Rui Paulo, Pedro Mendes
P97 The geriatric care: ways and means of comforting
Patrícia Sousa, Rita Marques
P98 The influence of relative age, subcutaneous adiposity and physical growth on Castelo Branco under-15 soccer players 2015
António Faustino, Paulo Silveira, João Serrano, Rui Paulo, Pedro Mendes, Samuel Honório
P99 Data for the diagnostic process focused on self-care – managing medication regime: An integrative literature review
Catarina Oliveira, Fernanda Bastos, Inês Cruz
P100 Art therapy as mental health promotion for children
Cláudia K. Rodriguez, Márcia R. Kretzer, Nazaré O. Nazário
P101 Chemical characterization of fungal chitosan for industrial applications
Pedro Cruz, Daniela C. Vaz, Rui B. Ruben, Francisco Avelelas, Susana Silva, Mª Jorge Campos
P102 The impact of caring older people at home
Maria Almeida, Liliana Gonçalves, Lígia Antunes
P103 Development of the first pressure ulcer in an inpatient setting: Focus on patients’ characteristics
Pedro Sardo, Jenifer Guedes, João Simões, Paulo Machado, Elsa Melo
P104 Association between General Self-efficacy and Physical Activity among Adolescents
Susana Cardoso, Osvaldo Santos, Carla Nunes, Isabel Loureiro
O203 Characterization of the habits of online acquisition of medicinal products in Portugal
Flávia Santos, Gilberto Alves
O204 Waiting room – A space for health education
Cláudia Soar, Teresa O. Marsi
O205 Safey culture evaluation in hospitalized children
Ernestina Silva, Dora Pedrosa, Andrea Leça, Daniel Silva
O206 Sexual Self-awareness and Body Image
Ana Galvão, Maria Gomes, Paula Fernandes, Ana Noné
O207 Perception of a Portuguese population regarding the acquisition and consumption of functional foods
Jaime Combadão, Cátia Ramalhete, Paulo Figueiredo, Patrícia Caeiro
O208 The work process in primary health care: evaluation in municipalities of southern Brazil
Karine C. Fontana, Josimari T. Lacerda, Patrícia O. Machado
O209 Exploration and evaluation of potential probiotic lactic acid bacteria isolated from Amazon buffalo milk
Raphaelle Borges, Flávio Barbosa, Dayse Sá
O210 Road safety for children: Using children’s observation, as a passenger
Germana Brunhoso, Graça Aparício, Amâncio Carvalho
O211 Perception and application of quality-by-design by the Pharmaceutical industry in Portugal
Ana P. Garcia, Paula O. Fernandes, Adriana Santos
O212 Oral health among Portuguese children and adolescents: a public health issue
Nélio Veiga, Carina Brás, Inês Carvalho, Joana Batalha, Margarida Glória, Filipa Bexiga, Inês Coelho, Odete Amaral, Carlos Pereira
O213 Plant species as a medicinal resource in Igatu-Chapada Diamantina (Bahia, Brazil)
Cláudia Pinho, Nilson Paraíso, Ana I. Oliveira, Cristóvão F. Lima, Alberto P. Dias
O214 Characterization of cognitive and functional performance in everyday tasks: Implications for health in institutionalised older adults
Pedro Silva, Mário Espada, Mário Marques, Ana Pereira
O215 BMI and the perception of the importance given to sexuality in obese and overweight people
Ana Mª Pereira, Mª Veiga-Branco, Filomena Pereira, Maria Ribeiro
O216 Analysis and comparison of microbiological contaminations of two different composition pacifiers
Vera Lima, Ana I. Oliveira, Cláudia Pinho, Graça Cruz, Rita F. Oliveira, Luísa Barreiros, Fernando Moreira
O217 Experiences of couple relationships in the transition to retirement
Ana Camarneiro, Mª Helena Loureiro, Margarida Silva
O218 Preventive and corrective treatment of drug-induced calcium deficiency: an analysis in a community pharmacy setting
Catarina Duarte, Ângelo Jesus, Agostinho Cruz
O219 Profile of mood states in physically active elderly subjects: Is there a relation with health perception?
Maria Mota, Sandra Novais, Paulo Nogueira, Ana Pereira, Lara Carneiro, Paulo V. João
O220 (Un)Safety behaviour at work: the role of education towards a health and safety culture
Teresa Maneca Lima
O221 Analysis of the entrepreneurial profile of students attending higher education in Portugal: the Carland Entrepreneurship Index application
Anabela Salgueiro-Oliveira, Marina Vaquinhas, Pedro Parreira, Rosa Melo, João Graveto, Amélia Castilho, José H. Gomes
O222 Evaluation of welfare and quality of life of pregnant working women regarding the age of the pregnant
María S. Medina, Valeriana G. Blanco
O223 Psychological wellbeing protection among unemployed and temporary workers: Uncovering effective community-based interventions with a Delphi panel
Osvaldo Santos, Elisa Lopes, Ana Virgolino, Alexandra Dinis, Sara Ambrósio, Inês Almeida, Tatiana Marques, Mª João Heitor
O224 Chilean population norms derived from the Health-related quality of life SF-6D
Miguel A. Garcia-Gordillo, Daniel Collado-Mateo, Pedro R. Olivares, José A. Parraça, José A. Sala
O225 Motivation of college students toward Entrepreneurship: The influence of social and economic instability
Amélia Castilho, João Graveto, Pedro Parreira, Anabela Oliveira, José H. Gomes, Rosa Melo, Marina Vaquinhas
O226 Use of aromatic and medicinal plants, drugs and herbal products in Bragança city
Mónia Cheio, Agostinho Cruz, Olívia R. Pereira
O227 Edible flowers as new novel foods concept for health promotion
Sara Pinto, Adriana Oliveira, M. Conceição Manso, Carla Sousa, Ana F. Vinha
O228 The influence of leisure activities on the health and welfare of older people living in nursing homes
Mª Manuela Machado, Margarida Vieira
O229 Risk of falling, fear of falling and functionality in community-dwelling older adults
Beatriz Fernandes, Teresa Tomás, Diogo Quirino
O230 Musculoskeletal pain and postural habits in children and teenage students
Gustavo Desouzart, Rui Matos, Magali Bordini, Pedro Mouroço
O231 What's different in Southern Europe? The question of citizens’ participation in health systems
Ana R. Matos, Mauro Serapioni
O232 Occupational stress in Portuguese police officers
Teresa Guimarães, Virgínia Fonseca, André Costa, João Ribeiro, João Lobato
O233 Is occupational therapy culturally relevant to promote mental health in Burkina Faso?
Inmaculada Z. Martin, Anita Björklund
P105 Pay-for-performance satisfaction and quality in primary care
Aida I. Tavares, Pedro Ferreira, Rui Passadouro
P106 Economic development through life expectancy lenses
Sónia Morgado
P107 What is the effectiveness of exercise on smoking cessation to prevent clinical complications of smoking?
Nuno Tavares, João Valente, Anabela C. Martins
P108 A systematic review of the effects of yoga on mental health
Patrícia Araújo, Rosina Fernandes, Francisco Mendes, Cátia Magalhães, Emília Martins
P109 Healthy lifestyle: comparison between higher education students that lived until adult age in rural and urban environment
Pedro Mendes, Rui Paulo, António Faustino, Helena Mesquita, Samuel Honório, Marco Batista
P110 Evaluation of the Mobile Emergency Care Service (SAMU) in Brazil
Josimari T. Lacerda, Angela B. Ortiga, Mª Cristina Calvo, Sônia Natal
P111 Bioactive compounds - antioxidant activity of tropical fruits
Marta Pereira
P112 Use of non-pharmacological methods to relieve pain in labour
Manuela Ferreira, Ana R. Prata, Paula Nelas, João Duarte
P113 Mechanical safety of pacifiers sold in Portuguese pharmacies and childcare stores
Juliana Carneiro, Ana I. Oliveira, Cláudia Pinho, Cristina Couto, Rita F. Oliveira, Fernando Moreira
P114 The importance of prenatal consultation: Information to pregnant women given on a unit of primary care
Ana S. Maia, Michelle T. Oliveira, Anderson R. Sousa, Paulo P. Ferreira, Géssica M. Souza, Lívia F. Almada, Milena A. Conceição, Eujcely C. Santiago
P115 Influence of different backpack loading conditions on neck and lumbar muscles activity of elementary school children
Sandra Rodrigues, Gabriela Domingues, Irina Ferreira, Luís Faria, Adérito Seixas
P116 Efficacy and safety of dry extract Hedera helix in the treatment of productive cough
Ana R. Costa, Ângelo Jesus, Américo Cardoso, Alexandra Meireles, Armanda Colaço, Agostinho Cruz
P117 A portrait of the evaluation processes of education groups in primary health care
Viviane L. Vieira, Kellem R. Vincha, Ana Mª Cervato-Mancuso
P118 Benefits of vitamins C and E in sensorineural hearing loss: a review
Melissa Faria, Cláudia Reis
P119 BODY SNAPSHOT – a web-integrated anthropometric evaluation system
Marco P. Cova, Rita T. Ascenso, Henrique A. Almeida, Eunice G. Oliveira
P120 Anthropometric evaluation and variation during pregnancy
Miguel Santana, Rafael Pereira, Eunice G. Oliveira, Henrique A. Almeida, Rita T. Ascenso
P121 Knowledge of college students on the amendments of their eating habits and physical activity index in the transition to higher education
Rita Jesus, Rodrigo Tapadas, Carolina Tim-Tim, Catarina Cezanne, Matilde Lagoa, Sara S. Dias, Jorge Torgal
P122 Muscular activity of a rally race car driver
João Lopes, Henrique Almeida, Sandra Amado, Luís Carrão
O234 Literacy and results in health
Madalena Cunha, Luís Saboga-Nunes, Carlos Albuquerque, Olivério Ribeiro
O235 Literacy promotion and empowerment of type 2 diabetics elderly in four family health units of the group of health centers of Dão Lafões
Suzete Oliveira, Mª Carminda Morais
O236 Mediterranean diet, health and life quality among Portuguese children
Emília Martins, Francisco Mendes, Rosina Fernandes, Cátia Magalhães, Patrícia Araújo
O237 Health literacy, from data to action - translation, validation and application of the European Health Literacy Survey in Portugal (HLS-EU-PT)
Ana R. Pedro, Odete Amaral, Ana Escoval
O238 Oral health literacy evaluation in a Portuguese military population
Victor Assunção, Henrique Luís, Luís Luís
O239 Preferences to Internet-based cognitive behavioural therapy – do attachment orientations matter?
Jennifer Apolinário-Hagen, Viktor Vehreschild
O240 A comparative transnational study in health literacy between Austria and Portugal
Ulrike Fotschl, Gerald Lirk, Anabela C. Martins, Isabel Andrade, Fernando Mendes
O241 Health literacy and social behaviours: relationship with sexually transmitted diseases?
Verónica Mendonça, Sandra Antunes, Isabel Andrade, Nádia Osório, Ana Valado, Armando Caseiro, António Gabriel, Anabela C. Martins, Fernando Mendes
O242 Parenting styles and attachment to parents: what relationships?
Paula A. Silva, Lisete M. Mónico, Pedro M. Parreira, Carla Carvalho
O243 Work-life balance in health professionals and professors: comparative study of workers with shift work and fixed schedule
Carla Carvalho, Pedro M. Parreira, Lisete M. Mónico, Joana Ruivo
O244 Technology literacy in self-management of diabetes
Vânia Silva, Paulino Sousa, José M. Padilha
O245 Satisfaction with therapeutic education and its relationship with clinical variables in children with type 1 diabetes
Vera Ferraz, Graça Aparício, João Duarte
O246 Nutrition-related knowledge in middle-age and older patients with type 2 diabetes
Carlos Vasconcelos, António Almeida, Joel Neves, Telma Correia, Helena Amorim, Romeu Mendes
O247 Validating the HLS-EU-(PT) questionnaire to measure health literacy in adolescents (CrAdLiSa project: HLS-EU-PT)
Luís Saboga-Nunes, Madalena Cunha, Carlos Albuquerque
O248 Health education in people with coronary heart disease: Experience of the cardiology department of a hospital on the outskirts of Lisbon
Elsa S. Pereira, Leonino S. Santos, Ana S. Reis, Helena R. Silva, João Rombo, Jorge C. Fernandes, Patrícia Fernandes
O249 Information and training needs of informal caregivers of individuals with stroke sequelae: a qualitative survey
Jaime Ribeiro, Catarina Mangas, Ana Freire
O250 Prevention of psychoactive substances consumption in students from 6th grade of Albergaria-a-Velha´s School Group
Sara Silva, Irene Francisco, Ana Oliveira
O251 Promoting healthy sexuality: shared responsibility for family, youth and educators
Helena Catarino, Mª Anjos Dixe, Mª Clarisse Louro
O252 Sexual risk behaviour in adolescents and young people
Saudade Lopes, Anjos Dixe
O253 Knowledge of school staff on type 1 diabetes
Mª Anjos Dixe, Eva Menino, Helena Catarino, Fátima Soares, Ana P. Oliveira, Sara Gordo, Teresa Kraus
O254 Sexual health in adolescents: the impact of information search in literacy
Catarina Tomás, Paulo Queirós, Teresa Rodrigues
P123 Improving basic life support skills in adolescents through a training programme
Pedro Sousa, João G. Frade, Catarina Lobão
P124 Difficulties in sexual education reported by basic education teachers in the city of Foz do Iguaçu - Brazil
Cynthia B. Moura, Laysa C. Dreyer, Vanize Meneghetti, Priscila P. Cabral
P125 Breast cancer survivors: subjects and resources for information. A qualitative systematic review
Francisca Pinto, Paulino Sousa, Mª Raquel Esteves
P126 Relationship between health literacy and prevalence of STI in Biomedical Laboratory Science students
Sofia Galvão, Ite Tytgat, Isabel Andrade, Nádia Osório, Ana Valado, Armando Caseiro, António Gabriel, Anabela C. Martins, Fernando Mendes
P127 Health literacy, risk behaviours and sexually transmitted diseases among blood donors
Mónica Casas-Novas, Helena Bernardo, Isabel Andrade, Gracinda Sousa, Ana P. Sousa, Clara Rocha, Pedro Belo, Nádia Osório, Ana Valado, Armando Caseiro, António Gabriel, Anabela C. Martins, Fernando Mendes
P128 Promoting literacy in pregnancy health-care
Fátima Martins, Montserrat Pulido-Fuentes
P129 The lifestyles of the operating assistants of education
Isabel Barroso, Gil Cabral, M. João Monteiro, Conceição Rainho
P130 Experiences of service-learning health and the literary art: reflections about the health education
Alessandro Prado, Yara M. Carvalho
P131 Life long swimming – a European Erasmus + project
Maria Campos, Liliana Moreira, José Ferreira, Ana Teixeira, Luís Rama
doi:10.1186/s12913-016-1423-5
PMCID: PMC4943498  PMID: 27409075
7.  Experiences with Policing among People Who Inject Drugs in Bangkok, Thailand: A Qualitative Study 
PLoS Medicine  2013;10(12):e1001570.
Using thematic analysis, Kerr and colleagues document the experiences of policing among people who inject drugs in Bangkok and examine how interactions with police can affect drug-using behaviors and health care access.
Please see later in the article for the Editors' Summary
Background
Despite Thailand's commitment to treating people who use drugs as “patients” not “criminals,” Thai authorities continue to emphasize criminal law enforcement for drug control. In 2003, Thailand's drug war received international criticism due to extensive human rights violations. However, few studies have since investigated the impact of policing on drug-using populations. Therefore, we sought to examine experiences with policing among people who inject drugs (PWID) in Bangkok, Thailand, between 2008 and 2012.
Methods and Findings
Between July 2011 and June 2012, semi-structured, in-depth interviews were conducted with 42 community-recruited PWID participating in the Mitsampan Community Research Project in Bangkok. Interviews explored PWID's encounters with police during the past three years. Audio-recorded interviews were transcribed verbatim, and a thematic analysis was conducted to document the character of PWID's experiences with police. Respondents indicated that policing activities had noticeably intensified since rapid urine toxicology screening became available to police. Respondents reported various forms of police misconduct, including false accusations, coercion of confessions, excessive use of force, and extortion of money. However, respondents were reluctant to report misconduct to the authorities in the face of social and structural barriers to seeking justice. Respondents' strategies to avoid police impeded access to health care and facilitated transitions towards the misuse of prescribed pharmaceuticals. The study's limitations relate to the transferability of the findings, including the potential biases associated with the small convenience sample.
Conclusions
This study suggests that policing in Bangkok has involved injustices, human rights abuses, and corruption, and policing practices in this setting appeared to have increased PWID's vulnerability to poor health through various pathways. Novel to this study are findings pertaining to the use of urine drug testing by police, which highlight the potential for widespread abuse of this emerging technology. These findings raise concern about ongoing policing practices in this setting.
Please see later in the article for the Editors' Summary
Editors' Summary
Background
In many countries, the dominant strategy used to control illegal drugs such as heroin and methamphetamine is criminal law enforcement, a strategy that sometimes results in human rights abuses such as ill-treatment by police, extrajudicial killings, and arbitrary detention. Moreover, growing evidence suggests that aggressive policing of illicit drug use can have adverse public-health consequences. For example, the fear engendered by intensive policing may cause people who inject drugs (PWID) to avoid services such as needle exchanges, thereby contributing to the HIV/AIDS epidemic. One country with major epidemics of illicit drug use and of HIV/AIDS among PWID is Thailand. Although Thailand reclassified drug users as “patients” instead of “criminals” in 2002, possession and consumption of illicit drugs remain criminal offenses. The 2002 legislation also created a system of compulsory drug detention centers, most of which lack evidence-based addiction treatment services. In 2003, the Thai government launched a campaign to suppress drug trafficking and to enrol 300,000 people who use drugs into treatment. This campaign received international criticism because it involved extensive human rights violations, including more than 2,800 extrajudicial killings of suspected drug users and dealers.
Why Was This Study Done?
Drug-related arrests and compulsory detention of drug users are increasing in Thailand but what is the impact of current policing practices on drug users and on public health? In this qualitative study (a study that aims for an in-depth understanding of human behavior), the researchers use thematic analysis informed by the Rhodes' Risk Environment Framework to document the social and structural factors that led to encounters with the police among PWID in Bangkok between 2008 and 2012, the policing tactics employed during these encounters, and the associated health consequences of these encounters. The Risk Environment Framework posits that a range of social, political, economic, and physical environmental factors interact with each other and shape the production of drug-related harm.
What Did the Researchers Do and Find?
Between July 2011 and June 2012, the researchers conducted in-depth interviews with a convenience sample (a non-random sample from a nearby population) of 42 participants in the Mitsampan Community Research Project, an investigation of drug-using behavior, health care access, and drug-related harms among PWID in Bangkok. Respondents reported that policing activities had intensified since rapid urine toxicology screening became widely available and since the initiation of a crackdown on drug users in 2011. They described various forms of violence and misconduct that they had experienced during confrontations with police, including false accusations, degrading stop and search procedures, and excessive use of force. Urine drug testing was identified as a key tool used by the police, with some respondents describing how police caused unnecessary humiliation by requesting urine samples in public places. It was also reported that the police used positive test results as a means of extortion. Finally, some respondents reported feeling powerless in relation to the police and cited fear of retaliation as an important barrier to obtaining redress for police corruption. Others reported that they had adopted strategies to avoid the police such as staying indoors, a strategy likely to impede access to health care, or changing their drug-using behavior by, for example, injecting midazolam rather than methamphetamine, a practice associated with an increased risk of injection-related complications.
What Do These Findings Mean?
These findings suggest that the policing of PWID in Bangkok between 2008 and 2012 involved injustices, human rights abuses, and corruption and highlight the potential for widespread misuse of urine drug testing. Moreover, they suggest that policing practices in this setting may have increased the vulnerability of PWID to poor health by impeding their access to health care and by increasing the occurrence of risky drug-using behaviors. Because this study involved a small convenience sample of PWID, these findings may not be generalizable to other areas of Bangkok or Thailand and do not indicate whether police misconduct and corruption is highly prevalent across the all police departments in Bangkok. Nevertheless, these findings suggest that multilevel structural changes and interventions are needed to mitigate the harm associated with policing of illicit drug use in Bangkok. These changes will need to ensure full accountability for police misconduct and access to legal services for victims of this misconduct. They will also need to include ethical guidelines for urine drug testing and the reform of policies that promote repressive policing and compulsory detention.
Additional Information
Please access these websites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001570.
This study is further discussed in a PLOS Medicine Perspective by Burris and Koester
Human Rights Watch, a global organization dedicated to defending and protecting human rights, has information about drug policy and human rights, which includes information on Thailand
The Global Commission on Drug Policy published a report in June 2012 entitled “The War on Drugs and HIV/AIDS: How the Criminalization of Drug Use Fuels the Global Pandemic” (available in several languages)
The Global Commission on HIV and the Law published a report in July 2012 entitled “HIV and the Law: Risk, Rights and Health” (available in several languages), the Open Society Foundations have prepared a briefing on this report
More information about the Mitsampan Community Research Project is available
doi:10.1371/journal.pmed.1001570
PMCID: PMC3858231  PMID: 24339753
8.  Quality of Private and Public Ambulatory Health Care in Low and Middle Income Countries: Systematic Review of Comparative Studies 
PLoS Medicine  2011;8(4):e1000433.
Paul Garner and colleagues conducted a systematic review of 80 studies to compare the quality of private versus public ambulatory health care in low- and middle-income countries.
Background
In developing countries, the private sector provides a substantial proportion of primary health care to low income groups for communicable and non-communicable diseases. These providers are therefore central to improving health outcomes. We need to know how their services compare to those of the public sector to inform policy options.
Methods and Findings
We summarised reliable research comparing the quality of formal private versus public ambulatory health care in low and middle income countries. We selected studies against inclusion criteria following a comprehensive search, yielding 80 studies. We compared quality under standard categories, converted values to a linear 100% scale, calculated differences between providers within studies, and summarised median values of the differences across studies. As the results for for-profit and not-for-profit providers were similar, we combined them. Overall, median values indicated that many services, irrespective of whether public or private, scored low on infrastructure, clinical competence, and practice. Overall, the private sector performed better in relation to drug supply, responsiveness, and effort. No difference between provider groups was detected for patient satisfaction or competence. Synthesis of qualitative components indicates the private sector is more client centred.
Conclusions
Although data are limited, quality in both provider groups seems poor, with the private sector performing better in drug availability and aspects of delivery of care, including responsiveness and effort, and possibly being more client orientated. Strategies seeking to influence quality in both groups are needed to improve care delivery and outcomes for the poor, including managing the increasing burden of non-communicable diseases.
Please see later in the article for the Editors' Summary
Editors' Summary
Background
The provision of private (“for-profit” hospitals and self-employed practitioners, and “not-for-profit” non-government providers, including faith-based organizations) versus public health care services in low and middle income countries raises considerable ideological debate. Ideological arguments aside—which can be very passionate on both sides—there is general agreement that improving the quality of both public and private health care could have a major impact on improved health outcomes, especially as the private sector is so widely used in low and middle income countries. For example, almost three quarters and half of children from the poorest households of South Asia and sub-Saharan Africa, respectively, seek health care from a private provider when they are ill. Private providers are also increasingly responsible for outpatient care for non-communicable diseases.
As a result of the mixed health care system in many low and middle income countries, adequate oversight and stewardship of the mixed system from the national government is essential yet often missing.
Why Was This Study Done?
An understanding of how quality and performance in the private sector compares with that in the public sector would help governments to prioritize where they need to concentrate their efforts. So, for example, if the private sector is generally providing poorer quality care than the public sector, then there is an imperative to improve the quality and outcomes; on the other hand, if the quality of care offered by the private sector is good, the policy priority is to influence the market to further improve access to such health care for low income groups.
In order to help with this comparison, the researchers wanted to systematically identify and summarize the results of studies that directly compared the quality of care offered by public providers with the one offered by “formal” private providers (recognized by law) and “informal” private providers (providers that are not legally recognized, such as lay health workers and shop keepers). For the purposes of this study the researchers focused their comparison on the private and public provision of outpatient care in low and middle income countries.
What Did the Researchers Do and Find?
In their literature review, the researchers searched for relevant studies reported in English, French, or German and published between January 1970 and April 2009. Only studies that compared private and public outpatient medical services in the same country, at the same time, using the same methods, and which met particular quality criteria, were included in the analysis. The researchers also had strict criteria for including qualitative studies, and they retrieved the full text of articles, contacted study authors where appropriate, and verified with a second researcher most (80%) of the extracted study data. In order to evaluate and compare the studies, the researchers converted study values to a linear 100% scale, calculated differences between providers within studies, and summarized the median values of the differences across studies.
The researchers identified a total of 8,812 relevant titles and abstracts and found 80 studies that included direct quantitative comparisons of public and private formal providers. Ten studies included qualitative data. Most studies were conducted after 1990, and mainly in sub-Saharan Africa (n = 39) and Asia and the Pacific (n = 23). Most studies did not report socio-economic status of public and private service users, and only five studies presented data by different income groups. No study compared the same individual providers working in public and private care settings. Only two studies compared public providers and private informal providers, so the authors excluded these from subsequent analysis.
For the formal sector, since the results for “for-profit” and “not-for-profit” providers were similar, the researchers decided to combine the results. Overall, the researchers found that the median values indicated that many services, irrespective of whether public or private, scored low (less than 50%) on infrastructure, clinical competence, and practice. Generally, the private sector performed better in relation to drug supply, responsiveness, and effort, but there was no detectable difference between provider groups for patient satisfaction. Furthermore, a synthesis of qualitative data suggested that the private sector may be more client-centered.
What Do These Findings Mean?
Based on the findings of this review, there is a clear need to consider the quality of primary health services in both the public and private sector in order to improve health outcomes in low and middle income countries. These findings also indicate that, for some aspects of care, on average the private sector provided better quality services. The overall low quality of care in both the formal private and public sector found in this review is worrying, and calls for the governments of low and middle income countries to find and implement effective strategies to improve the quality in both sectors. This is particularly important given the increasing volume of conditions that require relatively sophisticated, long-term ambulatory medical care, such as non-communicable diseases.
Additional Information
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1000433.
This study is further discussed in a PLoS Medicine Perspective by Jishnu Das
WHO has more information on health service delivery in low- and middle-income countries
WHO has more information on noncommunicable diseases
The World Bank's World Development Report for 2004 addresses health care for poor people
doi:10.1371/journal.pmed.1000433
PMCID: PMC3075233  PMID: 21532746
9.  “Working the System”—British American Tobacco's Influence on the European Union Treaty and Its Implications for Policy: An Analysis of Internal Tobacco Industry Documents 
PLoS Medicine  2010;7(1):e1000202.
Katherine Smith and colleagues investigate the ways in which British American Tobacco influenced the European Union Treaty so that new EU policies advance the interests of major corporations, including those that produce products damaging to health.
Background
Impact assessment (IA) of all major European Union (EU) policies is now mandatory. The form of IA used has been criticised for favouring corporate interests by overemphasising economic impacts and failing to adequately assess health impacts. Our study sought to assess how, why, and in what ways corporations, and particularly the tobacco industry, influenced the EU's approach to IA.
Methods and Findings
In order to identify whether industry played a role in promoting this system of IA within the EU, we analysed internal documents from British American Tobacco (BAT) that were disclosed following a series of litigation cases in the United States. We combined this analysis with one of related literature and interviews with key informants. Our analysis demonstrates that from 1995 onwards BAT actively worked with other corporate actors to successfully promote a business-oriented form of IA that favoured large corporations. It appears that BAT favoured this form of IA because it could advance the company's European interests by establishing ground rules for policymaking that would: (i) provide an economic framework for evaluating all policy decisions, implicitly prioritising costs to businesses; (ii) secure early corporate involvement in policy discussions; (iii) bestow the corporate sector with a long-term advantage over other actors by increasing policymakers' dependence on information they supplied; and (iv) provide businesses with a persuasive means of challenging potential and existing legislation. The data reveal that an ensuing lobbying campaign, largely driven by BAT, helped secure binding changes to the EU Treaty via the Treaty of Amsterdam that required EU policymakers to minimise legislative burdens on businesses. Efforts subsequently focused on ensuring that these Treaty changes were translated into the application of a business orientated form of IA (cost–benefit analysis [CBA]) within EU policymaking procedures. Both the tobacco and chemical industries have since employed IA in apparent attempts to undermine key aspects of European policies designed to protect public health.
Conclusions
Our findings suggest that BAT and its corporate allies have fundamentally altered the way in which all EU policy is made by making a business-oriented form of IA mandatory. This increases the likelihood that the EU will produce policies that advance the interests of major corporations, including those that produce products damaging to health, rather than in the interests of its citizens. Given that the public health community, focusing on health IA, has largely welcomed the increasing policy interest in IA, this suggests that urgent consideration is required of the ways in which IA can be employed to undermine, as well as support, effective public health policies.
Please see later in the article for the Editors' Summary
Editors' Summary
Background
The primary goal of public health, the branch of medicine concerned with the health of communities, is to improve lives by preventing disease. Public-health groups do this by assessing and monitoring the health of communities, by ensuring that populations have access to appropriate and cost-effective health care, and by helping to formulate public policies that safeguard human health. Until recently, most of the world's major public-health concerns related to infectious diseases. Nowadays, however, many major public-health concerns are linked to the goods made and marketed by large corporations such as fast food, alcohol, tobacco, and chemicals. In Europe, these corporations are regulated by policies drawn up both by member states and by the European Commission, the executive organ of the European Union (EU; an economic and political partnership among 27 democratic European countries). Thus, for example, the tobacco industry, which is widely recognized as a driver of the smoking epidemic, is regulated by Europe-wide tobacco control policies and member state level policies.
Why Was This Study Done?
Since 1997, the European Commission has been required by law to assess the economic, social (including health), and environmental consequences of new policy initiatives using a process called an “impact assessment” (IA). Because different types of IA examine the likely effects of policies on different aspects of daily life—a health impact assessment, for example, focuses on a policy's effect on health—the choice of IA can lead to different decisions being taken about new policies. Although the IA tool adopted by the European Commission aims to assess economic, environmental and social impacts, independent experts suggest this tool does not adequately assess health impacts. Instead, economic impacts receive the most attention, a situation that may favour the interests of large businesses. In this study, the researchers seek to identify how and why the EU's approach to IA developed. More specifically, the researchers analyze internal documents from British American Tobacco (BAT), which have been disclosed because of US litigation cases, to find out whether industry has played a role in promoting the EU's system of IA.
What Did the Researchers Do and Find?
The researchers analyzed 714 BAT internal documents (identified by searching the Legacy Tobacco Documents Library, which contains more than 10 million internal tobacco company documents) that concerned attempts made by BAT to influence regulatory reforms in Europe. They also analyzed related literature from other sources (for example, academic publications) and interviewed 16 relevant people (including people who had worked at the European Commission). This analysis shows that from 1995, BAT worked with other businesses to promote European regulatory reforms (in particular, the establishment of a business-orientated form of IA) that favor large corporations. A lobbying campaign, initiated by BAT but involving a “policy network” of other companies, first helped to secure binding changes to the EU Treaty that require policymakers to minimize legislative burdens on businesses. The analysis shows that after achieving this goal, which BAT described as an “important victory,” further lobbying ensured that these treaty changes were translated into the implementation of a business-orientated form of IA within the EU. Both the tobacco industry and the chemical industry, the researchers argue, have since used the IA to delay and/or weaken EU legislation intended to protect public health.
What Do These Findings Mean?
These findings suggest that BAT and its corporate allies have fundamentally altered the way in which EU policy is made by ensuring that all significant EU policy decisions have to be assessed using a business-orientated IA. As the authors note, this situation increases the likelihood that the EU will produce policies that favor big business rather than the health of its citizens. Furthermore, these findings suggest that by establishing a network of other industries to help in lobbying for EU Treaty changes, BAT was able to distance itself from the push to establish a business-orientated IA to the extent that Commission officials were unaware of the involvement of the tobacco industry in campaigns for IA. Thus, in future, to safeguard public health, policymakers and public-health groups must pay more attention to corporate efforts to shape decision-making processes. In addition, public-health groups must take account of the ways in which IA can be used to undermine as well as support effective public-health policies and they must collaborate more closely in their efforts to ensure effective national and international policy.
Additional Information
Please access these Web sites via the online version of this summary at http://dx.doi.org/0.1371/journal.pmed.1000202.
Wikipedia has a page on public health (note that Wikipedia is a free online encyclopedia that anyone can edit; available in several languages)
More information on the European Union (in several languages), on public health in the European Union, and on impact assessment by the European Commission is available
The Legacy Tobacco Documents Library is a public, searchable database of tobacco company internal documents detailing their advertising, manufacturing, marketing, sales, and scientific activities
The World Health Organization provides information about the dangers of tobacco (in several languages)
The Smoke Free Partnership contains more information about smoking prevalence in Europe and about European policies to tackle the public health issues associated with tobacco use
For more information about tobacco industry influence on policy see the 2009 World Health Organization report on tobacco industry interference with tobacco control
doi:10.1371/journal.pmed.1000202
PMCID: PMC2797088  PMID: 20084098
10.  Global Health Governance and the Commercial Sector: A Documentary Analysis of Tobacco Company Strategies to Influence the WHO Framework Convention on Tobacco Control 
PLoS Medicine  2012;9(6):e1001249.
Heide Weishaar and colleagues did an analysis of internal tobacco industry documents together with other data and describe the industry's strategic response to the proposed World Health Organization Framework Convention on Tobacco Control.
Background
In successfully negotiating the Framework Convention on Tobacco Control (FCTC), the World Health Organization (WHO) has led a significant innovation in global health governance, helping to transform international tobacco control. This article provides the first comprehensive review of the diverse campaign initiated by transnational tobacco corporations (TTCs) to try to undermine the proposed convention.
Methods and Findings
The article is primarily based on an analysis of internal tobacco industry documents made public through litigation, triangulated with data from official documentation relating to the FCTC process and websites of relevant organisations. It is also informed by a comprehensive review of previous studies concerning tobacco industry efforts to influence the FCTC. The findings demonstrate that the industry's strategic response to the proposed WHO convention was two-fold. First, arguments and frames were developed to challenge the FCTC, including: claiming there would be damaging economic consequences; depicting tobacco control as an agenda promoted by high-income countries; alleging the treaty conflicted with trade agreements, “good governance,” and national sovereignty; questioning WHO's mandate; claiming the FCTC would set a precedent for issues beyond tobacco; and presenting corporate social responsibility (CSR) as an alternative. Second, multiple tactics were employed to promote and increase the impact of these arguments, including: directly targeting FCTC delegations and relevant political actors, enlisting diverse allies (e.g., mass media outlets and scientists), and using stakeholder consultation to delay decisions and secure industry participation.
Conclusions
TTCs' efforts to undermine the FCTC were comprehensive, demonstrating the global application of tactics that TTCs have previously been found to have employed nationally and further included arguments against the FCTC as a key initiative in global health governance. Awareness of these strategies can help guard against industry efforts to disrupt the implementation of the FCTC and support the development of future, comparable initiatives in global health.
Please see later in the article for the Editors' Summary
Editors' Summary
Background
Every year, about 5 million people die worldwide from tobacco-related causes and, if current trends continue, annual deaths from tobacco-related causes will increase to 10 million by 2030. In response to this global tobacco epidemic, the World Health Organization (WHO) has developed an international instrument for tobacco control called the Framework Convention on Tobacco Control (FCTC). Negotiations on the FCTC began in 1999, and the international treaty—the first to be negotiated under the auspices of WHO—entered into force on 27 February 2005. To date, 174 countries have become parties to the FCTC. As such, they agree to implement comprehensive bans on tobacco advertising, promotion, and sponsorship; to ban misleading and deceptive terms on cigarette packaging; to implement health warnings on tobacco packaging; to protect people from tobacco smoke exposure in public spaces and indoor workplaces; to implement taxation policies aimed at reducing tobacco consumption; and to combat illicit trade in tobacco products.
Why Was This Study Done?
Transnational tobacco corporations (TTCs) are sometimes described as “vectors” of the global tobacco epidemic because of their drive to maximize shareholder value and tobacco consumption. Just like conventional disease vectors (agents that carry or transmit infectious organisms), TTCs employ a variety of tactics to ensure the spread of tobacco consumption. For example, various studies have shown that TTCs have developed strategies that attempt to limit the impact of tobacco control measures such as the FCTC. However, to date, studies investigating the influence of TTCs on the FCTC have concentrated on specific countries or documented specific tactics. Here, the researchers undertake a comprehensive review of the diverse tactics employed by TTCs to undermine the development of the FCTC. Such a review is important because its results should facilitate the effective implementation of FCTC measures and could support the development of future tobacco control initiatives and of global initiatives designed to control alcohol-related and food-related disease and death.
What Did the Researchers Do and Find?
The researchers analyzed documents retrieved from the Legacy Tobacco Documents Library (a collection of internal tobacco industry documents released as a result of US litigation cases) dealing with the strategies employed by TTCs to influence the FCTC alongside data from the websites of industry, consultancy, and other organizations cited in the documents; the official records of the FCTC process; and previous studies of tobacco industry efforts to influence the FCTC. Their analysis reveals that the strategic response of the major TTCs to the proposed FCTC was two-fold. First, the TTCs developed a series of arguments and “frames” (beliefs and ideas that provide a framework for thinking about an issue) to challenge the FCTC. Core frames included claiming that the FCTC would have damaging economic consequences, questioning WHO's mandate to develop a legally binding international treaty by claiming that tobacco was not a cross-border problem, and presenting corporate social responsibility (the commitment by business to affect the environment, consumers, employees, and society positively in addition to making money for shareholders) as an alternative to the FCTC. Second, the TTCs employed multiple strategies to promote and increase the impact of these arguments and frames, such as targeting FCTC delegations and enlisting the help of diverse allies including media outlets and scientists.
What Do These Findings Mean?
These findings illustrate the variety and complexity of the tobacco industry's efforts to undermine the FCTC and show the extent to which TTCs combined and coordinated tactics on a global stage that they had previously used on a national stage. Indeed, “the comprehensiveness and scale of the tobacco industry's response to the FCTC suggests that it is reasonable to speak of a ‘globalisation of tobacco industry strategy’ in combating the development of effective tobacco control policies,” write the researchers. Awareness of the strategies employed by TTCs to influence the FCTC should help guard against industry efforts to disrupt the implementation of the FCTC and should support the development of future global tobacco control initiatives. More generally, these findings should support the development of global health initiatives designed to tackle cardiovascular disease, cancer, chronic respiratory diseases and diabetes – non-communicable diseases that together account for 60% of global deaths and are partly driven by the commercial activities of food, alcohol, and tobacco corporations.
Additional Information
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001249.
The World Health Organization provides information about the dangers of tobacco (in several languages) and about the Framework Convention on Tobacco Control
For information about the tobacco industry's influence on policy, see the 2009 World Health Organization report Tobacco interference with tobacco control
The Framework Convention Alliance provides more information about the FCTC
The Legacy Tobacco Documents Library is a public, searchable database of tobacco company internal documents detailing their advertising, manufacturing, marketing, sales, and scientific activities
The UK Centre for Tobacco Control Studies is a network of UK universities that undertakes original research, policy development, advocacy, and teaching and training in the field of tobacco control
SmokeFree, a website provided by the UK National Health Service, offers advice on quitting smoking and includes personal stories from people who have stopped smoking
Smokefree.gov, from the US National Cancer Institute, offers online tools and resources to help people quit smoking and not start again
doi:10.1371/journal.pmed.1001249
PMCID: PMC3383743  PMID: 22745607
11.  Implementing the 2009 Institute of Medicine recommendations on resident physician work hours, supervision, and safety 
Long working hours and sleep deprivation have been a facet of physician training in the US since the advent of the modern residency system. However, the scientific evidence linking fatigue with deficits in human performance, accidents and errors in industries from aeronautics to medicine, nuclear power, and transportation has mounted over the last 40 years. This evidence has also spawned regulations to help ensure public safety across safety-sensitive industries, with the notable exception of medicine.
In late 2007, at the behest of the US Congress, the Institute of Medicine embarked on a year-long examination of the scientific evidence linking resident physician sleep deprivation with clinical performance deficits and medical errors. The Institute of Medicine’s report, entitled “Resident duty hours: Enhancing sleep, supervision and safety”, published in January 2009, recommended new limits on resident physician work hours and workload, increased supervision, a heightened focus on resident physician safety, training in structured handovers and quality improvement, more rigorous external oversight of work hours and other aspects of residency training, and the identification of expanded funding sources necessary to implement the recommended reforms successfully and protect the public and resident physicians themselves from preventable harm.
Given that resident physicians comprise almost a quarter of all physicians who work in hospitals, and that taxpayers, through Medicare and Medicaid, fund graduate medical education, the public has a deep investment in physician training. Patients expect to receive safe, high-quality care in the nation’s teaching hospitals. Because it is their safety that is at issue, their voices should be central in policy decisions affecting patient safety. It is likewise important to integrate the perspectives of resident physicians, policy makers, and other constituencies in designing new policies. However, since its release, discussion of the Institute of Medicine report has been largely confined to the medical education community, led by the Accreditation Council for Graduate Medical Education (ACGME).
To begin gathering these perspectives and developing a plan to implement safer work hours for resident physicians, a conference entitled “Enhancing sleep, supervision and safety: What will it take to implement the Institute of Medicine recommendations?” was held at Harvard Medical School on June 17–18, 2010. This White Paper is a product of a diverse group of 26 representative stakeholders bringing relevant new information and innovative practices to bear on a critical patient safety problem. Given that our conference included experts from across disciplines with diverse perspectives and interests, not every recommendation was endorsed by each invited conference participant. However, every recommendation made here was endorsed by the majority of the group, and many were endorsed unanimously. Conference members participated in the process, reviewed the final product, and provided input before publication. Participants provided their individual perspectives, which do not necessarily represent the formal views of any organization.
In September 2010 the ACGME issued new rules to go into effect on July 1, 2011. Unfortunately, they stop considerably short of the Institute of Medicine’s recommendations and those endorsed by this conference. In particular, the ACGME only applied the limitation of 16 hours to first-year resident physicans. Thus, it is clear that policymakers, hospital administrators, and residency program directors who wish to implement safer health care systems must go far beyond what the ACGME will require. We hope this White Paper will serve as a guide and provide encouragement for that effort.
Resident physician workload and supervision
By the end of training, a resident physician should be able to practice independently. Yet much of resident physicians’ time is dominated by tasks with little educational value. The caseload can be so great that inadequate reflective time is left for learning based on clinical experiences. In addition, supervision is often vaguely defined and discontinuous. Medical malpractice data indicate that resident physicians are frequently named in lawsuits, most often for lack of supervision. The recommendations are: The ACGME should adjust resident physicians workload requirements to optimize educational value. Resident physicians as well as faculty should be involved in work redesign that eliminates nonessential and noneducational activity from resident physician dutiesMechanisms should be developed for identifying in real time when a resident physician’s workload is excessive, and processes developed to activate additional providersTeamwork should be actively encouraged in delivery of patient care. Historically, much of medical training has focused on individual knowledge, skills, and responsibility. As health care delivery has become more complex, it will be essential to train resident and attending physicians in effective teamwork that emphasizes collective responsibility for patient care and recognizes the signs, both individual and systemic, of a schedule and working conditions that are too demanding to be safeHospitals should embrace the opportunities that resident physician training redesign offers. Hospitals should recognize and act on the potential benefits of work redesign, eg, increased efficiency, reduced costs, improved quality of care, and resident physician and attending job satisfactionAttending physicians should supervise all hospital admissions. Resident physicians should directly discuss all admissions with attending physicians. Attending physicians should be both cognizant of and have input into the care patients are to receive upon admission to the hospitalInhouse supervision should be required for all critical care services, including emergency rooms, intensive care units, and trauma services. Resident physicians should not be left unsupervised to care for critically ill patients. In settings in which the acuity is high, physicians who have completed residency should provide direct supervision for resident physicians. Supervising physicians should always be physically in the hospital for supervision of resident physicians who care for critically ill patientsThe ACGME should explicitly define “good” supervision by specialty and by year of training. Explicit requirements for intensity and level of training for supervision of specific clinical scenarios should be providedCenters for Medicare and Medicaid Services (CMS) should use graduate medical education funding to provide incentives to programs with proven, effective levels of supervision. Although this action would require federal legislation, reimbursement rules would help to ensure that hospitals pay attention to the importance of good supervision and require it from their training programs
Resident physician work hours
Although the IOM “Sleep, supervision and safety” report provides a comprehensive review and discussion of all aspects of graduate medical education training, the report’s focal point is its recommendations regarding the hours that resident physicians are currently required to work. A considerable body of scientific evidence, much of it cited by the Institute of Medicine report, describes deteriorating performance in fatigued humans, as well as specific studies on resident physician fatigue and preventable medical errors.
The question before this conference was what work redesign and cultural changes are needed to reform work hours as recommended by the Institute of Medicine’s evidence-based report? Extensive scientific data demonstrate that shifts exceeding 12–16 hours without sleep are unsafe. Several principles should be followed in efforts to reduce consecutive hours below this level and achieve safer work schedules. The recommendations are: Limit resident physician work hours to 12–16 hour maximum shiftsA minimum of 10 hours off duty should be scheduled between shiftsResident physician input into work redesign should be actively solicitedSchedules should be designed that adhere to principles of sleep and circadian science; this includes careful consideration of the effects of multiple consecutive night shifts, and provision of adequate time off after night work, as specified in the IOM reportResident physicians should not be scheduled up to the maximum permissible limits; emergencies frequently occur that require resident physicians to stay longer than their scheduled shifts, and this should be anticipated in scheduling resident physicians’ work shiftsHospitals should anticipate the need for iterative improvement as new schedules are initiated; be prepared to learn from the initial phase-in, and change the plan as neededAs resident physician work hours are redesigned, attending physicians should also be considered; a potential consequence of resident physician work hour reduction and increased supervisory requirements may be an increase in work for attending physicians; this should be carefully monitored, and adjustments to attending physician work schedules made as needed to prevent unsafe work hours or working conditions for this group“Home call” should be brought under the overall limits of working hours; work load and hours should be monitored in each residency program to ensure that resident physicians and fellows on home call are getting sufficient sleepMedicare funding for graduate medical education in each hospital should be linked with adherence to the Institute of Medicine limits on resident physician work hours
Moonlighting by resident physicians
The Institute of Medicine report recommended including external as well as internal moonlighting in working hour limits. The recommendation is: All moonlighting work hours should be included in the ACGME working hour limits and actively monitored. Hospitals should formalize a moonlighting policy and establish systems for actively monitoring resident physician moonlighting
Safety of resident physicians
The “Sleep, supervision and safety” report also addresses fatigue-related harm done to resident physicians themselves. The report focuses on two main sources of physical injury to resident physicians impaired by fatigue, ie, needle-stick exposure to blood-borne pathogens and motor vehicle crashes. Providing safe transportation home for resident physicians is a logistical and financial challenge for hospitals. Educating physicians at all levels on the dangers of fatigue is clearly required to change driving behavior so that safe hospital-funded transport home is used effectively. Fatigue-related injury prevention (including not driving while drowsy) should be taught in medical school and during residency, and reinforced with attending physicians; hospitals and residency programs must be informed that resident physicians’ ability to judge their own level of impairment is impaired when they are sleep deprived; hence, leaving decisions about the capacity to drive to impaired resident physicians is not recommendedHospitals should provide transportation to all resident physicians who report feeling too tired to drive safely; in addition, although consecutive work should not exceed 16 hours, hospitals should provide transportation for all resident physicians who, because of unforeseen reasons or emergencies, work for longer than consecutive 24 hours; transportation under these circumstances should be automatically provided to house staff, and should not rely on self-identification or request
Training in effective handovers and quality improvement
Handover practice for resident physicians, attendings, and other health care providers has long been identified as a weak link in patient safety throughout health care settings. Policies to improve handovers of care must be tailored to fit the appropriate clinical scenario, recognizing that information overload can also be a problem. At the heart of improving handovers is the organizational effort to improve quality, an effort in which resident physicians have typically been insufficiently engaged. The recommendations are: Hospitals should train attending and resident physicians in effective handovers of careHospitals should create uniform processes for handovers that are tailored to meet each clinical setting; all handovers should be done verbally and face-to-face, but should also utilize written toolsWhen possible, hospitals should integrate hand-over tools into their electronic medical records (EMR) systems; these systems should be standardized to the extent possible across residency programs in a hospital, but may be tailored to the needs of specific programs and services; federal government should help subsidize adoption of electronic medical records by hospitals to improve signoutWhen feasible, handovers should be a team effort including nurses, patients, and familiesHospitals should include residents in their quality improvement and patient safety efforts; the ACGME should specify in their core competency requirements that resident physicians work on quality improvement projects; likewise, the Joint Commission should require that resident physicians be included in quality improvement and patient safety programs at teaching hospitals; hospital administrators and residency program directors should create opportunities for resident physicians to become involved in ongoing quality improvement projects and root cause analysis teams; feedback on successful quality improvement interventions should be shared with resident physicians and broadly disseminatedQuality improvement/patient safety concepts should be integral to the medical school curriculum; medical school deans should elevate the topics of patient safety, quality improvement, and teamwork; these concepts should be integrated throughout the medical school curriculum and reinforced throughout residency; mastery of these concepts by medical students should be tested on the United States Medical Licensing Examination (USMLE) stepsFederal government should support involvement of resident physicians in quality improvement efforts; initiatives to improve quality by including resident physicians in quality improvement projects should be financially supported by the Department of Health and Human Services
Monitoring and oversight of the ACGME
While the ACGME is a key stakeholder in residency training, external voices are essential to ensure that public interests are heard in the development and monitoring of standards. Consequently, the Institute of Medicine report recommended external oversight and monitoring through the Joint Commission and Centers for Medicare and Medicaid Services (CMS). The recommendations are: Make comprehensive fatigue management a Joint Commission National Patient Safety Goal; fatigue is a safety concern not only for resident physicians, but also for nurses, attending physicians, and other health care workers; the Joint Commission should seek to ensure that all health care workers, not just resident physicians, are working as safely as possibleFederal government, including the Centers for Medicare and Medicaid Services and the Agency for Healthcare Research and Quality, should encourage development of comprehensive fatigue management programs which all health systems would eventually be required to implementMake ACGME compliance with working hours a “ condition of participation” for reimbursement of direct and indirect graduate medical education costs; financial incentives will greatly increase the adoption of and compliance with ACGME standards
Future financial support for implementation
The Institute of Medicine’s report estimates that $1.7 billion (in 2008 dollars) would be needed to implement its recommendations. Twenty-five percent of that amount ($376 million) will be required just to bring hospitals into compliance with the existing 2003 ACGME rules. Downstream savings to the health care system could potentially result from safer care, but these benefits typically do not accrue to hospitals and residency programs, who have been asked historically to bear the burden of residency reform costs. The recommendations are: The Institute of Medicine should convene a panel of stakeholders, including private and public funders of health care and graduate medical education, to lay down the concrete steps necessary to identify and allocate the resources needed to implement the recommendations contained in the IOM “Resident duty hours: Enhancing sleep, supervision and safety” report. Conference participants suggested several approaches to engage public and private support for this initiativeEfforts to find additional funding to implement the Institute of Medicine recommendations should focus more broadly on patient safety and health care delivery reform; policy efforts focused narrowly upon resident physician work hours are less likely to succeed than broad patient safety initiatives that include residency redesign as a key componentHospitals should view the Institute of Medicine recommendations as an opportunity to begin resident physician work redesign projects as the core of a business model that embraces safety and ultimately saves resourcesBoth the Secretary of Health and Human Services and the Director of the Centers for Medicare and Medicaid Services should take the Institute of Medicine recommendations into consideration when promulgating rules for innovation grantsThe National Health Care Workforce Commission should consider the Institute of Medicine recommendations when analyzing the nation’s physician workforce needs
Recommendations for future research
Conference participants concurred that convening the stakeholders and agreeing on a research agenda was key. Some observed that some sectors within the medical education community have been reluctant to act on the data. Several logical funders for future research were identified. But above all agencies, Centers for Medicare and Medicaid Services is the only stakeholder that funds graduate medical education upstream and will reap savings downstream if preventable medical errors are reduced as a result of reform of resident physician work hours.
doi:10.2147/NSS.S19649
PMCID: PMC3630963  PMID: 23616719
resident; hospital; working hours; safety
12.  Pharmaceutical Industry Off-label Promotion and Self-regulation: A Document Analysis of Off-label Promotion Rulings by the United Kingdom Prescription Medicines Code of Practice Authority 2003–2012 
PLoS Medicine  2016;13(1):e1001945.
Background
European Union law prohibits companies from marketing drugs off-label. In the United Kingdom—as in some other European countries, but unlike the United States—industry self-regulatory bodies are tasked with supervising compliance with marketing rules. The objectives of this study were to (1) characterize off-label promotion rulings in the UK compared to the whistleblower-initiated cases in the US and (2) shed light on the UK self-regulatory mechanism for detecting, deterring, and sanctioning off-label promotion.
Methods and Findings
We conducted structured reviews of rulings by the UK self-regulatory authority, the Prescription Medicines Code of Practice Authority (PMCPA), between 2003 and 2012. There were 74 off-label promotion rulings involving 43 companies and 65 drugs. Nineteen companies were ruled in breach more than once, and ten companies were ruled in breach three or more times over the 10-y period. Drawing on a typology previously developed to analyse US whistleblower complaints, we coded and analysed the apparent strategic goals of each off-label marketing scheme and the practices consistent with those alleged goals. 50% of rulings cited efforts to expand drug use to unapproved indications, and 39% and 38% cited efforts to expand beyond approved disease entities and dosing strategies, respectively. The most frequently described promotional tactic was attempts to influence prescribers (n = 72, 97%), using print material (70/72, 97%), for example, advertisements (21/70, 30%). Although rulings cited prescribers as the prime target of off-label promotion, competing companies lodged the majority of complaints (prescriber: n = 16, 22%, versus companies: n = 42, 57%). Unlike US whistleblower complaints, few UK rulings described practices targeting consumers (n = 3, 4%), payers (n = 2, 3%), or company staff (n = 2, 3%). Eight UK rulings (11%) pertaining to six drugs described promotion of the same drug for the same off-label use as was alleged by whistleblowers in the US. However, while the UK cases typically related to only one or a few claims made in printed material, several complaints in the US alleged multifaceted and covert marketing activities. Because this study is limited to PMCPA rulings and whistleblower-initiated federal cases, it may offer a partial view of exposed off-label marketing.
Conclusion
The UK self-regulatory system for exposing marketing violations relies largely on complaints from company outsiders, which may explain why most off-label promotion rulings relate to plainly visible promotional activities such as advertising. This contrasts with the US, where Department of Justice investigations and whistleblower testimony have alleged complex off-label marketing campaigns that remain concealed to company outsiders. UK authorities should consider introducing increased incentives and protections for whistleblowers combined with US-style governmental investigations and meaningful sanctions. UK prescribers should be attentive to, and increasingly report, off-label promotion.
In a document analysis of legal cases, Shai Mulinari and colleagues characterize off-label drug promotion by pharmaceutical companies in the UK.
Editors' Summary
Background
Before a pharmaceutical company can market a new prescription drug, the drug has to go through a long approval process. After extensive studies in the laboratory and in animals, the company must test the drug’s safety and efficacy in series of clinical trials in which patients with specific diseases receive the drug under carefully controlled conditions. Regulatory bodies such as the US FDA, the UK MHRA and the European Medicines Agency (EMA) then review the results of these trials and, when they are satisfied that the drug is safe and effective for the conditions in which it was tested, give the pharmaceutical company approval to market the drug in the relevant country. An important part of the approval process is the creation of the “drug label,” a detailed report that specifies the exact diseases and patient groups in which the drug can be used and the drug’s approved doses.
Why Was This Study Done?
Physicians can use approved drugs “off-label.” That is, they can prescribe drugs for a different disease, in a different group of patients, or at a different dose to that specified in the label. However, in the UK, the US, and other countries, national law prohibits the promotion of off-label uses of prescription drugs by pharmaceutical companies, which stand to benefit financially from off-label use through increased drugs sales. The primary rationale for banning off-label promotion is that it might encourage the widespread use of drugs in settings where they have not been rigorously tested, thereby exposing patients to uncertain benefits and possible adverse effects. In the US, the FDA regulates and prosecutes off-label promotion, but enforcement actions against companies can also be brought by federal and state prosecutors and private citizens. In the UK, the MHRA has delegated an important part of its responsibility for supervising off-label marketing to a self-regulatory body set up by the pharmaceutical industry—the PMCPA. Here, by reviewing off-label promotion rulings made by the PMCPA between 2003 and 2012, the researchers compare off-label promotion cases ruled on in the UK with whistleblower (company insider)-initiated cases from the US and shed light on the UK self-regulatory mechanism for detecting, deterring, and sanctioning off-label promotion.
What Did the Researchers Do and Find?
The researchers identified 74 UK off-label promotion rulings over the ten-year study period involving 43 companies (including 19 that were ruled in breach more than once) and 65 drugs. They coded and analyzed each off-label promotion ruling using a typology (a classification according to general type) previously developed to analyze US whistleblower-initiated off-label promotion cases. Half of the rulings cited efforts to expand drug use to unapproved indications (for example, using a drug to treat all patients with MS rather than only patients with recent relapses); 39% and 38% of the rulings cited efforts to expand drug use beyond approved diseases and dosing strategies, respectively. The most commonly cited off-label promotional tactic was attempts to influence prescribers using advertisements and other print material; competing companies lodged 57% of complaints whereas prescribers (the prime target of off-label promotion) lodged only 22% of the complaints. Unlike US whistleblower complaints, which often alleged promotional tactics targeting consumers, payers and company staff, few UK rulings described practices targeting these classes of individuals. Finally, although several US whistleblower-initiated cases alleged multifaceted and covert marketing activities, the UK cases typically related to one or a few claims made in printed material.
What Do These Findings Mean?
Because this study only describes PMCPA rulings and whistleblower-initiated US cases of off-label promotion, these findings provide an incomplete view of off-label marketing violations (some of which may not be deliberate) in the UK and US. The findings suggest that the UK self-regulatory approach, which relies mainly on complaints from company outsiders, is capable of detecting and dealing with instances of off-label promotion with high visibility (for example, advertisements). However, the UK self-regulatory approach may be less capable of uncovering complex marketing campaigns than the US government-led approach. The researchers suggest, therefore, that the UK authorities should consider the introduction of increased incentives and protections for whistleblowers and of US-style governmental investigation (the PMCPA rulings are based on complainant and company submissions alone) and that both the MHRA and PMCPA should strengthen their regulatory oversight of promotional material. Finally, prescribers—the main target of off-label promotion in the UK—should be encouraged to identify and report off-label promotion.
Additional Information
This list of resources contains links that can be accessed when viewing the PDF on a device or via the online version of the article at http://dx.doi.org/10.1371/journal.pmed.1001945.
The PLOS Medicine Research Article by Aaron Kesselheim and colleagues provides information about whistleblower-initiated cases on off-label promotion in the US
Wikipedia provides information on prescription drugs, pharmaceutical marketing (mainly in the US), and off-label drug use (mainly in the US) (note that Wikipedia is a free online encyclopedia that anyone can edit; available in several languages)
The US FDA Office of Prescription Drug Promotion aims to protect public health by assuring prescription drug information is truthful, balanced, and accurately communicated; the FDA’s Bad Ads Program aims to educate health care professionals about the role they can play in ensuring that drug advertising and promotion is truthful and not misleading
Information on the UK regulatory framework is available from the MHRA; the MHRA website also includes information on advertising investigations by the MHRA.
Information on the UK self-regulatory body, the PMCPA, is available; the PMCPA website includes information about the UK Code of Practice for medicines promotion
Healthy Skepticism is an international non-profit membership association that aims to improve health by reducing harm from misleading health information
doi:10.1371/journal.pmed.1001945
PMCID: PMC4727894  PMID: 26812151
13.  Configuring Balanced Scorecards for Measuring Health System Performance: Evidence from 5 Years' Evaluation in Afghanistan 
PLoS Medicine  2011;8(7):e1001066.
Anbrasi Edward and colleagues report the results of a balanced scorecard performance system used to examine 29 key performance indicators over a 5-year period in Afghanistan, between 2004 and 2008.
Background
In 2004, Afghanistan pioneered a balanced scorecard (BSC) performance system to manage the delivery of primary health care services. This study examines the trends of 29 key performance indicators over a 5-year period between 2004 and 2008.
Methods and Findings
Independent evaluations of performance in six domains were conducted annually through 5,500 patient observations and exit interviews and 1,500 provider interviews in >600 facilities selected by stratified random sampling in each province. Generalized estimating equation (GEE) models were used to assess trends in BSC parameters. There was a progressive improvement in the national median scores scaled from 0–100 between 2004 and 2008 in all six domains: patient and community satisfaction of services (65.3–84.5, p<0.0001); provider satisfaction (65.4–79.2, p<0.01); capacity for service provision (47.4–76.4, p<0.0001); quality of services (40.5–67.4, p<0.0001); and overall vision for pro-poor and pro-female health services (52.0–52.6). The financial domain also showed improvement until 2007 (84.4–95.7, p<0.01), after which user fees were eliminated. By 2008, all provinces achieved the upper benchmark of national median set in 2004.
Conclusions
The BSC has been successfully employed to assess and improve health service capacity and service delivery using performance benchmarking during the 5-year period. However, scorecard reconfigurations are needed to integrate effectiveness and efficiency measures and accommodate changes in health systems policy and strategy architecture to ensure its continued relevance and effectiveness as a comprehensive health system performance measure. The process of BSC design and implementation can serve as a valuable prototype for health policy planners managing performance in similar health care contexts.
Please see later in the article for the Editors' Summary
Editors' Summary
Background
Traditionally, the performance of a health system (the complete network of health care agencies, facilities, and providers in a defined geographical region) has been measured in terms of health outcomes: how many people have been treated, how many got better, and how many died. But, nowadays, with increased demand for improved governance and accountability, policy makers are seeking comprehensive performance measures that show in detail how innovations designed to strengthen health systems are affecting service delivery and health outcomes. One such performance measure is the “balanced scorecard,” an integrated management and measurement tool that enables organizations to clarify their vision and strategy and translate them into action. The balanced scorecard—essentially a list of key performance indicators and performance benchmarks in several domains—was originally developed for industry but is now becoming a popular strategic management tool in the health sector. For example, balanced scorecards have been successfully integrated into the Dutch and Italian public health care systems.
Why Was This Study Done?
Little is known about the use of balanced scorecards in the national public health care systems of developing countries but the introduction of performance management into health system reform in fragile states in particular (developing countries where the state fails to perform the fundamental functions necessary to meet its citizens' basic needs and expectations) could help to promote governance and leadership, and facilitate essential policy changes. One fragile state that has introduced the balanced scorecard system for public health care management is Afghanistan, which emerged from decades of conflict in 2002 with some of the world's worst health indicators. To deal with an extremely high burden of disease, the Ministry of Public Health (MOPH) designed a Basic Package of Health Services (BPHS), which is delivered by nongovernmental organizations and MOPH agencies. In 2004, the MOPH introduced the National Health Service Performance Assessment (NHSPA), an annual country-wide assessment of service provision and patient satisfaction and pioneered a balanced scorecard, which uses data collected in the NHSPA, to manage the delivery of primary health care services. In this study, the researchers examine the trends between 2004 and 2008 of the 29 key performance indicators in six domains included in this balanced scorecard, and consider the potential and limitations of the scorecard as a management tool to measure and improve health service delivery in Afghanistan and other similar countries.
What Did the Researchers Do and Find?
Each year of the study, a random sample of 25 facilities (district hospitals and comprehensive and basic health centers) in 28 of Afghanistan's 34 provinces was chosen (one province did not have functional facilities in 2004 and the other five missing provinces were inaccessible because of ongoing conflicts). NHSPA surveyors collected approximately 5,000 patient observations, 5,000 exit interviews with patients or their caregivers, and 1,500 health provider interviews by observing consultations involving five children under 5 years old and five patients over 5 years old in each facility. The researchers then used this information to evaluate the key performance indicators in the balanced scorecard and a statistical method called generalized estimating equation modeling to assess trends in these indicators. They report that there was a progressive improvement in national average scores in all six domains (patients and community satisfaction with services, provider satisfaction, capacity for service provision, quality of services, overall vision for pro-poor and pro-female health services, and financial systems) between 2004 and 2008.
What Do These Findings Mean?
These findings suggest that the balanced scorecard was successfully used to improve health system capacity and service delivery through performance benchmarking over the 5-year study period. Importantly, the use of the balanced scorecard helped to show the effects of investments, facilitate policy change, and create a more evidence-based decision-making culture in Afghanistan's primary health care system. However, the researchers warn that the continuing success of the balanced scorecard in Afghanistan will depend on its ability to accommodate changes in health systems policy. Furthermore, reconfigurations of the scorecard are needed to include measures of the overall effectiveness and efficiency of the health system such as mortality rates. More generally, the researchers conclude that the balanced scorecard offers a promising measure of health system performance that could be used to examine the effectiveness of health care strategies and innovations in other fragile and developing countries.
Additional Information
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001066.
A 2010 article entitled An Afghan Success Story: The Balanced Scorecard and Improved Health Services in The Globe, a newsletter produced by the Department of International Health at the John Hopkins Bloomberg School of Public Health, provides a detailed description of the balanced scorecard used in this study
Wikipedia has a page on health systems and on balanced scorecards (note that Wikipedia is a free online encyclopedia that anyone can edit; available in several languages)
The World Health Organization country profile of Afghanistan provides information on the country's health system and burden of disease (in several languages)
doi:10.1371/journal.pmed.1001066
PMCID: PMC3144209  PMID: 21814499
14.  “Key to the Future”: British American Tobacco and Cigarette Smuggling in China 
PLoS Medicine  2006;3(7):e228.
Background
Cigarette smuggling is a major public health issue, stimulating increased tobacco consumption and undermining tobacco control measures. China is the ultimate prize among tobacco's emerging markets, and is also believed to have the world's largest cigarette smuggling problem. Previous work has demonstrated the complicity of British American Tobacco (BAT) in this illicit trade within Asia and the former Soviet Union.
Methods and Findings
This paper analyses internal documents of BAT available on site from the Guildford Depository and online from the BAT Document Archive. Documents dating from the early 1900s to 2003 were searched and indexed on a specially designed project database to enable the construction of an historical narrative. Document analysis incorporated several validation techniques within a hermeneutic process. This paper describes the huge scale of this illicit trade in China, amounting to billions of (United States) dollars in sales, and the key supply routes by which it has been conducted. It examines BAT's efforts to optimise earnings by restructuring operations, and controlling the supply chain and pricing of smuggled cigarettes.
Conclusions
Our research shows that smuggling has been strategically critical to BAT's ongoing efforts to penetrate the Chinese market, and to its overall goal to become the leading company within an increasingly global industry. These findings support the need for concerted efforts to strengthen global collaboration to combat cigarette smuggling.
Editors' Summary
Background.
Smoking tobacco kills about 5 million people around the world every year, and according to the World Health Organization, half of the people who smoke will eventually die as a result. The habit is in decline in most of the world's richer nations, but it is growing in developing countries. Governments can control consumption, and raise substantial tax revenues, by levying high taxes on tobacco. However, this is undermined when tobacco is smuggled into the country and sold illegally. Smuggling makes cigarettes more affordable, thus stimulating consumption, and undermines efforts to reduce smoking rates.
  British American Tobacco (BAT) is one of the largest international tobacco companies. Following a legal case in the United States, millions of pages of BAT internal documents (dating back to the early 1900s) have been made public. They are held in a depository in the United Kingdom, and most can now be seen online. Researchers have already undertaken wide-ranging studies of these documents and have drawn conclusions about the way BAT has sought to enter emerging markets throughout the world.
Why Was This Study Done?
Previously published studies have concluded that BAT has been “complicit” in large-scale cigarette smuggling, described in documents by the euphemisms “transit,” “general trade” (“GT”), “duty not paid” (“DNP”), and “free market.” This study focuses on such activities in China, which is believed to have the world's biggest tobacco smuggling problem. China is a key market for BAT and other tobacco companies because of the size of its population, high smoking prevalence, and rapidly growing economy. The development of effective tobacco control policy in China constitutes one of the greatest opportunities to advance global health. The State Tobacco Monopoly Administration is the only agency legally allowed to trade in tobacco in China.
What Did the Researchers Do and Find?
The authors have put together an account of the company's trading in China in the period from 1986 to 1999. They begin by describing the scale on which tobacco was smuggled into China and the main supply routes through which tobacco entered the country. They found evidence that smuggling increased considerably during the period.
  The researchers found that BAT's own documents describe the company's efforts to improve its earnings from China by restructuring operations and controlling the supply chain—that is, how cigarettes are manufactured and legally exported, are handled by various “agents” or middlemen, and then are sold illicitly as contraband. The title of this article is taken from one BAT document that states that exports from Hong Kong to China are the “key to the future” of the company's planned growth. The researchers say that this can be taken to mean smuggling, and that BAT's documents indicate that the company benefited from, encouraged, and attempted to control the smuggling of tobacco into China.
What Do These Findings Mean?
BAT has stated publicly that it does not approve of smuggling. However, from the researchers' analysis of the information in the internal papers, they conclude that “the documents demonstrate that contraband has been a hugely profitable and integral part of BAT operations in China over the past two decades.” They estimate that the value of the illicit trade amounts to billions of (United States) dollars and go on to say that “for the Chinese government, this illicit trade undermined restrictions on imports, represented an enormous loss of tax revenue, and stimulated demand for premium brand cigarettes.” The researchers argue that action should be taken internationally to reduce tobacco smuggling.
Additional Information.
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.0030228.
• Most of the documents used in this paper can be found at the British American Tobacco Documents Archive created by public health researchers (the Web site also contains useful information on tobacco document research)
• The Tobacco Free Initiative, based at the World Health Organization, provides information on the global scale of the tobacco problem, and about efforts to combat the situation
• Many countries have national anti-smoking organizations; the United Kingdom charity Action on Smoking and Health has a useful list of these
• Information about the dangers of smoking to personal health and advice on giving up the habit are available from the Web sites of the American Academy of Family Physicians and NHS Direct (United Kingdom National Health Service)
Internal documents from British American Tobacco demonstrate the scale of tobacco smuggling into China and show that this illicit trade has been a critical factor in BAT's expansion in this market.
doi:10.1371/journal.pmed.0030228
PMCID: PMC1502159  PMID: 16834455
15.  Driving a decade of change: HIV/AIDS, patents and access to medicines for all 
Since 2000, access to antiretroviral drugs to treat HIV infection has dramatically increased to reach more than five million people in developing countries. Essential to this achievement was the dramatic reduction in antiretroviral prices, a result of global political mobilization that cleared the way for competitive production of generic versions of widely patented medicines.
Global trade rules agreed upon in 1994 required many developing countries to begin offering patents on medicines for the first time. Government and civil society reaction to expected increases in drug prices precipitated a series of events challenging these rules, culminating in the 2001 World Trade Organization's Doha Declaration on the Agreement on Trade-Related Aspects of Intellectual Property Rights and Public Health. The Declaration affirmed that patent rules should be interpreted and implemented to protect public health and to promote access to medicines for all. Since Doha, more than 60 low- and middle-income countries have procured generic versions of patented medicines on a large scale.
Despite these changes, however, a "treatment timebomb" awaits. First, increasing numbers of people need access to newer antiretrovirals, but treatment costs are rising since new ARVs are likely to be more widely patented in developing countries. Second, policy space to produce or import generic versions of patented medicines is shrinking in some developing countries. Third, funding for medicines is falling far short of needs. Expanded use of the existing flexibilities in patent law and new models to address the second wave of the access to medicines crisis are required.
One promising new mechanism is the UNITAID-supported Medicines Patent Pool, which seeks to facilitate access to patents to enable competitive generic medicines production and the development of improved products. Such innovative approaches are possible today due to the previous decade of AIDS activism. However, the Pool is just one of a broad set of policies needed to ensure access to medicines for all; other key measures include sufficient and reliable financing, research and development of new products targeted for use in resource-poor settings, and use of patent law flexibilities. Governments must live up to their obligations to protect access to medicines as a fundamental component of the human right to health.
doi:10.1186/1758-2652-14-15
PMCID: PMC3078828  PMID: 21439089
16.  Tobacco Company Efforts to Influence the Food and Drug Administration-Commissioned Institute of Medicine Report Clearing the Smoke: An Analysis of Documents Released through Litigation 
PLoS Medicine  2013;10(5):e1001450.
Stanton Glantz and colleagues investigate efforts by tobacco companies to influence Clearing the Smoke, a 2001 Institute of Medicine report on harm reduction tobacco products.
Please see later in the article for the Editors' Summary
Background
Spurred by the creation of potential modified risk tobacco products, the US Food and Drug Administration (FDA) commissioned the Institute of Medicine (IOM) to assess the science base for tobacco “harm reduction,” leading to the 2001 IOM report Clearing the Smoke. The objective of this study was to determine how the tobacco industry organized to try to influence the IOM committee that prepared the report.
Methods and Findings
We analyzed previously secret tobacco industry documents in the University of California, San Francisco Legacy Tobacco Documents Library, and IOM public access files. (A limitation of this method includes the fact that the tobacco companies have withheld some possibly relevant documents.) Tobacco companies considered the IOM report to have high-stakes regulatory implications. They developed and implemented strategies with consulting and legal firms to access the IOM proceedings. When the IOM study staff invited the companies to provide information on exposure and disease markers, clinical trial design for safety and efficacy, and implications for initiation and cessation, tobacco company lawyers, consultants, and in-house regulatory staff shaped presentations from company scientists. Although the available evidence does not permit drawing cause-and-effect conclusions, and the IOM may have come to the same conclusions without the influence of the tobacco industry, the companies were pleased with the final report, particularly the recommendations for a tiered claims system (with separate tiers for exposure and risk, which they believed would ease the process of qualifying for a claim) and license to sell products comparable to existing conventional cigarettes (“substantial equivalence”) without prior regulatory approval. Some principles from the IOM report, including elements of the substantial equivalence recommendation, appear in the 2009 Family Smoking Prevention and Tobacco Control Act.
Conclusions
Tobacco companies strategically interacted with the IOM to win several favored scientific and regulatory recommendations.
Please see later in the article for the Editors' Summary
Editors' Summary
Background
Up to half of tobacco users will die of cancer, lung disease, heart disease, stroke, or another tobacco-related disease. Cigarettes and other tobacco products cause disease because they expose their users to nicotine and numerous other toxic chemicals. Tobacco companies have been working to develop a “safe” cigarette for more than half a century. Initially, their attention focused on cigarettes that produced lower tar and nicotine yields in machine-smoking tests. These products were perceived as “safer” products by the public and scientists for many years, but it is now known that the use of low-yield cigarettes can actually expose smokers to higher levels of toxins than standard cigarettes. More recently, the tobacco companies have developed other products (for example, products that heat aerosols of nicotine, rather than burning the tobacco) that claim to reduce harm and the risk of tobacco-related disease, but they can only market these modified risk tobacco products in the US after obtaining Food and Drug Administration (FDA) approval. In 1999, the FDA commissioned the US Institute of Medicine (IOM, an influential source of independent expert advice on medical issues) to assess the science base for tobacco “harm reduction.” In 2001, the IOM published its report Clearing the Smoke: Assessing the Science Base for Tobacco Harm and Reduction, which, although controversial, set the tone for the development and regulation of tobacco products in the US, particularly those claiming to be less dangerous, in subsequent years.
Why Was This Study Done?
Tobacco companies have a long history of working to shape scientific discussions and agendas. For example, they have produced research results designed to “create controversy” about the dangers of smoking and secondhand smoke. In this study, the researchers investigate how tobacco companies organized to try to influence the IOM committee that prepared the Clearing the Smoke report on modified risk tobacco products by analyzing tobacco industry and IOM documents.
What Did the Researchers Do and Find?
The researchers searched the Legacy Tobacco Documents Library (a collection of internal tobacco industry documents released as a result of US litigation cases) for documents outlining how tobacco companies tried to influence the IOM Committee to Assess the Science Base for Tobacco Harm Reduction and created a timeline of events from the 1,000 or so documents they retrieved. They confirmed and supplemented this timeline using information in 80 files that detailed written interactions between the tobacco companies and the IOM committee, which they obtained through a public records access request. Analysis of these documents indicates that the tobacco companies considered the IOM report to have important regulatory implications, that they developed and implemented strategies with consulting and legal firms to access the IOM proceedings, and that tobacco company lawyers, consultants, and regulatory staff shaped presentations to the IOM committee by company scientists on various aspects of tobacco harm reduction products. The analysis also shows that tobacco companies were pleased with the final report, particularly its recommendation that tobacco products can be marketed with exposure or risk reduction claims provided the products substantially reduce exposure and provided the behavioral and health consequences of these products are determined in post-marketing surveillance and epidemiological studies (“tiered testing”) and its recommendation that, provided no claim of reduced exposure or risk is made, new products comparable to existing conventional cigarettes (“substantial equivalence”) can be marketed without prior regulatory approval.
What Do These Findings Mean?
These findings suggest that tobacco companies used their legal and regulatory staff to access the IOM committee that advised the FDA on modified risk tobacco products and that they used this access to deliver specific, carefully formulated messages designed to serve their business interests. Although these findings provide no evidence that the efforts of tobacco companies influenced the IOM committee in any way, they show that the companies were satisfied with the final IOM report and its recommendations, some of which have policy implications that continue to reverberate today. The researchers therefore call for the FDA and other regulatory bodies to remember that they are dealing with companies with a long history of intentionally misleading the public when assessing the information presented by tobacco companies as part of the regulatory process and to actively protect their public-health policies from the commercial interests of the tobacco industry.
Additional Information
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001450.
This study is further discussed in a PLOS Medicine Perspective by Thomas Novotny
The World Health Organization provides information about the dangers of tobacco (in several languages); for information about the tobacco industry's influence on policy, see the 2009 World Health Organization report Tobacco interference with tobacco control
A PLOS Medicine Research Article by Heide Weishaar and colleagues describes tobacco company efforts to undermine the Framework Convention on Tobacco Control, an international instrument for tobacco control
Wikipedia has a page on tobacco harm reduction (note: Wikipedia is a free online encyclopedia that anyone can edit; available in several languages)
The IOM report Clearing the Smoke: Assessing the Science Base for Tobacco Harm Reduction is available to read online
The Legacy Tobacco Documents Library is a public, searchable database of tobacco company internal documents detailing their advertising, manufacturing, marketing, sales, and scientific activities
The University of California, San Francisco Center for Tobacco Control Research and Education is the focal point for University of California, San Francisco (UCSF) scientists in disciplines ranging from the molecular biology of nicotine addiction through political science who combine their efforts to eradicate the use of tobacco and tobacco-induced cancer and other diseases worldwide
SmokeFree, a website provided by the UK National Health Service, offers advice on quitting smoking and includes personal stories from people who have stopped smoking
Smokefree.gov, from the US National Cancer Institute, offers online tools and resources to help people quit smoking
doi:10.1371/journal.pmed.1001450
PMCID: PMC3665841  PMID: 23723740
17.  Interventions to reduce corruption in the health sector 
Background
Corruption is the abuse or complicity in abuse, of public or private position, power or authority to benefit oneself, a group, an organisation or others close to oneself; where the benefits may be financial, material or non-material. It is wide-spread in the health sector and represents a major problem.
Objectives
Our primary objective was to systematically summarise empirical evidence of the effects of strategies to reduce corruption in the health sector. Our secondary objective was to describe the range of strategies that have been tried and to guide future evaluations of promising strategies for which there is insufficient evidence.
Search methods
We searched 14 electronic databases up to January 2014, including: CENTRAL; MEDLINE; EMBASE; sociological, economic, political and other health databases; Human Resources Abstracts up to November 2010; Euroethics up to August 2015; and PubMed alerts from January 2014 to June 2016. We searched another 23 websites and online databases for grey literature up to August 2015, including the World Bank, the International Monetary Fund, the U4 Anti-Corruption Resource Centre, Transparency International, healthcare anti-fraud association websites and trial registries. We conducted citation searches in Science Citation Index and Google Scholar, and searched PubMed for related articles up to August 2015. We contacted corruption researchers in December 2015, and screened reference lists of articles up to May 2016.
Selection criteria
For the primary analysis, we included randomised trials, non-randomised trials, interrupted time series studies and controlled before-after studies that evaluated the effects of an intervention to reduce corruption in the health sector. For the secondary analysis, we included case studies that clearly described an intervention to reduce corruption in the health sector, addressed either our primary or secondary objective, and stated the methods that the study authors used to collect and analyse data.
Data collection and analysis
One review author extracted data from the included studies and a second review author checked the extracted data against the reports of the included studies. We undertook a structured synthesis of the findings. We constructed a results table and 'Summaries of findings' tables. We used the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach to assess the certainty of the evidence.
Main results
No studies met the inclusion criteria of the primary analysis. We included nine studies that met the inclusion criteria for the secondary analysis.
One study found that a package of interventions coordinated by the US Department of Health and Human Services and Department of Justice recovered a large amount of money and resulted in hundreds of new cases and convictions each year (high certainty of the evidence). Another study from the USA found that establishment of an independent agency to investigate and enforce efforts against overbilling might lead to a small reduction in overbilling, but the certainty of this evidence was very low. A third study from India suggested that the impacts of coordinated efforts to reduce corruption through increased detection and enforcement are dependent on continued political support and that they can be limited by a dysfunctional judicial system (very low certainty of the evidence).
One study in South Korea and two in the USA evaluated increased efforts to investigate and punish corruption in clinics and hospitals without establishing an independent agency to coordinate these efforts. It is unclear whether these were effective because the evidence is of very low certainty.
One study from Kyrgyzstan suggested that increased transparency and accountability for co-payments together with reduction of incentives for demanding informal payments may reduce informal payments (low certainty of the evidence).
One study from Germany suggested that guidelines that prohibit hospital doctors from accepting any form of benefits from the pharmaceutical industry may improve doctors' attitudes about the influence of pharmaceutical companies on their choice of medicines (low certainty of the evidence).
A study in the USA, evaluated the effects of introducing a law that required pharmaceutical companies to report the gifts they gave to healthcare workers. Another study in the USA evaluated the effects of a variety of internal control mechanisms used by community health centres to stop corruption. The effects of these strategies is unclear because the evidence was of very low certainty.
Authors' conclusions
There is a paucity of evidence regarding how best to reduce corruption. Promising interventions include improvements in the detection and punishment of corruption, especially efforts that are coordinated by an independent agency. Other promising interventions include guidelines that prohibit doctors from accepting benefits from the pharmaceutical industry, internal control practices in community health centres, and increased transparency and accountability for co-payments combined with reduced incentives for informal payments. The extent to which increased transparency alone reduces corruption is uncertain. There is a need to monitor and evaluate the impacts of all interventions to reduce corruption, including their potential adverse effects.
Interventions to reduce corruption in the health sector
What is the aim of this review?
The aim of this Cochrane review is to assess the effectiveness of strategies to reduce corruption in the health sector. Cochrane researchers searched for all potentially relevant studies, and found nine studies that met their criteria.
Key messages
The review suggests that some strategies to fight corruption in the health sector can have an effect on corruption. These strategies include the use of independent agencies to investigate and punish corruption, telling healthcare workers that they are not allowed to accept payments from pharmaceutical companies, ensuring that information about healthcare prices is clear and accessible to the public together with increasing healthcare worker salaries. However, the certainty of this evidence varies. We need more high-quality studies that assess the effects of these and other strategies.
What was studied in the review?
Corruption can occur in any area of the health sector, and happens when people abuse their own position to benefit themselves, their organisation, or other people close to them. It can take many forms, including bribes, theft, or giving incorrect or inaccurate information deliberately.
Healthcare officials, for instance, may steal healthcare funds, hospital administrators may change patient records to increase hospital payments, doctors may accept bribes from pharmaceutical companies in exchange for using their products, and patients may try to bribe hospital staff to avoid treatment queues.
Corruption affects the health sector in many ways. It can take money away from healthcare, lead to poorer quality care and make access to healthcare unfair, and often affects poor people the hardest.
What are the main results of the review?
The review authors included nine relevant studies that used different strategies to stop corruption.
• In a study from the USA, efforts to investigate and punish corruption in the health sector were also increased. An independent agency at the national level coordinated these efforts, which led to convictions and the recovery of large amounts of money (high certainty evidence). These efforts may also have led to substantial savings to the government (low certainty evidence). In another study from the USA establishment of an independent agency to investigate and enforce efforts against overbilling was established, but the effects of these efforts are unclear because the evidence was of very low certainty. In India, there were efforts to stop corruption through the appointment of an ombudsman in one state. However, the effect of this strategy is unclear because the evidence was of very low certainty.
• In one study in South Korea and two in the USA, efforts to investigate and punish corruption in clinics and hospitals were increased, without establishing an independent agency. However, it is unclear whether these were effective because the evidence is of very low certainty.
• In a study in Kyrgyzstan, the government carried out a number of strategies, including giving patients and the public information about how much they should be paying, and increasing healthcare workers' salaries. This study shows that these strategies may have led to fewer patients giving their doctors informal payments (low certainty evidence).
• In a study in Germany, hospital doctors were given guidelines telling them that they were not allowed to accept money or gifts from pharmaceutical companies. The study suggests that this may have changed doctors' attitudes about the influence of pharmaceutical companies on their choice of medicines (low certainty evidence).
• In one study in the USA, the authorities introduced a law that required pharmaceutical companies to report the gifts they gave to healthcare workers. In another USA-based study, community health centres attempted to stop corruption using a variety of internal control mechanisms. However, the effect of these strategies is unclear because the evidence was of very low certainty.
We don't know what the effects of these strategies have on healthcare or people's health, or if these strategies had any harmful effects. This is because the studies only assessed the effects of the strategies on corruption and the use of resources, or because the evidence was of very low certainty.
How up to date is this review?
The review authors searched for studies that had been published up to 06 June 2016.
doi:10.1002/14651858.CD008856.pub2
PMCID: PMC5014759  PMID: 27528494
18.  Estimated Effects of Different Alcohol Taxation and Price Policies on Health Inequalities: A Mathematical Modelling Study 
PLoS Medicine  2016;13(2):e1001963.
Introduction
While evidence that alcohol pricing policies reduce alcohol-related health harm is robust, and alcohol taxation increases are a WHO “best buy” intervention, there is a lack of research comparing the scale and distribution across society of health impacts arising from alternative tax and price policy options. The aim of this study is to test whether four common alcohol taxation and pricing strategies differ in their impact on health inequalities.
Methods and Findings
An econometric epidemiological model was built with England 2014/2015 as the setting. Four pricing strategies implemented on top of the current tax were equalised to give the same 4.3% population-wide reduction in total alcohol-related mortality: current tax increase, a 13.4% all-product duty increase under the current UK system; a value-based tax, a 4.0% ad valorem tax based on product price; a strength-based tax, a volumetric tax of £0.22 per UK alcohol unit (= 8 g of ethanol); and minimum unit pricing, a minimum price threshold of £0.50 per unit, below which alcohol cannot be sold. Model inputs were calculated by combining data from representative household surveys on alcohol purchasing and consumption, administrative and healthcare data on 43 alcohol-attributable diseases, and published price elasticities and relative risk functions. Outcomes were annual per capita consumption, consumer spending, and alcohol-related deaths. Uncertainty was assessed via partial probabilistic sensitivity analysis (PSA) and scenario analysis.
The pricing strategies differ as to how effects are distributed across the population, and, from a public health perspective, heavy drinkers in routine/manual occupations are a key group as they are at greatest risk of health harm from their drinking. Strength-based taxation and minimum unit pricing would have greater effects on mortality among drinkers in routine/manual occupations (particularly for heavy drinkers, where the estimated policy effects on mortality rates are as follows: current tax increase, −3.2%; value-based tax, −2.9%; strength-based tax, −6.1%; minimum unit pricing, −7.8%) and lesser impacts among drinkers in professional/managerial occupations (for heavy drinkers: current tax increase, −1.3%; value-based tax, −1.4%; strength-based tax, +0.2%; minimum unit pricing, +0.8%). Results from the PSA give slightly greater mean effects for both the routine/manual (current tax increase, −3.6% [95% uncertainty interval (UI) −6.1%, −0.6%]; value-based tax, −3.3% [UI −5.1%, −1.7%]; strength-based tax, −7.5% [UI −13.7%, −3.9%]; minimum unit pricing, −10.3% [UI −10.3%, −7.0%]) and professional/managerial occupation groups (current tax increase, −1.8% [UI −4.7%, +1.6%]; value-based tax, −1.9% [UI −3.6%, +0.4%]; strength-based tax, −0.8% [UI −6.9%, +4.0%]; minimum unit pricing, −0.7% [UI −5.6%, +3.6%]). Impacts of price changes on moderate drinkers were small regardless of income or socioeconomic group. Analysis of uncertainty shows that the relative effectiveness of the four policies is fairly stable, although uncertainty in the absolute scale of effects exists. Volumetric taxation and minimum unit pricing consistently outperform increasing the current tax or adding an ad valorem tax in terms of reducing mortality among the heaviest drinkers and reducing alcohol-related health inequalities (e.g., in the routine/manual occupation group, volumetric taxation reduces deaths more than increasing the current tax in 26 out of 30 probabilistic runs, minimum unit pricing reduces deaths more than volumetric tax in 21 out of 30 runs, and minimum unit pricing reduces deaths more than increasing the current tax in 30 out of 30 runs). Study limitations include reducing model complexity by not considering a largely ineffective ban on below-tax alcohol sales, special duty rates covering only small shares of the market, and the impact of tax fraud or retailer non-compliance with minimum unit prices.
Conclusions
Our model estimates that, compared to tax increases under the current system or introducing taxation based on product value, alcohol-content-based taxation or minimum unit pricing would lead to larger reductions in health inequalities across income groups. We also estimate that alcohol-content-based taxation and minimum unit pricing would have the largest impact on harmful drinking, with minimal effects on those drinking in moderation.
In this mathematical modelling study, Petra Meier and colleagues estimate the impact of different alcohol taxation and pricing structures on consumption, spending, and health inequalities.
Editors' Summary
Background
People have drunk alcoholic beverages throughout history. However, harmful alcohol consumption is currently responsible for around 2.7 million deaths every year and is a leading risk factor worldwide for heart disease, liver disease, and many other health problems. It also affects the well-being and health of people around those who drink, both within the household and through alcohol-related crime and road traffic crashes. As with most products, the price of alcohol influences how much people buy and consume. Alcohol affordability is an important driver of alcohol consumption, and in many countries, including the UK and US, alcohol prices have not kept pace with inflation and rising incomes. Alcohol taxes have the dual function of raising revenues and regulating alcohol prices. Different countries employ different alcohol-specific taxation structures including taxation by beverage volume, by value, or by alcohol content. Some countries also have additional price control measures that prevent the sale of very cheap alcohol.
Why Was This Study Done?
Although research shows that increases in the price of alcohol brought about by taxation or other pricing policies reduce alcohol consumption and alcohol-related harm, little is known about how alternative tax and price policy options affect the scale and distribution of alcohol-related health impacts across society. This is important because people with lower social status and/or income are disproportionately affected by alcohol-related disease. An effective public health policy to reduce alcohol harm might, therefore, help to reduce social disparities in health (health inequality), a major goal of population health policies in affluent countries.
What Did the Researchers Do and Find?
Here, the researchers use the Sheffield Alcohol Policy Model (SAPM) to investigate the effects of four common alcohol taxation and price policies on health inequalities in England during 2014/2015. SAPM is a deterministic mathematical simulation model that estimates how price changes affect individual-level alcohol consumption and how consumption changes affect the illnesses (morbidity), deaths (mortality), and economic costs associated with 43 alcohol-attributable conditions. The researchers used SAPM to simulate the effect of increasing the existing UK duty on all alcohol products by 13.4% (current tax increase), introducing a 4% tax based on product price (value-based, or ad valorem, taxation), introducing a tax of £0.22 per alcohol unit (strength-based, or volumetric, taxation), or setting a minimum price threshold of £0.50 per alcohol unit (minimum unit pricing). The magnitudes of the different policy-induced price increases modeled were chosen to result in the same overall population-wide 4.3% decrease in alcohol-related mortality. Notably, the impacts of policy changes on moderate drinkers were small, regardless of income/socioeconomic group. However, among heavy drinkers, the effects of the four policies were differentially distributed across the population. Among heavy drinkers in the lowest socioeconomic group (the population group at greatest risk of harm from alcohol use), the estimated effects on mortality rates were −3.2% for the current tax increase (that is, it reduced alcohol-related deaths by 3.2%), −2.9% for value-based taxation, −6.1% for strength-based taxation, and −7.8% for minimum unit pricing. Among heavy drinkers in the highest socioeconomic group, the corresponding effects on mortality rates were −1.3%, −1.4%, +0.2%, and +0.8%.
What Do These Findings Mean?
As with any policy modelling, the accuracy of these findings depends on the evidence base, the quality of the data incorporated into the model, and the assumptions used. Limitations to the analysis here include that, due to an absence of evidence, the researchers have not examined the impact of any tax avoidance, which could potentially vary between the policies. The study findings suggest that in England (and probably in other countries) the introduction of strength-based taxation or minimum unit pricing would lead to larger reductions in health inequalities among heavy drinkers than an increase in the current tax rate or the introduction of value-based taxation. That is, the two policy options that target cheap, high-strength alcohol are likely to outperform value-based taxation and increasing the current UK tax in terms of reducing health inequalities. Thus, although these policies might be considered “regressive” (i.e., affecting the poor more than the rich) in terms of consumption and spending, they are at the same time “progressive” in that they reduce health inequalities. Finally, these findings suggest that minimum unit pricing and strength-based taxation, unlike the other two options tested, would target harmful drinking without unnecessarily penalizing people with low incomes who drink moderate amounts of alcohol.
Additional Information
This list of resources contains links that can be accessed when viewing the PDF on a device or via the online version of the article at http://dx.doi.org/10.1371/journal.pmed.1001963.
The World Health Organization provides detailed information about alcohol, including a fact sheet on the harmful use of alcohol; its Global Status Report on Alcohol and Health 2014 provides country information on the impact of alcohol use on health and policy responses; its Global Strategy to Reduce Harmful Use of Alcohol includes information on pricing policies; the Global Information System on Alcohol and Health provides further information about alcohol control policies
The US National Institute on Alcohol Abuse and Alcoholism has information about alcohol and its effects on health; it provides interactive worksheets to help people evaluate their drinking and decide whether and how to make a change
The US Centers for Disease Control and Prevention provides information on alcohol and public health and a fact sheet on preventing excessive alcohol use
The UK National Health Service Choices website provides detailed information about drinking and alcohol, including information on the risks of drinking too much, tools for calculating alcohol consumption, and personal stories
EuroCare is an alliance of non-governmental public health and social organizations working on the prevention and reduction of alcohol-related harm in Europe; it provides information about alcohol taxation in the European Union
The UK Institute of Alcohol Studies advocates for the use of scientific evidence in policymaking to reduce alcohol-related harm and produces easily accessible briefings on alcohol policy issues
MedlinePlus provides links to many other resources on alcohol
Information about the Sheffield Alcohol Policy Model is available
The UK Chief Medical Officers’ proposed new alcohol guidelines are available
doi:10.1371/journal.pmed.1001963
PMCID: PMC4764336  PMID: 26905063
19.  Canada and access to medicines in developing countries: intellectual property rights first 
Canadian reports have recommended that health as a human right must be Canada’s overarching global commitment and that the primacy of human rights should be prioritized over other elements of international law including international trade and investment law as it applies to access to pharmaceuticals. This paper uses a series of case reports to examine Canada’s commitment to this goal. Specifically it examines cases where improved access has been in conflict with increased intellectual property rights. The 6 cases are: Canada’s position when 39 pharmaceutical companies took South Africa to court in 1998 over its legislation to allow parallel importation of patented medicines and to regulate the price of medications; the stance that Canada took in the negotiations around the Doha Declaration in 2001; the passage of Canada’s Access to Medicines Regime in 2004 and subsequent attempts to amend the legislation in 2011 and 2012; Canada’s involvement in the final declaration at the United Nations High-Level meeting on non-communicable diseases in 2012; Canada’s views about the terms in the Anti-Counterfeiting Trade Agreement as expressed in 2009; and Canada’s 2013 position on the extension of the exemption for least developed countries from having to comply with the terms of the Trade Related Aspects of Intellectual Property Rights Agreement. In the first case Canada was neutral but in the remaining 5 cases Canada prioritized intellectual property rights over access. This position is consistent with how Canada has acted around domestic issues involving intellectual property rights for pharmaceutical products. Canada has supported strengthened rights despite the fact that their touted benefits have not been realized either domestically or in developing countries. As a result Canada has failed in its humanitarian duty to protect the human right to health in the form of safe and low cost medicines for the people in developing countries.
doi:10.1186/1744-8603-9-42
PMCID: PMC3844468  PMID: 24007595
Access; Anti-Counterfeiting Trade Agreement; Canada; Canada’s Access to Medicines Regime; Doha Declaration; Intellectual property rights; Least developed countries; Non-communicable diseases; TRIPS
20.  Corporate Social Responsibility and Access to Policy Élites: An Analysis of Tobacco Industry Documents 
PLoS Medicine  2011;8(8):e1001076.
Gary Fooks and colleagues undertook a review of tobacco industry documents and show that policies on corporate social responsibility can enable access to and dialogue with policymakers at the highest level.
Background
Recent attempts by large tobacco companies to represent themselves as socially responsible have been widely dismissed as image management. Existing research supports such claims by pointing to the failings and misleading nature of corporate social responsibility (CSR) initiatives. However, few studies have focused in depth on what tobacco companies hoped to achieve through CSR or reflected on the extent to which these ambitions have been realised.
Methods and Findings
Iterative searching relating to CSR strategies was undertaken of internal British American Tobacco (BAT) documents, released through litigation in the US. Relevant documents (764) were indexed and qualitatively analysed. In the past decade, BAT has actively developed a wide-ranging CSR programme. Company documents indicate that one of the key aims of this programme was to help the company secure access to policymakers and, thereby, increase the company's chances of influencing policy decisions. Taking the UK as a case study, this paper demonstrates the way in which CSR can be used to renew and maintain dialogue with policymakers, even in ostensibly unreceptive political contexts. In practice, the impact of this political use of CSR is likely to be context specific; depending on factors such as policy élites' understanding of the credibility of companies as a reliable source of information.
Conclusions
The findings suggest that tobacco company CSR strategies can enable access to and dialogue with policymakers and provide opportunities for issue definition. CSR should therefore be seen as a form of corporate political activity. This underlines the need for broad implementation of Article 5.3 of the Framework Convention on Tobacco Control. Measures are needed to ensure transparency of interactions between all parts of government and the tobacco industry and for policy makers to be made more aware of what companies hope to achieve through CSR.
Please see later in the article for the Editors' Summary
Editors' Summary
Background
In the past, companies and multinational corporations were judged on the profits they made. Nowadays, though, much is made of corporate social responsibility (CSR). CSR is the commitment by business to behave ethically and to contribute to economic development while improving the quality of life of the workforce, their families, the local community, and society at large. Put simply, companies and corporations now endeavor to show that they have a positive impact on the environment, consumers, employees, and society in addition to making money for their shareholders. Large tobacco companies are no exception. British American Tobacco (BAT, the world's second largest publicly traded tobacco company), for example, began working on a wide-ranging CSR program more than a decade ago. Given that tobacco is responsible for an estimated 5.4 million deaths worldwide annually, this program was initially met with hostility and dismissed as an image management exercise. However, large parts of the investment and CSR communities now approve of BAT's CSR program, which has won numerous awards.
Why Was This Study Done?
But what do BAT and other tobacco companies actually hope to achieve through their CSR initiatives and how successful have they been in achieving these aims? Few studies have addressed these important questions. In particular, there has been little research into the extent to which tobacco companies use CSR initiatives as a form of corporate political activity that can help them gain “access” to policymakers and define the legitimate concerns and optimal alternatives of public policy (“issue definition”). Access is defined as taking place when policymakers consider the views of policy advocates such as tobacco company employees and is a crucial component of issue definition, which refers to the strategies adopted by bodies such as multinational corporations to influence the policy agenda by defining what issues public policy should concern itself with and how it should approach them. In this case study, the researchers explore whether BAT's CSR program works as a form of corporate political activity by systematically examining internal BAT documents made publicly available as a result of US litigation. Specifically, the researchers examine BAT's efforts through its CSR program to reestablish access with the UK Department of Health following the department's decision in the late 1990s to restrict contact with major tobacco companies.
What Did the Researchers Do and Find?
Using iterative searching, the researchers identified 764 documents in the Legacy Tobacco Documents Library (a large collection of internal tobacco company documents released as a result of US litigation cases) that contain information relevant to BAT's CSR strategies. Their analysis of these documents indicates that one of the key aims of the CSR program actively developed over the past decade by BAT was to help secure access to policymakers and shows how BAT used CSR to renew and maintain dialogue with policymakers at a time when contact between government and tobacco companies was extremely restricted. The documents also show that BAT employees used CSR initiatives as a means of issue definition to both optimize the probability of subsequent discussions taking place and to frame their content. Finally, the documents illustrate how BAT used its CSR program to expand the number of access points across government, thereby providing BAT with more opportunities to meet and talk to officials.
What Do These Findings Mean?
These findings suggest that CSR is a form of corporate political activity that potentially has important implications for public health given the documented impact of the political activity of tobacco companies in delaying and blocking health-related tobacco control policies. In practice, the impact of the political use of CSR is likely to be context specific and will depend on factors such as whether senior policymakers regard companies as reliable sources of information. Importantly, these findings underline the need for broad implementation of Article 5.3 of the World Health Organization's Framework Convention on Tobacco Control (FCTC), an international treaty that calls for the introduction of multiple measures to reduce tobacco consumption, including tobacco advertizing bans and relevant taxation policies. Article 5.3 aims to protect public-health policies on tobacco control from tobacco industry influence. The findings of this study indicate that implementation of Article 5.3 will require measures that ensure transparency in interactions between all parts of government and the tobacco industry and will need an increased awareness across government of what tobacco companies hope to achieve through CSR.
Additional Information
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001076.
The Corporate Responsibility (CORE) coalition, an alliance of voluntary organizations, trade unions, and companies, maintains a Web site that contains useful material on corporate social responsibility
The European Coalition for Corporate Justice (ECCJ) promotes corporate accountability by bringing together national platforms of civil society organizations (including NGOs, trade unions, consumer advocacy groups, and academic institutions) from all over Europe
The Legacy Tobacco Documents Library is a public, searchable database of tobacco company internal documents detailing their advertising, manufacturing, marketing, sales, and scientific activities
The World Health Organization provides information about the dangers of tobacco (in several languages), details of the Framework Convention on Tobacco Control (in several languages), and guidelines for the implementation of Article 5.3 of the FCTC
The Framework Convention Alliance provides more information about the FCTC
For information about tobacco industry influence on policy, see the 2009 World Health Organization report Tobacco interference with tobacco control
doi:10.1371/journal.pmed.1001076
PMCID: PMC3160341  PMID: 21886485
21.  eRegistries: governance for electronic maternal and child health registries 
Background
The limited availability of maternal and child health data has limited progress in reducing mortality and morbidity among pregnant women and children. Global health agencies, leaders, and funders are prioritizing strategies that focus on acquiring high quality health data. Electronic maternal and child health registries (eRegistries) offer a systematic data collection and management approach that can serve as an entry point for preventive, curative and promotive health services. Due to the highly sensitive nature of reproductive health information, careful consideration must be accorded to privacy, access, and data security. In the third paper of the eRegistries Series, we report on the current landscape of ethical and legal governance for maternal and child health registries in developing countries.
Methods
This research utilizes findings from two web-based surveys, completed in 2015 that targeted public health officials and health care providers in 76 countries with high global maternal and child mortality burden. A sample of 298 public health officials from 64 countries and 490 health care providers from 59 countries completed the online survey. Based on formative research in the development of the eRegistries Governance Guidance Toolkit, the surveys were designed to investigate topics related to maternal and child health registries including ethical and legal issues.
Results
According to survey respondents, the prevailing legal landscape is characterized by inadequate data security safeguards and weak support for core privacy principles. Respondents from the majority of countries indicated that health information from medical records is typically protected by legislation although legislation dealing specifically or comprehensively with data privacy may not be in place. Health care provider trust in the privacy of health data at their own facilities is associated with the presence of security safeguards.
Conclusion
Addressing legal requirements and ensuring that privacy and data security of women’s and children’s health information is protected is an ethical responsibility that must not be ignored or postponed, particularly where the need is greatest. Not only are the potential harm and unintended consequences of inaction serious for individuals, but they could impact public trust in health registries leading to decreased participation and compromised data integrity.
doi:10.1186/s12884-016-1063-0
PMCID: PMC5035445  PMID: 27663979
Ethics; Law; Data privacy; Security; Governance; Registry; Maternal and child health
22.  Gene patents and personalized medicine - what lies ahead? 
Genome Medicine  2009;1(9):92.
Gene patents have generally not impeded biomedical research, but some problems that arise in genetic diagnostics can be attributed to exclusively licensed gene patents. Gene patents for therapeutics have often been litigated but have received surprisingly little public outcry. In stark contrast, genetic diagnostics have been highly controversial but rarely litigated: no case has gone to trial and there is little case law to guide policy. Most recently the Secretary's Advisory Committee for Genetics Health and Society (SACGHS) released a draft report examining how patenting and licensing affect access to clinical genetic testing in the US. The SACGHS reported that patents neither greatly hindered nor facilitated patient access to genetic testing; both the harms and the benefits of patents on genetic diagnostics have been exaggerated. Problems do occur when patents are exclusively licensed to a single provider and no alternative is available. Courts have been changing the thresholds for what can be patented, and how strongly patents can be enforced. Technologies for sequencing, genotyping and gene expression profiling promise to guide clinical decisions in managing common chronic diseases and infectious diseases, and will likely be an integral part of personalized medicine. Developing such genomic tests may require mapping a complex intellectual property landscape and cutting through thickets of patented DNA sequences and related methods. Our preliminary studies have found patent claims that, if strictly enforced, might block the use of multi-gene tests or full-genome sequence data. Yet new technologies promise to reduce the costs of complete genomic sequencing to prices that are comparable to current genetic tests for a single condition. Courts, companies, and policy makers seem unlikely to allow intellectual property to obstruct such technological advance, but prudent policy will depend on careful analysis and foresight. The SACGHS report signals that the US government is paying attention, and increases the odds that policy will foster socially beneficial uses of genetic testing while preserving intellectual property incentives and mitigating the problems that arise from legal monopolies.
doi:10.1186/gm92
PMCID: PMC2768999  PMID: 19804612
23.  Medicine, Media Communication and Ethical Aspects 
Materia Socio-Medica  2010;22(1):6-13.
Summary
On World Press Freedom Day (3rd of May 2009) details of the Frida Haus ranking list of press freedom in countries around the world were officially disclosed. Bosnia and Herzegovina is ranked at 98 place, and in the region better ranked is only Montenegro, which is located between 78 and 80 place along with Botswana and Eastern Timor. Top rated is Iceland with 9 points and on the last place is North Korea, with 98 points. Almost every profession has its deontology/ethical principles. However, medicine and the media are specifically targeted by public controversy with regard to the consequences of their responsibilities for the individual and the overall population. Until twenty years ago, the media were the main social system or a reflection of the social system and dominated the field of public communication, which implicitly reflected in the organization, operation and effects of companies, corporations, etc. as the overall social system, increasing the gross national product and its various categories enabled boom. Medicine and health represent to a wide range of people, perhaps, the most interesting source of information, and probably there isn’t a person that once was not interested in quality professional and verified information regarding some of their medical condition or overall health status. It is estimated that today there are more than a million Web sites on health and diseases, which means that the availability of health information for users is better today than ever before. However, it is important to patients and users of web sites with health information to learn how to properly use them, and learn to assess whether the information published on this site are of reliable quality, which depends on the authors who put the information on the web site, their topicality, simplicity in use and especially the diversity of the medical content of these web pages. It is the Internet that allows the revolution in relation patient-health care- health services provider. First look is at the symptoms and other health information on the Internet before patients actually go to the doctor. In response to this there is change in the relation patient- doctor, there are attempts to allow the patient to make a test, for example, cholesterol in the blood prior to scheduling the examination by the doctor. The vision of the future is Web-based and secure health record (Medical Record) that can be maintained in some kind of health plan or supervised by a physician. Such a site can be used when the patient is traveling or when he or she goes to the pharmacy or doctor of any specialty. Access to appropriate information may strengthen patients to express their demands and medical professionalism in order to improve clinical decision making. Information on support of patients and their involvement in prevention, alternative treatments and their care should be a central part of quality improvement strategies. Improving the quality of information and helping people use the most of what is offered have to be realized by implementing the strategies. Governments should invest in public education programs to encourage people to critically evaluate health information. For their share, they will have to be aware of the scope and quality of information sources that can be used by patients, so that they can get advice from them in an appropriate manner.
doi:10.5455/msm.2010.22.6-13
PMCID: PMC3813544  PMID: 24493979
media; medicine; ethical aspects
24.  A Case Analysis of INFOMED: The Cuban National Health Care Telecommunications Network and Portal 
Background
The Internet and telecommunications technologies contribute to national health care system infrastructures and extend global health care services markets. The Cuban national health care system offers a model to show how a national information portal can contribute to system integration, including research, education, and service delivery as well as international trade in products and services.
Objective
The objectives of this paper are (1) to present the context of the Cuban national health care system since the revolution in 1959, (2) to identify virtual institutional infrastructures of the system associated with the Cuban National Health Care Telecommunications Network and Portal (INFOMED), and (3) to show how they contribute to Cuban trade in international health care service markets.
Methods
Qualitative case research methods were used to identify the integrated virtual infrastructure of INFOMED and to show how it reflects socialist ideology. Virtual institutional infrastructures include electronic medical and information services and the structure of national networks linking such services.
Results
Analysis of INFOMED infrastructures shows integration of health care information, research, and education as well as the interface between Cuban national information networks and the global Internet. System control mechanisms include horizontal integration and coordination through virtual institutions linked through INFOMED, and vertical control through the Ministry of Public Health and the government hierarchy. Telecommunications technology serves as a foundation for a dual market structure differentiating domestic services from international trade.
Conclusions
INFOMED is a model of interest for integrating health care information, research, education, and services. The virtual infrastructures linked through INFOMED support the diffusion of Cuban health care products and services in global markets. Transferability of this model is contingent upon ideology and interpretation of values such as individual intellectual property and confidentiality of individual health information. Future research should focus on examination of these issues and their consequences for global markets in health care.
doi:10.2196/jmir.8.1.e1
PMCID: PMC1550691  PMID: 16585025
Case analysis; Cuban national health care system; INFOMED; ideology; virtual infrastructure; health care markets; globalization
25.  Transnational Tobacco Company Interests in Smokeless Tobacco in Europe: Analysis of Internal Industry Documents and Contemporary Industry Materials 
PLoS Medicine  2013;10(9):e1001506.
In light lobbying by transnational tobacco companies to remove the European Union ban on the sale of snus (a smokeless tobacco product), Silvy Peeters and Anna Gilmore explore the motivation behind tobacco companies' interests in smokeless tobacco products in Europe.
Please see later in the article for the Editors' Summary
Background
European Union (EU) legislation bans the sale of snus, a smokeless tobacco (SLT) which is considerably less harmful than smoking, in all EU countries other than Sweden. To inform the current review of this legislation, this paper aims to explore transnational tobacco company (TTC) interests in SLT and pure nicotine in Europe from the 1970s to the present, comparing them with TTCs' public claims of support for harm reduction.
Methods and Results
Internal tobacco industry documents (in total 416 documents dating from 1971 to 2009), obtained via searching the online Legacy Tobacco Documents Library, were analysed using a hermeneutic approach. This library comprises documents obtained via litigation in the US and does not include documents from Imperial Tobacco, Japan Tobacco International, or Swedish Match. To help overcome this limitation and provide more recent data, we triangulated our documentary findings with contemporary documentation including TTC investor presentations. The analysis demonstrates that British American Tobacco explored SLT opportunities in Europe from 1971 driven by regulatory threats and health concerns, both likely to impact cigarette sales negatively, and the potential to create a new form of tobacco use among those no longer interested in taking up smoking. Young people were a key target. TTCs did not, however, make SLT investments until 2002, a time when EU cigarette volumes started declining, smoke-free legislation was being introduced, and public health became interested in harm reduction. All TTCs have now invested in snus (and recently in pure nicotine), yet both early and recent snus test markets appear to have failed, and little evidence was found in TTCs' corporate materials that snus is central to their business strategy.
Conclusions
There is clear evidence that BAT's early interest in introducing SLT in Europe was based on the potential for creating an alternative form of tobacco use in light of declining cigarette sales and social restrictions on smoking, with young people a key target. We conclude that by investing in snus, and recently nicotine, TTCs have eliminated competition between cigarettes and lower-risk products, thus helping maintain the current market balance in favour of (highly profitable) cigarettes while ensuring TTCs' long-term future should cigarette sales decline further and profit margins be eroded.
Please see later in the article for the Editors' Summary
Editors' Summary
Background
Every year, about 5 million people die from cancer, heart disease, and other tobacco-related diseases. In recent years, to reduce this growing loss of life, international and national bodies have drawn up various tobacco control conventions and directives. For example, the European Union (EU) Directives on tobacco control call for member states to ban tobacco advertising, promotion, and sponsorship and to adopt taxation policies aimed at reducing tobacco consumption. The 2001 EU Tobacco Products Directive also bans the sale of snus, a form of smokeless tobacco (SLT), in all EU countries except Sweden. Snus, which originated in Sweden in the early 19th century, is a moist tobacco product that is placed under the upper lip. Although snus is considerably less harmful than smoking, the sale of snus was banned in the EU in 1992 because of fears that it might cause cancer and was being marketed to young people. When Sweden joined the EU in 1994, exemption from the ban was made a condition of the membership treaty.
Why Was This Study Done?
Transnational tobacco companies (TTCs) have been investing in European snus manufacturers since 2002 and more recently in pure nicotine products, and it has been suggested that, faced with declining cigarette markets in Europe and elsewhere, TTCs are preparing for a “post-cigarette era”. Since 2008, TTCs have been lobbying EU member states and the European Commission to remove the ban on snus sales, arguing that public health would be improved if governments allowed potentially reduced-harm products like snus onto the market. At the end of 2012, however, the European Commission proposed that the ban on snus sales should be continued. Here, to help inform this controversial policy debate, the researchers explore the interest of TTCs in SLT and pure nicotine in Europe from the 1970s to the present by examining internal tobacco documents and compare these interests with public claims of support for harm reduction made by TTCs.
What Did the Researchers Do and Find?
By searching the Legacy Tobacco Documents Library (internal tobacco industry documents released following US litigation cases), the researchers identified 416 documents that detail the historical interest of TTCs in SLT and pure nicotine and their efforts to enter European markets, and to influence national and EU public-health policy. The researchers analyzed these documents using a “hermeneutic” approach—methodical reading and re-reading of the documents to identify themes and sub-themes. Finally, they used TTC investor presentations and other documents to confirm these themes and to provide recent data on TTC investment in SLT. British American Tobacco (BAT) explored the opportunities for marketing SLT products in Europe from 1971 onwards. This exploration was driven by regulatory threats and health concerns, both of which were likely to impact tobacco sales, and by the potential to create a new form of tobacco use among people no longer interested in taking up smoking. TTCs did not begin to invest in SLT, however, until 2002, a time when EU cigarette sale volumes started to decline, smoke-free legislation was being introduced, and tobacco harm reduction first became a major public-health issue. All the TTCs have now invested in snus even though snus test markets appear to have failed and even though there is little evidence in corporate materials that snus is central to the business strategy of TTCs.
What Do These Findings Mean?
These findings suggest that BAT's early interest in SLT in Europe was driven by business concerns and was based on the potential for creating an alternative form of tobacco use among people—particularly young people—who would no longer take up smoking because of health concerns. They also suggest that TTC investments in snus were defensive—by buying up snus manufacturers and more recently nicotine producers, TTCs have eliminated competition between cigarettes and lower-risk products, thereby helping to maintain the current market balance in favor of cigarettes while ensuring the long-term future of TTCs should cigarette sales decline further. Although these findings are limited by the possibility that some relevant documents may have been omitted from this analysis, they nevertheless raise the concern that, if TTC investment in SLT continues, competition between cigarettes and SLT will reduce the potential for harm reduction to benefit public health. Legalization of snus sales in the European Union may therefore have considerably less benefit than envisaged.
Additional Information
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001506.
The World Health Organization provides information about the dangers of tobacco (in several languages) and about the Framework Convention on Tobacco Control, an international treaty for tobacco control; for information about the tobacco industry's influence on policy, see the 2009 World Health Organization report Tobacco interference with tobacco control
Details of European Union legislation on the manufacture, presentation, and sale of tobacco products is available (in several languages)
Wikipedia has pages on tobacco harm reduction and on snus (note: Wikipedia is a free online encyclopedia that anyone can edit; available in several languages)
The Legacy Tobacco Documents Library is a searchable public database of tobacco company internal documents detailing their advertising, manufacturing, marketing, sales, and scientific activities
The UK Centre for Tobacco Control Studies is a network of UK universities that undertakes original research, policy development, advocacy, and teaching and training in the field of tobacco control
SmokeFree, a website provided by the UK National Health Service, offers advice on quitting smoking and includes personal stories from people who have stopped smoking
Smokefree.gov, from the US National Cancer Institute, offers online tools and resources to help people quit smoking
TobaccoTactics.org, an online resource managed by the University of Bath, provides up-to-date information on the tobacco industry and their tactics to influence tobacco regulation
doi:10.1371/journal.pmed.1001506
PMCID: PMC3769209  PMID: 24058299

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