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1.  Guidelines on uncomplicated urinary tract infections are difficult to follow: perceived barriers and suggested interventions 
BMC Family Practice  2010;11:51.
Background
Urinary tract infections (UTI) are among the most common health problems seen in general practice. Evidence-based guidelines on UTI are available, but adherence to these guidelines varies widely among practitioners for reasons not well understood. The aim of this study was to identify the barriers to the implementation of a guideline on UTI perceived by Dutch general practitioners (GPs) and to explore interventions to overcome these barriers.
Methods
A focus group study, including 13 GPs working in general practices in the Netherlands, was conducted. Key recommendations on diagnosis and treatment of uncomplicated UTI were selected from the guideline. Barriers to guideline adherence and possible interventions to address these barriers were discussed. The focus group session was audio-taped and transcribed verbatim. Barriers were classified according to an existing framework.
Results
Lack of agreement with the recommendations, unavailable and inconvenient materials (i.e. dipslides), and organisational constraints were perceived as barriers for the diagnostic recommendations. Barriers to implementing the treatment recommendations were lack of applicability and organisational constraints related to the availability of drugs in pharmacies. Suggested interventions were to provide small group education to GPs and practice staff members, to improve organisation and coordination of care in out of hour services, to improve the availability of preferred dosages of drugs, and to pilot-test guidelines regionally.
Conclusions
Despite sufficient knowledge of the recommendations on UTI, attitudinal and external barriers made it difficult to follow them in practice. The care concerning UTI could be optimized if these barriers are adequately addressed in implementation strategies. The feasibility and success of these strategies could be improved by involving the target group of the guideline in selecting useful interventions to address the barriers to implementation.
doi:10.1186/1471-2296-11-51
PMCID: PMC2908068  PMID: 20584276
2.  Why don't physicians adhere to guideline recommendations in practice? An analysis of barriers among Dutch general practitioners 
Background
Despite wide distribution and promotion of clinical practice guidelines, adherence among Dutch general practitioners (GPs) is not optimal. To improve adherence to guidelines, an analysis of barriers to implementation is advocated. Because different recommendations within a guideline can have different barriers, in this study we focus on key recommendations rather than guidelines as a whole, and explore the barriers to implementation perceived by Dutch GPs.
Methods
A qualitative study using six focus groups was conducted, in which 30 GPs participated, with an average of seven per session. Fifty-six key recommendations were derived from twelve national guidelines. In each focus group, barriers to the implementation of the key recommendations of two clinical practice guidelines were discussed. Focus group discussions were audiotaped and transcribed verbatim. Data was analysed by using an existing framework of barriers.
Results
The barriers varied largely within guidelines, with each key recommendation having a unique pattern of barriers. The most perceived barriers were lack of agreement with the recommendations due to lack of applicability or lack of evidence (68% of key recommendations), environmental factors such as organisational constraints (52%), lack of knowledge regarding the guideline recommendations (46%), and guideline factors such as unclear or ambiguous guideline recommendations (43%).
Conclusion
Our study findings suggest a broad range of barriers. As the barriers largely differ within guidelines, tailored and barrier-driven implementation strategies focusing on key recommendations are needed to improve adherence in practice. In addition, guidelines should be more transparent concerning the underlying evidence and applicability, and further efforts are needed to address complex issues such as comorbidity in guidelines. Finally, it might be useful to include focus groups in continuing medical education as an innovative medium for guideline education and implementation.
doi:10.1186/1748-5908-4-54
PMCID: PMC2734568  PMID: 19674440
3.  Barriers to adherence to chronic obstructive pulmonary disease guidelines by primary care physicians 
Purpose:
Even with the dissemination of several clinical guidelines, chronic obstructive pulmonary disease (COPD) remains underdiagnosed and mismanaged by many primary care physicians (PCPs). The objective of this study was to elucidate barriers to consistent implementation of COPD guidelines.
Patients and methods:
A cross-sectional study implemented in July 2008 was designed to assess attitudes and barriers to COPD guideline usage.
Results:
Five hundred US PCPs (309 family medicine physicians, 191 internists) were included in the analysis. Overall, 23.6% of the surveyed PCPs reported adherence to spirometry guidelines over 90% of the time; 25.8% reported adherence to guidelines related to long-acting bronchodilator (LABD) use in COPD patients. In general, physicians were only somewhat familiar with COPD guidelines, and internal medicine physicians were significantly more familiar than family physicians (P < 0.05). In a multivariate model controlling for demographics and barriers to guideline adherence, we found significant associations with two tested guideline components. Adherence to spirometry guidelines was associated with agreement with guidelines, confidence in interpreting data, ambivalence to outcome expectancy, and ability to incorporate spirometry into patient flow. Adherence to LABD therapy guidelines was associated with agreement with guidelines and confidence in gauging pharmacologic response.
Conclusions:
Adherence to guideline recommendations of spirometry use was predicted by agreement with the recommendations, self-efficacy, perceived outcome expectancy if recommendations were adhered to, and resource availability. Adherence to recommendations of LABD use was predicted by agreement with guideline recommendations and self-efficacy. Increasing guideline familiarity alone may have limited patient outcomes, as other barriers, such as low confidence and outcome expectancy, are more likely to impact guideline adherence.
doi:10.2147/COPD.S16396
PMCID: PMC3064423  PMID: 21468169
COPD; primary care; barriers; guideline adoption
4.  Developing a questionnaire to identify perceived barriers for implementing the Dutch physical therapy COPD clinical practice guideline 
Background
Clinical practice guidelines have been developed to assist healthcare practitioners in clinical decision making. Publication of clinical practice guidelines does not automatically lead to their uptake and barrier identification has been recognized as an important step in implementation planning. This study aimed at developing a questionnaire to identify perceived barriers for implementing the Dutch COPD guideline for physical therapists and its recommended measurement instruments.
Methods
An overall questionnaire, based on two existing questionnaires, was constructed to identify barriers and facilitators for implementing the COPD guideline. The construct of the questionnaire was assessed in a cross-sectional study among 246 chest physical therapists. Factor analysis was conducted to explore underlying dimensions. Psychometric properties were analyzed using Cronbach’s alpha. Barriers and facilitators were assessed using descriptive statistics.
Results
Some 139 physical therapists (57%) responded. Factor analysis revealed 4-factor and 5-factor solutions with an explained variance of 36% and 39% respectively. Cronbach’s alpha of the overall questionnaire was 0.90, and varied from 0.66 to 0.92 for the different factors. Underlying domains of the 5-factor solution were characterized as: attitude towards using measurement instruments, knowledge and skills of the physical therapist, applicability of the COPD guideline, required investment of time & money, and patient characteristics. Physical therapists showed a positive attitude toward using the COPD guideline. Main barriers for implementation were required time investment and financial constraints.
Conclusions
The construct of the questionnaire revealed relevant underlying domains for the identification of barriers and facilitators for implementing the COPD guideline. The questionnaire allowed for tailoring to the target group and may be used across health care professionals as basis for in-depth analysis of barriers to specific recommendations in guidelines. The results of the questionnaire alone do not provide sufficient information to inform the development of an implementation strategy. The infrastructure for developing the guideline can be used for addressing key barriers by the guideline development group, using the questionnaire as well as in-depth analysis such as focus group interviews. Further development of methods for prospective identification of barriers and consequent tailoring of implementation interventions is required.
doi:10.1186/1472-6963-13-159
PMCID: PMC3645972  PMID: 23631555
Chronic Obstructive Pulmonary Disease (COPD); Data collection tools; Guideline; Physical therapy; Pulmonary rehabilitation
5.  Physicians’ attitudes toward, use of, and perceived barriers to clinical guidelines: a survey among Swiss physicians 
Background
Little is known about the attitudes toward, use of, and perceived barriers to clinical guidelines in Switzerland, a country with no national guideline agency. Moreover, there is no available data on the objective assessment of guideline knowledge in Switzerland. Therefore, we conducted a study at a large university’s Department of General Internal Medicine in Switzerland to assess physicians’ attitudes toward, use of, perceived barriers to, and knowledge of clinical guidelines.
Participants and methods
Ninety-six physicians (residents, n=78, and attendings, n=18) were invited to take part in a survey. Attitudes toward, self-reported use of, and barriers hindering adherence to the clinical guidelines were assessed using established scales and frameworks. Knowledge of the guidelines was objectively tested in a written assessment comprising of 14 multiple-choice and 3 short answer case-based questions.
Results
Fifty-five participants completed the survey (residents, n=42, and attendings, n=13; overall response rate 57%). Of these, 50 took part in the knowledge assessment (residents, n=37, and attendings, n=13; overall response rate 52%). Attitudes toward guidelines were favorable. They were considered to be a convenient source of advice (94% agreement), good educational tools (89% agreement), and likely to improve patient quality of care (91% agreement). Self-reported use of guidelines was limited, with only one-third reporting using guidelines often or very often. The main barriers to guideline adherence were identified as lack of guideline awareness and familiarity, applicability of existing guidelines to multimorbid patients, unfavorable guideline factors, and lack of time as well as inertia toward changing previous practice. In the assessment of guideline knowledge, the scores were rather modest (mean ± standard deviation: 60.5%±12.7% correct answers).
Conclusion
In general, this study found favorable physician attitudes toward clinical guidelines. However, several barriers hindering guideline implementation were identified. The importance of improving guideline implementation was supported by modest results in a guideline knowledge test.
doi:10.2147/AMEP.S115149
PMCID: PMC5167524  PMID: 28008300
clinical guidelines; attitudes; barriers; knowledge; survey; physicians
6.  Occupational physicians’ perceived barriers and suggested solutions to improve adherence to a guideline on mental health problems: analysis of a peer group training 
Background
Despite the impact of mental health problems on sickness absence, only few occupational health guidelines addressing these problems are available. Moreover, adherence has found to be suboptimal. To improve adherence to the Dutch guideline on mental health problems a training was developed for Dutch occupational physicians (OPs) focusing on identifying barriers and addressing them. The aim of this study was to provide an overview of the barriers that OPs perceived in adhering to the Dutch guideline on mental health problems as well as their solutions to overcome them.
Methods
A qualitative study was conducted using data from the peer group training. Thirty-two (6 groups of 4 to 6) OPs received a multiple-session interactive training over the course of a year, focusing on identifying and addressing barriers, using a Plan-Do-Check-Act approach. Sessions were audio-taped and transcribed verbatim. Thematic content analysis was performed by two researchers with a selection of 50 % (21 out of 42) of the transcripts to identify the perceived barriers and the suggested solutions, using AtlasTi 7.0.
Results
Knowledge-related barriers were perceived regarding the content of all parts of the guideline. Commonly perceived attitude-related barriers were a lack of self-efficacy to perform certain guideline recommendations and difficulties with changing habits and routines. External barriers that were commonly perceived were work-contextual barriers, such as a lack of time/work pressure, tight contracts between occupational health services (OHSs) and employers, and conflicting policy of and a lack of collaboration with other parties (e.g. employer, other healthcare providers). The most often tested solutions by OPs during the training were sharing information, experiences, tips and tricks and referring to existing tools, or developing new tools to facilitate guideline usage.
Conclusions
Dutch OPs perceive a range of knowledge-related, attitude-related and external barriers in adhering to the guideline on mental health problems. The tested solutions during the training particularly seemed to focus on knowledge and attitude-related barriers. To optimally implement this or similar mental health guidelines, it may be important to complement guideline training and education of individual or groups of OPs, with interventions that address external barriers such as changing tight contracts, or improving communication and collaboration with other parties.
doi:10.1186/s12913-016-1530-3
PMCID: PMC4947285  PMID: 27423463
Mental health; Practice guideline; Occupational medicine; Barriers; Solutions; Implementation
7.  Improving occupational physicians’ adherence to a practice guideline: feasibility and impact of a tailored implementation strategy 
BMC Medical Education  2015;15:82.
Background
Although practice guidelines are important tools to improve quality of care, implementation remains challenging. To improve adherence to an evidence-based guideline for the management of mental health problems, we developed a tailored implementation strategy targeting barriers perceived by occupational physicians (OPs). Feasibility and impact on OPs’ barriers were evaluated.
Methods
OPs received 8 training-sessions in small peer-learning groups, aimed at discussing the content of the guideline and their perceived barriers to adhere to guideline recommendations; finding solutions to overcome these barriers; and implementing solutions in practice. The training had a plan-do-check-act (PDCA) structure and was guided by a trainer. Protocol compliance and OPs’ experiences were qualitatively and quantitatively assessed. Using a questionnaire, impact on knowledge, attitude, and external barriers to guideline adherence was investigated before and after the training.
Results
The training protocol was successfully conducted; guideline recommendations and related barriers were discussed with peers, (innovative) solutions were found and implemented in practice. The participating 32 OPs were divided into 6 groups and all OPs attended 8 sessions. Of the OPs, 90% agreed that the peer-learning groups and the meetings spread over one year were highly effective training components. Significant improvements (p < .05) were found in knowledge, self-efficacy, motivation to use the guideline and its applicability to individual patients. After the training, OPs did not perceive any barriers related to knowledge and self-efficacy. Perceived adherence increased from 48.8% to 96.8% (p < .01).
Conclusions
The results imply that an implementation strategy focusing on perceived barriers and tailor-made implementation interventions is a feasible method to enhance guideline adherence. Moreover, the strategy contributed to OPs’ knowledge, attitudes, and skills in using the guideline. As a generic approach to overcome barriers perceived in specific situations, this strategy provides a useful method to guideline implementation for other health care professionals too.
Electronic supplementary material
The online version of this article (doi:10.1186/s12909-015-0364-8) contains supplementary material, which is available to authorized users.
doi:10.1186/s12909-015-0364-8
PMCID: PMC4469464  PMID: 25903280
Healthcare quality improvement; Implementation strategy; Perceived barriers; Mental health; Plan-do-check-act; Guideline adherence; Continuing medical education
8.  Adherence to the European Society of Cardiology (ESC) guidelines for chronic heart failure - A national survey of the cardiologists in Pakistan 
Background
The aims of this study were to evaluate the awareness of and attitudes towards the 2005 European Society of Cardiology (ESC) guidelines for Heart Failure (HF) of the cardiologists in Pakistan and assess barriers to adherence to guidelines.
Methods
A cross-sectional survey was conducted in person from March to July 2009 to all cardiologists practicing in 4 major cities in Pakistan (Karachi, Lahore, Quetta and Peshawar). A validated, semi-structured questionnaire assessing ESC 2005 Guidelines for HF was used to obtain information from cardiologists. It included questions about awareness and relevance of HF guidelines (See Additional File 1). Respondents' management choices were compared with those of an expert panel based on the guidelines for three fictitious patient cases. Cardiologists were also asked about major barriers to adherence to guidelines.
Results
A total of 372 cardiologists were approached; 305 consented to participate (overall response rate, 82.0%). The survey showed a very high awareness of CHF guidelines; 97.4% aware of any guideline. About 13.8% considered ESC guidelines as relevant or very relevant for guiding treatment decisions while 92.8% chose AHA guidelines in relevance. 87.2% of respondents perceived that they adhered to the HF guidelines. For the patient cases, the proportions of respondents who made recommendations that completely matched those of the guidelines were 7% (Scenario 1), 0% (Scenario 2) and 20% (Scenario 3). Respondents considered patient compliance (59%) and cost/health economics (50%) as major barriers to guideline implementation.
Conclusion
We found important self reported departures from recommended HF management guidelines among cardiologists of Pakistan.
doi:10.1186/1471-2261-11-68
PMCID: PMC3250933  PMID: 22093082
Heart failure; cardiologist; guidelines; awareness
9.  Labour intensity of guidelines may have a greater effect on adherence than GPs' workload 
BMC Family Practice  2009;10:74.
Background
Physicians' heavy workload is often thought to jeopardise the quality of care and to be a barrier to improving quality. The relationship between these has, however, rarely been investigated. In this study quality of care is defined as care 'in accordance with professional guidelines'. In this study we investigated whether GPs with a higher workload adhere less to guidelines than those with a lower workload and whether guideline recommendations that require a greater time investment are less adhered to than those that can save time.
Methods
Data were used from the Second Dutch National survey of General Practice (DNSGP-2). This nationwide study was carried out between April 2000 and January 2002.
A multilevel logistic-regression analysis was conducted of 170,677 decisions made by GPs, referring to 41 Guideline Adherence Indicators (GAIs), which were derived from 32 different guidelines. Data were used from 130 GPs, working in 83 practices with 98,577 patients. GP-characteristics as well as guideline characteristics were used as independent variables. Measures include workload (number of contacts), hours spent on continuing medical education, satisfaction with available time, practice characteristics and patient characteristics. Outcome measure is an indicator score, which is 1 when a decision is in accordance with professional guidelines or 0 when the decision deviates from guidelines.
Results
On average, 66% of the decisions GPs made were in accordance with guidelines. No relationship was found between the objective workload of GPs and their adherence to guidelines. Subjective workload (measured on a five point scale) was negatively related to guideline adherence (OR = 0.95). After controlling for all other variables, the variation between GPs in adherence to guideline recommendations showed a range of less than 10%.
84% of the variation in guideline adherence was located at the GAI-level. Which means that the differences in adherence levels between guidelines are much larger than differences between GPs. Guideline recommendations that require an extra time investment during the same consultation are significantly less adhered to: (OR = 0.46), while those that can save time have much higher adherence levels: OR = 1.55). Recommendations that reduce the likelihood of a follow-up consultation for the same problem are also more often adhered to compared to those that have no influence on this (OR = 3.13).
Conclusion
No significant relationship was found between the objective workload of GPs and adherence to guidelines. However, guideline recommendations that require an extra time investment are significantly less well adhered to while those that can save time are significantly more often adhered to.
doi:10.1186/1471-2296-10-74
PMCID: PMC2791751  PMID: 19943953
10.  Physicians Report Barriers to Deliver Best Practice Care for Asplenic Patients: A Cross-Sectional Survey 
PLoS ONE  2011;6(3):e17302.
Background
Current management of asplenic patients is not in compliance with best practice standards, such as defined by the British Committee for Standards in Haematology. To improve quality of care, factors inhibiting best practice care delivery need to be identified first. With this study, we aimed to identify and quantify physicians' barriers to adhere to best practice management of asplenic patients in the Netherlands.
Methods and Principal Findings
A cross-sectional survey, preceded by multiple focus group discussions, was performed among Dutch physicians responsible for prevention of infections in asplenic patients, including specialists (of Internal medicine and Surgery) and general practitioners (GPs). Forty seven GPs and seventy three hospital specialists returned the questionnaire, yielding response rates of 47% and 36,5% respectively. Physicians reported several barriers to deliver best practice. For both GPs and specialists, the most frequently listed barriers were: poor patient knowledge (>80% of hospital specialists and GPs) and lack of clarity about which physician is responsible for the management of asplenic patients (50% of Internists, 46% of Surgeons, 55% of GPs). Both GPs and hospital specialists expressed to experience a lack of mutual trust: specialists were uncertain whether the GP would follow their advice given on patient discharge (33–59%), whereas half of GPs was not convinced that specialists' discharge letters contained the correct recommendations. Almost all physicians (>90%) indicated that availability of a national guideline would improve adherence to best practice, especially if accessible online.
Conclusion
This study showed that, in accordance with reports on international performance, care delivery for asplenic patients in the Netherlands is suboptimal. We identified and quantified perceived barriers by physicians that prevent adherence to post-splenectomy guidelines for the first time. Better transmural collaboration and better informed patients are likely to improve the quality of care of the asplenic patient population. A national, online-available guideline is urgently required.
doi:10.1371/journal.pone.0017302
PMCID: PMC3053367  PMID: 21423748
11.  BARRIERS TO ADHERENCE TO COPD GUIDELINES AMONG PRIMARY CARE PROVIDERS 
Respiratory Medicine  2011;106(3):374-381.
Background
Despite efforts to disseminate guidelines for managing chronic obstructive pulmonary disease (COPD), adherence to COPD guidelines remains suboptimal. Barriers to adhering to guidelines remain poorly understood.
Methods
Clinicians from two general medicine practices in New York City were surveyed to identify barriers to implementing seven recommendations from the Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines. Barriers assessed included unfamiliarity, disagreement, low perceived benefit, low self-efficacy, and time constraints. Exact conditional regression was used to identify barriers independently associated with non-adherence.
Results
The survey was completed by 154 clinicians. Adherence was lowest to referring patients with a forced expiratory volume in one second (FEV1) <80% predicted to pulmonary rehabilitation (5%); using FEV1 to guide management (12%); and ordering pulmonary function tests (PFTs) in smokers (17%). Adherence was intermediate to prescribing inhaled corticosteroids when FEV1 <50% predicted (41%) and long-acting bronchodilators when FEV1 <80% predicted (54%). Adherence was highest for influenza vaccination (90%) and smoking cessation counseling (91%). In unadjusted analyses, low familiarity with the guidelines, low self-efficacy, and time constraints were significantly associated with non-adherence to ≥2 recommendations. In adjusted analyses, low self-efficacy was associated with less adherence to prescribing inhaled corticosteroids (OR: 0.28; 95% CI: 0.10, 0.74) and time constraints were associated with less adherence to ordering PFTs in smokers (OR: 0.31; 95% CI: 0.08, 0.99).
Conclusions
Poor familiarity with recommendations, low self-efficacy, and time constraints are important barriers to adherence to COPD guidelines. This information can be used to develop tailored interventions to improve guideline adherence.
doi:10.1016/j.rmed.2011.09.010
PMCID: PMC3377746  PMID: 22000501
COPD; guidelines; adherence; primary care
12.  Swedish general practitioners’ attitudes towards treatment guidelines – a qualitative study 
BMC Family Practice  2014;15:199.
Background
Drug therapy in primary care is a challenge for general practitioners (GPs) and the prescribing decision is influenced by several factors. GPs obtain drug information in different ways, from evidence-based sources, their own or others’ experiences, or interactions with opinion makers, patients or colleagues. The need for objective drug information sources instead of drug industry-provided information has led to the establishment of local drug and therapeutic committees. They annually produce and implement local treatment guidelines in order to promote rational drug use. This study describes Swedish GPs’ attitudes towards locally developed evidence-based treatment guidelines.
Methods
Three focus group interviews were performed with a total of 17 GPs working at both public and private primary health care centres in Skåne in southern Sweden. Transcripts were analysed by conventional content analysis. Codes, categories and themes were derived from data during the analysis.
Results
We found two main themes: GP-related influencing factors and External influencing factors. The first theme emerged when we put together four main categories: Expectations and perceptions about existing local guidelines, Knowledge about evidence-based prescribing, Trust in development of guidelines, and Beliefs about adherence to guidelines. The second theme included the categories Patient-related aspects, Drug industry-related aspects, and Health economic aspects. The time-saving aspect, trust in evidence-based market-neutral guidelines and patient safety were described as key motivating factors for adherence. Patient safety was reported to be more important than adherence to guidelines or maintaining a good patient-doctor relationship. Cost containment was perceived both as a motivating factor and a barrier for adherence to guidelines. GPs expressed concerns about difficulties with adherence to guidelines when managing patients with drugs from other prescribers. GPs experienced a lack of time to self-inform and difficulties managing direct-to-consumer drug industry information.
Conclusions
Patient safety, trust in development of evidence-based recommendations, the patient-doctor encounter and cost containment were found to be key factors in GPs’ prescribing. Future studies should explore the need for transparency in forming and implementing guidelines, which might potentially increase adherence to evidence-based treatment guidelines in primary care.
doi:10.1186/s12875-014-0199-0
PMCID: PMC4276045  PMID: 25511989
Qualitative research; Focus groups; Guidelines; Attitudes; Primary care; GPs; Adherence; Drug therapy
13.  Clinical Utility of Vitamin D Testing 
Executive Summary
This report from the Medical Advisory Secretariat (MAS) was intended to evaluate the clinical utility of vitamin D testing in average risk Canadians and in those with kidney disease. As a separate analysis, this report also includes a systematic literature review of the prevalence of vitamin D deficiency in these two subgroups.
This evaluation did not set out to determine the serum vitamin D thresholds that might apply to non-bone health outcomes. For bone health outcomes, no high or moderate quality evidence could be found to support a target serum level above 50 nmol/L. Similarly, no high or moderate quality evidence could be found to support vitamin D’s effects in non-bone health outcomes, other than falls.
Vitamin D
Vitamin D is a lipid soluble vitamin that acts as a hormone. It stimulates intestinal calcium absorption and is important in maintaining adequate phosphate levels for bone mineralization, bone growth, and remodelling. It’s also believed to be involved in the regulation of cell growth proliferation and apoptosis (programmed cell death), as well as modulation of the immune system and other functions. Alone or in combination with calcium, Vitamin D has also been shown to reduce the risk of fractures in elderly men (≥ 65 years), postmenopausal women, and the risk of falls in community-dwelling seniors. However, in a comprehensive systematic review, inconsistent results were found concerning the effects of vitamin D in conditions such as cancer, all-cause mortality, and cardiovascular disease. In fact, no high or moderate quality evidence could be found concerning the effects of vitamin D in such non-bone health outcomes. Given the uncertainties surrounding the effects of vitamin D in non-bone health related outcomes, it was decided that this evaluation should focus on falls and the effects of vitamin D in bone health and exclusively within average-risk individuals and patients with kidney disease.
Synthesis of vitamin D occurs naturally in the skin through exposure to ultraviolet B (UVB) radiation from sunlight, but it can also be obtained from dietary sources including fortified foods, and supplements. Foods rich in vitamin D include fatty fish, egg yolks, fish liver oil, and some types of mushrooms. Since it is usually difficult to obtain sufficient vitamin D from non-fortified foods, either due to low content or infrequent use, most vitamin D is obtained from fortified foods, exposure to sunlight, and supplements.
Clinical Need: Condition and Target Population
Vitamin D deficiency may lead to rickets in infants and osteomalacia in adults. Factors believed to be associated with vitamin D deficiency include:
darker skin pigmentation,
winter season,
living at higher latitudes,
skin coverage,
kidney disease,
malabsorption syndromes such as Crohn’s disease, cystic fibrosis, and
genetic factors.
Patients with chronic kidney disease (CKD) are at a higher risk of vitamin D deficiency due to either renal losses or decreased synthesis of 1,25-dihydroxyvitamin D.
Health Canada currently recommends that, until the daily recommended intakes (DRI) for vitamin D are updated, Canada’s Food Guide (Eating Well with Canada’s Food Guide) should be followed with respect to vitamin D intake. Issued in 2007, the Guide recommends that Canadians consume two cups (500 ml) of fortified milk or fortified soy beverages daily in order to obtain a daily intake of 200 IU. In addition, men and women over the age of 50 should take 400 IU of vitamin D supplements daily. Additional recommendations were made for breastfed infants.
A Canadian survey evaluated the median vitamin D intake derived from diet alone (excluding supplements) among 35,000 Canadians, 10,900 of which were from Ontario. Among Ontarian males ages 9 and up, the median daily dietary vitamin D intake ranged between 196 IU and 272 IU per day. Among females, it varied from 152 IU to 196 IU per day. In boys and girls ages 1 to 3, the median daily dietary vitamin D intake was 248 IU, while among those 4 to 8 years it was 224 IU.
Vitamin D Testing
Two laboratory tests for vitamin D are available, 25-hydroxy vitamin D, referred to as 25(OH)D, and 1,25-dihydroxyvitamin D. Vitamin D status is assessed by measuring the serum 25(OH)D levels, which can be assayed using radioimmunoassays, competitive protein-binding assays (CPBA), high pressure liquid chromatography (HPLC), and liquid chromatography-tandem mass spectrometry (LC-MS/MS). These may yield different results with inter-assay variation reaching up to 25% (at lower serum levels) and intra-assay variation reaching 10%.
The optimal serum concentration of vitamin D has not been established and it may change across different stages of life. Similarly, there is currently no consensus on target serum vitamin D levels. There does, however, appear to be a consensus on the definition of vitamin D deficiency at 25(OH)D < 25 nmol/l, which is based on the risk of diseases such as rickets and osteomalacia. Higher target serum levels have also been proposed based on subclinical endpoints such as parathyroid hormone (PTH). Therefore, in this report, two conservative target serum levels have been adopted, 25 nmol/L (based on the risk of rickets and osteomalacia), and 40 to 50 nmol/L (based on vitamin D’s interaction with PTH).
Ontario Context
Volume & Cost
The volume of vitamin D tests done in Ontario has been increasing over the past 5 years with a steep increase of 169,000 tests in 2007 to more than 393,400 tests in 2008. The number of tests continues to rise with the projected number of tests for 2009 exceeding 731,000. According to the Ontario Schedule of Benefits, the billing cost of each test is $51.7 for 25(OH)D (L606, 100 LMS units, $0.517/unit) and $77.6 for 1,25-dihydroxyvitamin D (L605, 150 LMS units, $0.517/unit). Province wide, the total annual cost of vitamin D testing has increased from approximately $1.7M in 2004 to over $21.0M in 2008. The projected annual cost for 2009 is approximately $38.8M.
Evidence-Based Analysis
The objective of this report is to evaluate the clinical utility of vitamin D testing in the average risk population and in those with kidney disease. As a separate analysis, the report also sought to evaluate the prevalence of vitamin D deficiency in Canada. The specific research questions addressed were thus:
What is the clinical utility of vitamin D testing in the average risk population and in subjects with kidney disease?
What is the prevalence of vitamin D deficiency in the average risk population in Canada?
What is the prevalence of vitamin D deficiency in patients with kidney disease in Canada?
Clinical utility was defined as the ability to improve bone health outcomes with the focus on the average risk population (excluding those with osteoporosis) and patients with kidney disease.
Literature Search
A literature search was performed on July 17th, 2009 using OVID MEDLINE, MEDLINE In-Process and Other Non-Indexed Citations, EMBASE, the Cumulative Index to Nursing & Allied Health Literature (CINAHL), the Cochrane Library, and the International Agency for Health Technology Assessment (INAHTA) for studies published from January 1, 1998 until July 17th, 2009. Abstracts were reviewed by a single reviewer and, for those studies meeting the eligibility criteria, full-text articles were obtained. Reference lists were also examined for any additional relevant studies not identified through the search. Articles with unknown eligibility were reviewed with a second clinical epidemiologist, then a group of epidemiologists until consensus was established. The quality of evidence was assessed as high, moderate, low or very low according to GRADE methodology.
Observational studies that evaluated the prevalence of vitamin D deficiency in Canada in the population of interest were included based on the inclusion and exclusion criteria listed below. The baseline values were used in this report in the case of interventional studies that evaluated the effect of vitamin D intake on serum levels. Studies published in grey literature were included if no studies published in the peer-reviewed literature were identified for specific outcomes or subgroups.
Considering that vitamin D status may be affected by factors such as latitude, sun exposure, food fortification, among others, the search focused on prevalence studies published in Canada. In cases where no Canadian prevalence studies were identified, the decision was made to include studies from the United States, given the similar policies in vitamin D food fortification and recommended daily intake.
Inclusion Criteria
Studies published in English
Publications that reported the prevalence of vitamin D deficiency in Canada
Studies that included subjects from the general population or with kidney disease
Studies in children or adults
Studies published between January 1998 and July 17th 2009
Exclusion Criteria
Studies that included subjects defined according to a specific disease other than kidney disease
Letters, comments, and editorials
Studies that measured the serum vitamin D levels but did not report the percentage of subjects with serum levels below a given threshold
Outcomes of Interest
Prevalence of serum vitamin D less than 25 nmol/L
Prevalence of serum vitamin D less than 40 to 50 nmol/L
Serum 25-hydroxyvitamin D was the metabolite used to assess vitamin D status. Results from adult and children studies were reported separately. Subgroup analyses according to factors that affect serum vitamin D levels (e.g., seasonal effects, skin pigmentation, and vitamin D intake) were reported if enough information was provided in the studies
Quality of Evidence
The quality of the prevalence studies was based on the method of subject recruitment and sampling, possibility of selection bias, and generalizability to the source population. The overall quality of the trials was examined according to the GRADE Working Group criteria.
Summary of Findings
Fourteen prevalence studies examining Canadian adults and children met the eligibility criteria. With the exception of one longitudinal study, the studies had a cross-sectional design. Two studies were conducted among Canadian adults with renal disease but none studied Canadian children with renal disease (though three such US studies were included). No systematic reviews or health technology assessments that evaluated the prevalence of vitamin D deficiency in Canada were identified. Two studies were published in grey literature, consisting of a Canadian survey designed to measure serum vitamin D levels and a study in infants presented as an abstract at a conference. Also included were the results of vitamin D tests performed in community laboratories in Ontario between October 2008 and September 2009 (provided by the Ontario Association of Medical Laboratories).
Different threshold levels were used in the studies, thus we reported the percentage of subjects with serum levels of between 25 and 30 nmol/L and between 37.5 and 50 nmol/L. Some studies stratified the results according to factors affecting vitamin D status and two used multivariate models to investigate the effects of these characteristics (including age, season, BMI, vitamin D intake, skin pigmentation, and season) on serum 25(OH)D levels. It’s unclear, however, if these studies were adequately powered for these subgroup analyses.
Study participants generally consisted of healthy, community-dwelling subjects and most excluded individuals with conditions or medications that alter vitamin D or bone metabolism, such as kidney or liver disease. Although the studies were conducted in different parts of Canada, fewer were performed in Northern latitudes, i.e. above 53°N, which is equivalent to the city of Edmonton.
Adults
Serum vitamin D levels of < 25 to 30 nmol/L were observed in 0% to 25.5% of the subjects included in five studies; the weighted average was 3.8% (95% CI: 3.0, 4.6). The preliminary results of the Canadian survey showed that approximately 5% of the subjects had serum levels below 29.5 nmol/L. The results of over 600,000 vitamin D tests performed in Ontarian community laboratories between October 2008 and September 2009 showed that 2.6% of adults (> 18 years) had serum levels < 25 nmol/L.
The prevalence of serum vitamin D levels below 37.5-50 nmol/L reported among studies varied widely, ranging from 8% to 73.6% with a weighted average of 22.5%. The preliminary results of the CHMS survey showed that between 10% and 25% of subjects had serum levels below 37 to 48 nmol/L. The results of the vitamin D tests performed in community laboratories showed that 10% to 25% of the individuals had serum levels between 39 and 50 nmol/L.
In an attempt to explain this inter-study variation, the study results were stratified according to factors affecting serum vitamin D levels, as summarized below. These results should be interpreted with caution as none were adjusted for other potential confounders. Adequately powered multivariate analyses would be necessary to determine the contribution of risk factors to lower serum 25(OH)D levels.
Seasonal variation
Three adult studies evaluating serum vitamin D levels in different seasons observed a trend towards a higher prevalence of serum levels < 37.5 to 50 nmol/L during the winter and spring months, specifically 21% to 39%, compared to 8% to 14% in the summer. The weighted average was 23.6% over the winter/spring months and 9.6% over summer. The difference between the seasons was not statistically significant in one study and not reported in the other two studies.
Skin Pigmentation
Four studies observed a trend toward a higher prevalence of serum vitamin D levels < 37.5 to 50 nmol/L in subjects with darker skin pigmentation compared to those with lighter skin pigmentation, with weighted averages of 46.8% among adults with darker skin colour and 15.9% among those with fairer skin.
Vitamin D intake and serum levels
Four adult studies evaluated serum vitamin D levels according to vitamin D intake and showed an overall trend toward a lower prevalence of serum levels < 37.5 to 50 nmol/L with higher levels of vitamin D intake. One study observed a dose-response relationship between higher vitamin D intake from supplements, diet (milk), and sun exposure (results not adjusted for other variables). It was observed that subjects taking 50 to 400 IU or > 400 IU of vitamin D per day had a 6% and 3% prevalence of serum vitamin D level < 40 nmol/L, respectively, versus 29% in subjects not on vitamin D supplementation. Similarly, among subjects drinking one or two glasses of milk per day, the prevalence of serum vitamin D levels < 40 nmol/L was found to be 15%, versus 6% in those who drink more than two glasses of milk per day and 21% among those who do not drink milk. On the other hand, one study observed little variation in serum vitamin D levels during winter according to milk intake, with the proportion of subjects exhibiting vitamin D levels of < 40 nmol/L being 21% among those drinking 0-2 glasses per day, 26% among those drinking > 2 glasses, and 20% among non-milk drinkers.
The overall quality of evidence for the studies conducted among adults was deemed to be low, although it was considered moderate for the subgroups of skin pigmentation and seasonal variation.
Newborn, Children and Adolescents
Five Canadian studies evaluated serum vitamin D levels in newborns, children, and adolescents. In four of these, it was found that between 0 and 36% of children exhibited deficiency across age groups with a weighted average of 6.4%. The results of over 28,000 vitamin D tests performed in children 0 to 18 years old in Ontario laboratories (Oct. 2008 to Sept. 2009) showed that 4.4% had serum levels of < 25 nmol/L.
According to two studies, 32% of infants 24 to 30 months old and 35.3% of newborns had serum vitamin D levels of < 50 nmol/L. Two studies of children 2 to 16 years old reported that 24.5% and 34% had serum vitamin D levels below 37.5 to 40 nmol/L. In both studies, older children exhibited a higher prevalence than younger children, with weighted averages 34.4% and 10.3%, respectively. The overall weighted average of the prevalence of serum vitamin D levels < 37.5 to 50 nmol/L among pediatric studies was 25.8%. The preliminary results of the Canadian survey showed that between 10% and 25% of subjects between 6 and 11 years (N= 435) had serum levels below 50 nmol/L, while for those 12 to 19 years, 25% to 50% exhibited serum vitamin D levels below 50 nmol/L.
The effects of season, skin pigmentation, and vitamin D intake were not explored in Canadian pediatric studies. A Canadian surveillance study did, however, report 104 confirmed cases1 (2.9 cases per 100,000 children) of vitamin D-deficient rickets among Canadian children age 1 to 18 between 2002 and 2004, 57 (55%) of which from Ontario. The highest incidence occurred among children living in the North, i.e., the Yukon, Northwest Territories, and Nunavut. In 92 (89%) cases, skin pigmentation was categorized as intermediate to dark, 98 (94%) had been breastfed, and 25 (24%) were offspring of immigrants to Canada. There were no cases of rickets in children receiving ≥ 400 IU VD supplementation/day.
Overall, the quality of evidence of the studies of children was considered very low.
Kidney Disease
Adults
Two studies evaluated serum vitamin D levels in Canadian adults with kidney disease. The first included 128 patients with chronic kidney disease stages 3 to 5, 38% of which had serum vitamin D levels of < 37.5 nmol/L (measured between April and July). This is higher than what was reported in Canadian studies of the general population during the summer months (i.e. between 8% and 14%). In the second, which examined 419 subjects who had received a renal transplantation (mean time since transplantation: 7.2 ± 6.4 years), the prevalence of serum vitamin D levels < 40 nmol/L was 27.3%. The authors concluded that the prevalence observed in the study population was similar to what is expected in the general population.
Children
No studies evaluating serum vitamin D levels in Canadian pediatric patients with kidney disease could be identified, although three such US studies among children with chronic kidney disease stages 1 to 5 were. The mean age varied between 10.7 and 12.5 years in two studies but was not reported in the third. Across all three studies, the prevalence of serum vitamin D levels below the range of 37.5 to 50 nmol/L varied between 21% and 39%, which is not considerably different from what was observed in studies of healthy Canadian children (24% to 35%).
Overall, the quality of evidence in adults and children with kidney disease was considered very low.
Clinical Utility of Vitamin D Testing
A high quality comprehensive systematic review published in August 2007 evaluated the association between serum vitamin D levels and different bone health outcomes in different age groups. A total of 72 studies were included. The authors observed that there was a trend towards improvement in some bone health outcomes with higher serum vitamin D levels. Nevertheless, precise thresholds for improved bone health outcomes could not be defined across age groups. Further, no new studies on the association were identified during an updated systematic review on vitamin D published in July 2009.
With regards to non-bone health outcomes, there is no high or even moderate quality evidence that supports the effectiveness of vitamin D in outcomes such as cancer, cardiovascular outcomes, and all-cause mortality. Even if there is any residual uncertainty, there is no evidence that testing vitamin D levels encourages adherence to Health Canada’s guidelines for vitamin D intake. A normal serum vitamin D threshold required to prevent non-bone health related conditions cannot be resolved until a causal effect or correlation has been demonstrated between vitamin D levels and these conditions. This is as an ongoing research issue around which there is currently too much uncertainty to base any conclusions that would support routine vitamin D testing.
For patients with chronic kidney disease (CKD), there is again no high or moderate quality evidence supporting improved outcomes through the use of calcitriol or vitamin D analogs. In the absence of such data, the authors of the guidelines for CKD patients consider it best practice to maintain serum calcium and phosphate at normal levels, while supplementation with active vitamin D should be considered if serum PTH levels are elevated. As previously stated, the authors of guidelines for CKD patients believe that there is not enough evidence to support routine vitamin D [25(OH)D] testing. According to what is stated in the guidelines, decisions regarding the commencement or discontinuation of treatment with calcitriol or vitamin D analogs should be based on serum PTH, calcium, and phosphate levels.
Limitations associated with the evidence of vitamin D testing include ambiguities in the definition of an ‘adequate threshold level’ and both inter- and intra- assay variability. The MAS considers both the lack of a consensus on the target serum vitamin D levels and assay limitations directly affect and undermine the clinical utility of testing. The evidence supporting the clinical utility of vitamin D testing is thus considered to be of very low quality.
Daily vitamin D intake, either through diet or supplementation, should follow Health Canada’s recommendations for healthy individuals of different age groups. For those with medical conditions such as renal disease, liver disease, and malabsorption syndromes, and for those taking medications that may affect vitamin D absorption/metabolism, physician guidance should be followed with respect to both vitamin D testing and supplementation.
Conclusions
Studies indicate that vitamin D, alone or in combination with calcium, may decrease the risk of fractures and falls among older adults.
There is no high or moderate quality evidence to support the effectiveness of vitamin D in other outcomes such as cancer, cardiovascular outcomes, and all-cause mortality.
Studies suggest that the prevalence of vitamin D deficiency in Canadian adults and children is relatively low (approximately 5%), and between 10% and 25% have serum levels below 40 to 50 nmol/L (based on very low to low grade evidence).
Given the limitations associated with serum vitamin D measurement, ambiguities in the definition of a ‘target serum level’, and the availability of clear guidelines on vitamin D supplementation from Health Canada, vitamin D testing is not warranted for the average risk population.
Health Canada has issued recommendations regarding the adequate daily intake of vitamin D, but current studies suggest that the mean dietary intake is below these recommendations. Accordingly, Health Canada’s guidelines and recommendations should be promoted.
Based on a moderate level of evidence, individuals with darker skin pigmentation appear to have a higher risk of low serum vitamin D levels than those with lighter skin pigmentation and therefore may need to be specially targeted with respect to optimum vitamin D intake. The cause-effect of this association is currently unclear.
Individuals with medical conditions such as renal and liver disease, osteoporosis, and malabsorption syndromes, as well as those taking medications that may affect vitamin D absorption/metabolism, should follow their physician’s guidance concerning both vitamin D testing and supplementation.
PMCID: PMC3377517  PMID: 23074397
14.  Barriers and facilitators to the implementation of clinical practice guidelines: A cross-sectional survey among physicians in Estonia 
Background
In an era when an increasing amount of clinical information is available to health care professionals, the effective implementation of clinical practice guidelines requires the development of strategies to facilitate the use of these guidelines. The objective of this study was to assess attitudes towards clinical practice guidelines, as well as the barriers and facilitators to their use, among Estonian physicians. The study was conducted to inform the revision of the clinical practice guideline development process and can provide inspiration to other countries considering the increasing use of evidence-based medicine.
Methods
We conducted an online survey of physicians to assess resource, system, and attitudinal barriers. We also asked a set of questions related to improving the use of clinical practice guidelines and collected free-text comments. We hypothesized that attitudes concerning guidelines may differ by gender, years of experience and practice setting. The study population consisted of physicians from the database of the Department of Continuing Medical Education of the University of Tartu. Differences between groups were analyzed using the Kruskal-Wallis non-parametric test.
Results
41% (497/1212) of physicians in the database completed the questionnaire, comprising more than 10% of physicians in the country. Most respondents (79%) used treatment guidelines in their daily clinical practice. Lack of time was the barrier identified by the most physicians (42%), followed by lack of medical resources for implementation (32%). The majority of physicians disagreed with the statement that guidelines were not accessible (73%) or too complicated (70%). Physicians practicing in outpatient settings or for more than 25 years were the most likely to experience difficulties in guideline use. 95% of respondents agreed that an easy-to-find online database of guidelines would facilitate use.
Conclusions
Use of updated evidence-based guidelines is a prerequisite for the high-quality management of diseases, and recognizing the factors that affect guideline compliance makes it possible to work towards improving guideline adherence in clinical practice. In our study, physicians with long-term clinical experience and doctors in outpatient settings perceived more barriers, which should be taken into account when planning strategies in improving the use of guidelines. Informed by the results of the survey, leading health authorities are making an effort to develop specially designed interventions to implement clinical practice guidelines, including an easily accessible online database.
doi:10.1186/1472-6963-12-455
PMCID: PMC3532376  PMID: 23234504
Clinical practice guidelines; Implementation; Estonia; World health organization; Barriers; Facilitators
15.  Assessment of HBV Preventive Services in a Medically Underserved Asian and Pacific Islander Population Using Provider and Patient Data 
ABSTRACT
Background
Hepatitis B (HBV) represents a significant health disparity among medically underserved Asian and Hawaiian/Pacific Islander (API) populations. Studies evaluating adherence to HBV screening and vaccination guidelines in this population are limited.
Objective
The purpose of this study was to evaluate HBV screening and vaccination practices using both provider self-report and patient records.
Design
Medical records for 20,574 API adults were reviewed retrospectively and primary care providers were surveyed to evaluate rates and adherence to HBV screening and vaccination guidelines.
Participants
The study included primary care providers and their adult API patients in the San Francisco safety-net healthcare system.
Main Measures
Patient, practice, and provider factors, as well as HBV screening and vaccination practices, were assessed using provider survey constructs and patient laboratory and clinical data. Generalized linear mixed models and multivariate logistic regression analyses were used to identify factors associated with recommended HBV screening and vaccination.
Key Results
The mean age of patients was 52 years, and 63.4 % of patients were female. Only 61.5 % underwent HBV testing, and 47.4 % of HBV-susceptible patients were vaccinated. Of 148 (44.8 %) responding providers, most were knowledgeable and had a favorable attitude towards screening, but 43.2 % were unfamiliar with HBV guidelines. HBV screening was positively associated with favorable provider attitude score (OR per unit 1.80, 95 % CI 1.18–2.74) and negatively associated with female patient sex (OR 0.82, 95 % CI 0.73–0.92), a higher number of clinic patients per week (OR per 20 patients 0.46, 95 % CI 0.28–0.76), and provider barrier score (OR per unit 0.45, 95 % CI 0.24–0.87). HBV vaccination was negatively associated with provider barrier score (OR per unit 0.48, 95 % CI 0.25–0.91).
Conclusions
Rates of HBV screening and vaccination of API patients in this safety-net system are suboptimal, and provider factors play a significant role. Efforts to cultivate positive attitudes among providers and expand healthcare system resources to reduce provider barriers to HBV care are warranted.
doi:10.1007/s11606-014-3057-9
PMCID: PMC4284271  PMID: 25324148
HBV screening; HBV vaccination; HBV prevention; Safety net; Asians
16.  Hepatitis B Management in Vulnerable Populations: Gaps in Disease Monitoring and Opportunities for Improved Care 
Background
Hepatitis B (HBV) is prevalent in certain US populations and regular HBV disease monitoring is critical to reducing associated morbidity and mortality. Adherence to established HBV monitoring guidelines among primary care providers is unknown.
Aims
To evaluate HBV disease monitoring patterns and factors associated with adherence to HBV management guidelines in the primary care setting.
Methods
Primary providers within the San Francisco safety net healthcare system were surveyed for HBV management practices, knowledge, attitudes, and barriers to HBV care. Medical records from 1,727 HBV-infected patients were also reviewed retrospectively.
Results
Of 148 (45%) responding providers, 79% reported ALT and 44% reported HBV viral load testing every 6–12 months. Most providers were knowledgeable about HBV but 43% were unfamiliar with HBV management guidelines. Patient characteristics included: mean age 51 years; 54% male; 67% Asian. Within the past year, 75% had ALT; 24% viral load; 21% HBeAg tested, and 40% of at-risk patients had abdominal imaging for HCC. Provider familiarity with guidelines (OR 1.02, 95%CI 1.00–1.03), Asian patient race (OR 4.18, 95%CI 2.40–7.27), and patient age were associated with recommended HBV monitoring. Provider HBV knowledge and attitudes were positively associated, while provider age and perceived barriers were negatively associated with HCC surveillance.
Conclusions
Comprehensive HBV disease monitoring including HCC screening with imaging were suboptimal. While familiarity with AASLD guidelines and patient factors were associated with HBV monitoring, only provider and practice factors were associated with HCC surveillance. These findings highlight the importance of targeted provider education to improve HBV care.
doi:10.1007/s10620-013-2870-z
PMCID: PMC3947196  PMID: 24052195
Hepatitis B; Hepatocellular carcinoma; Primary care; Provider education; Practice guidelines; Health disparities
17.  Women's Access and Provider Practices for the Case Management of Malaria during Pregnancy: A Systematic Review and Meta-Analysis 
PLoS Medicine  2014;11(8):e1001688.
Jenny Hill and colleagues conduct a systematic review and meta-analysis of women’s access and healthcare provider adherence to WHO case-management policy of malaria during pregnancy.
Please see later in the article for the Editors' Summary
Background
WHO recommends prompt diagnosis and quinine plus clindamycin for treatment of uncomplicated malaria in the first trimester and artemisinin-based combination therapies in subsequent trimesters. We undertook a systematic review of women's access to and healthcare provider adherence to WHO case management policy for malaria in pregnant women.
Methods and Findings
We searched the Malaria in Pregnancy Library, the Global Health Database, and the International Network for the Rational Use of Drugs Bibliography from 1 January 2006 to 3 April 2014, without language restriction. Data were appraised for quality and content. Frequencies of women's and healthcare providers' practices were explored using narrative synthesis and random effect meta-analysis. Barriers to women's access and providers' adherence to policy were explored by content analysis using NVivo. Determinants of women's access and providers' case management practices were extracted and compared across studies. We did not perform a meta-ethnography. Thirty-seven studies were included, conducted in Africa (30), Asia (4), Yemen (1), and Brazil (2). One- to three-quarters of women reported malaria episodes during pregnancy, of whom treatment was sought by >85%. Barriers to access among women included poor knowledge of drug safety, prohibitive costs, and self-treatment practices, used by 5%–40% of women. Determinants of women's treatment-seeking behaviour were education and previous experience of miscarriage and antenatal care. Healthcare provider reliance on clinical diagnosis and poor adherence to treatment policy, especially in first versus other trimesters (28%, 95% CI 14%–47%, versus 72%, 95% CI 39%–91%, p = 0.02), was consistently reported. Prescribing practices were driven by concerns over side effects and drug safety, patient preference, drug availability, and cost. Determinants of provider practices were access to training and facility type (public versus private). Findings were limited by the availability, quality, scope, and methodological inconsistencies of the included studies.
Conclusions
A systematic assessment of the extent of substandard case management practices of malaria in pregnancy is required, as well as quality improvement interventions that reach all providers administering antimalarial drugs in the community. Pregnant women need access to information on which anti-malarial drugs are safe to use at different stages of pregnancy.
Please see later in the article for the Editors' Summary
Editors' Summary
Background
Malaria, a mosquito-borne parasite, kills about 600,000 people every year. Most of these deaths occur among young children in sub-Saharan Africa, but pregnant women and their unborn babies are also vulnerable to malaria. Infection with malaria during pregnancy can cause severe maternal anemia, miscarriages, and preterm births, and kills about 10,000 women and 100,000 children each year. Since 2006, the World Health Organization (WHO) has recommended that uncomplicated malaria (an infection that causes a fever but does not involve organ damage or severe anemia) should be treated with quinine and clindamycin if it occurs during the first trimester (first three months) of pregnancy and with an artemisinin-based combination therapy (ACT) if it occurs during the second or third trimester; ACTs should be used during the first trimester only if no other treatment is immediately available because their safety during early pregnancy has not been established. Since 2010, WHO has also recommended that clinical diagnosis of malaria should be confirmed before treatment by looking for parasites in patients' blood (parasitology).
Why Was This Study Done?
Prompt diagnosis and treatment of malaria in pregnancy in regions where malaria is always present (endemic regions) is extremely important, yet little is known about women's access to the recommended interventions for malaria in pregnancy or about healthcare providers' adherence to the WHO case management guidelines. In this systematic review and meta-analysis of qualitative, quantitative, and mixed methods studies, the researchers explore the factors that affect women's access to treatment and healthcare provider practices for case management of malaria during pregnancy. A systematic review uses predefined criteria to identify all the research on a given topic. Meta-analysis is a statistical method for combining the results of several studies. A qualitative study collects non-quantitative data such as reasons for refusing an intervention, whereas a qualitative study collects numerical data such as the proportion of a population receiving an intervention.
What Did the Researchers Do and Find?
The researchers identified 37 studies (mostly conducted in Africa) that provided data on the range of healthcare providers visited, antimalarials used, and the factors influencing the choice of healthcare provider and medicines among pregnant women seeking treatment for malaria and/or the type and quality of diagnostic and case management services offered to them by healthcare providers. The researchers explored the data in these studies using narrative synthesis (which summarizes the results from several qualitative studies) and content analysis (which identifies key themes within texts). Among the studies that provided relevant data, one-quarter to three-quarters of women reported malaria episodes during pregnancy. More than 85% of the women who reported a malaria episode during pregnancy sought some form of treatment. Barriers to access to WHO-recommended treatment among women included poor knowledge about drug safety, and the use of self-treatment practices such as taking herbal remedies. Factors that affected the treatment-seeking behavior of pregnant women (“determinants”) included prior use of antenatal care, education, and previous experience of a miscarriage. Among healthcare providers, reliance on clinical diagnosis of malaria was consistently reported, as was poor adherence to the treatment policy. Specifically, 28% and 72% of healthcare providers followed the treatment guidelines for malaria during the first and second/third trimesters of pregnancy, respectively. Finally, the researchers report that concerns over side effects and drug safety, patient preference, drug availability, and cost drove the prescribing practices of the healthcare providers, and that the determinants of provider practices included the type (cadre) of heathcare worker, access to training, and whether they were based in a public or private facility.
What Do These Findings Mean?
These findings reveal important limitations in the implementation of the WHO policy on the treatment of malaria in pregnancy across many parts of Africa and in several other malaria endemic regions. Notably, they show that women do not uniformly seek care within the formal healthcare system and suggest that, when they do seek care, they may not be given the appropriate treatment because healthcare providers frequently fail to adhere to the WHO diagnostic and treatment guidelines. Although limited by the sparseness of data and by inconsistencies in study methodologies, these findings nevertheless highlight the need for further systematic assessments of the extent of substandard case management of malaria in pregnancy in malaria endemic countries, and the need to develop interventions to improve access to and delivery of quality case management of malaria among pregnant women.
Additional Information
Please access these websites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001688.
Information is available from the World Health Organization on malaria (in several languages) and on malaria in pregnancy; the 2010 Guidelines for the Treatment of Malaria are available; the World Malaria Report 2013 provides details of the current global malaria situation
The US Centers for Disease Control and Prevention also provides information on malaria; a personal story about malaria in pregnancy is available
Information is available from the Roll Back Malaria Partnership on all aspects of global malaria control, including information on malaria in pregnancy
The Malaria in Pregnancy Consortium is undertaking research into the prevention and treatment of malaria in pregnancy and provides links to the consortium's publications and an online library on malaria in pregnancy
MedlinePlus provides links to additional information on malaria (in English and Spanish)
doi:10.1371/journal.pmed.1001688
PMCID: PMC4122360  PMID: 25093720
18.  Factors Affecting Clinician Educator Encouragement of Routine HIV Testing Among Trainees 
BACKGROUND
Adoption of CDC recommendations for routine, voluntary HIV screening of all Americans age 13–64 years has been slow. One method to increase adherence to clinical practice guidelines is through medical school and residency training.
OBJECTIVE
To explore the attitudes, barriers, and behaviors of clinician educators (CEs) regarding advocating routine HIV testing to their trainees.
DESIGN/PARTICIPANTS
We analyzed CE responses to a 2009 survey of Society of General Internal Medicine members from community, VA, and university-affiliated clinics regarding HIV testing practices.
MAIN MEASURES
Clinician educators were asked about their outpatient practices, knowledge and attitudes regarding the revised CDC recommendations and whether they encouraged trainees to perform routine HIV testing. Associations between HIV testing knowledge and attitudes and encouraging trainees to perform routine HIV testing were estimated using bivariate and multivariable logistic regression.
RESULTS
Of 515 respondents, 367 (71.3%) indicated they supervised trainees in an outpatient general internal medicine clinic. These CEs demonstrated suboptimal knowledge of CDC guidelines and over a third reported continued risk-based testing. Among CEs, 196 (53.4%) reported that they encourage trainees to perform routine HIV testing. Higher knowledge scores (aOR 5.10 (2.16, 12.0)) and more positive attitudes toward testing (aOR 8.83 (4.21, 18.5)) were independently associated with encouraging trainees to screen for HIV. Reasons for not encouraging trainees to screen included perceived low local prevalence (37.2%), competing teaching priorities (34.6%), and a busy clinic environment (34.0%).
CONCLUSIONS
Clinician educators have a special role in the dissemination of the CDC recommendations as they impact the knowledge and attitudes of newly practicing physicians. Despite awareness of CDC recommendations, many CEs do not recommend universal HIV testing to trainees. Interventions that improve faculty knowledge of HIV testing recommendations and address barriers in resident clinics may enhance adoption of routine HIV testing.
doi:10.1007/s11606-012-1985-9
PMCID: PMC3378731  PMID: 22302354
HIV; screening; clinician educator; residency training
19.  A survey of attitudes to clinical practice guidelines in general and adherence of the Korea practical guidelines for management of gallbladder polyp: a survey among private clinicians in Korea 
Backgrounds/Aims
While clinical practice guidelines are effective tools for improving the quality of patient care and provide specific recommendations for daily practice, the usage of them have been often suboptimal. Therefore, evaluation of physician attitude to guidelines is an important initial step in improving guideline adherence levels. The aim of this study was to survey the attitude on general guidelines and adherence with the Korea Practical Guidelines for gallbladder (GB) polyp two year after their publication and distribution among Korean private clinicians.
Methods
To evaluate the survey, questionnaires were sent with a stamp on an addressed envelope to 3,256 private clinicians who were registered at the Seoul Medical Association in April, 2010. From the 3,256 questionnaires, 376 clinicians (11.5%) responded to the survey.
Results
A total of 91.0% responders agreed to the statement that general guidelines were useful tools for improving patient care and quality of care. One hundred one responders (26.9%) stated that they were aware of the Korea GB polyp guidelines while 73 physicians (72.3%) founded the guideline had changed their practice and user-friendly. Most of physicians (73.4%) agreed to practical procedures recommended by guidelines.
Conclusions
Korean primary physicians were generally positive to the practical guidelines, as propagation of the guideline among primary physicians may improve adherence to guideline and patients care for GB polyps.
doi:10.14701/kjhbps.2014.18.2.52
PMCID: PMC4492318  PMID: 26155249
Attitude; Adherence; Guidelines; Survey; Gallbladder polyp
20.  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
21.  Interactions between Non-Physician Clinicians and Industry: A Systematic Review 
PLoS Medicine  2013;10(11):e1001561.
In a systematic review of studies of interactions between non-physician clinicians and industry, Quinn Grundy and colleagues found that many of the issues identified for physicians' industry interactions exist for non-physician clinicians.
Please see later in the article for the Editors' Summary
Background
With increasing restrictions placed on physician–industry interactions, industry marketing may target other health professionals. Recent health policy developments confer even greater importance on the decision making of non-physician clinicians. The purpose of this systematic review is to examine the types and implications of non-physician clinician–industry interactions in clinical practice.
Methods and Findings
We searched MEDLINE and Web of Science from January 1, 1946, through June 24, 2013, according to PRISMA guidelines. Non-physician clinicians eligible for inclusion were: Registered Nurses, nurse prescribers, Physician Assistants, pharmacists, dieticians, and physical or occupational therapists; trainee samples were excluded. Fifteen studies met inclusion criteria. Data were synthesized qualitatively into eight outcome domains: nature and frequency of industry interactions; attitudes toward industry; perceived ethical acceptability of interactions; perceived marketing influence; perceived reliability of industry information; preparation for industry interactions; reactions to industry relations policy; and management of industry interactions. Non-physician clinicians reported interacting with the pharmaceutical and infant formula industries. Clinicians across disciplines met with pharmaceutical representatives regularly and relied on them for practice information. Clinicians frequently received industry “information,” attended sponsored “education,” and acted as distributors for similar materials targeted at patients. Clinicians generally regarded this as an ethical use of industry resources, and felt they could detect “promotion” while benefiting from industry “information.” Free samples were among the most approved and common ways that clinicians interacted with industry. Included studies were observational and of varying methodological rigor; thus, these findings may not be generalizable. This review is, however, the first to our knowledge to provide a descriptive analysis of this literature.
Conclusions
Non-physician clinicians' generally positive attitudes toward industry interactions, despite their recognition of issues related to bias, suggest that industry interactions are normalized in clinical practice across non-physician disciplines. Industry relations policy should address all disciplines and be implemented consistently in order to mitigate conflicts of interest and address such interactions' potential to affect patient care.
Please see later in the article for the Editors' Summary
Editors' Summary
Background
Making and selling health care goods (including drugs and devices) and services is big business. To maximize the profits they make for their shareholders, companies involved in health care build relationships with physicians by providing information on new drugs, organizing educational meetings, providing samples of their products, giving gifts, and holding sponsored events. These relationships help to keep physicians informed about new developments in health care but also create the potential for causing harm to patients and health care systems. These relationships may, for example, result in increased prescription rates of new, heavily marketed medications, which are often more expensive than their generic counterparts (similar unbranded drugs) and that are more likely to be recalled for safety reasons than long-established drugs. They may also affect the provision of health care services. Industry is providing an increasingly large proportion of routine health care services in many countries, so relationships built up with physicians have the potential to influence the commissioning of the services that are central to the treatment and well-being of patients.
Why Was This Study Done?
As a result of concerns about the tension between industry's need to make profits and the ethics underlying professional practice, restrictions are increasingly being placed on physician–industry interactions. In the US, for example, the Physician Payments Sunshine Act now requires US manufacturers of drugs, devices, and medical supplies that participate in federal health care programs to disclose all payments and gifts made to physicians and teaching hospitals. However, other health professionals, including those with authority to prescribe drugs such as pharmacists, Physician Assistants, and nurse practitioners are not covered by this legislation or by similar legislation in other settings, even though the restructuring of health care to prioritize primary care and multidisciplinary care models means that “non-physician clinicians” are becoming more numerous and more involved in decision-making and medication management. In this systematic review (a study that uses predefined criteria to identify all the research on a given topic), the researchers examine the nature and implications of the interactions between non-physician clinicians and industry.
What Did the Researchers Do and Find?
The researchers identified 15 published studies that examined interactions between non-physician clinicians (Registered Nurses, nurse prescribers, midwives, pharmacists, Physician Assistants, and dieticians) and industry (corporations that produce health care goods and services). They extracted the data from 16 publications (representing 15 different studies) and synthesized them qualitatively (combined the data and reached word-based, rather than numerical, conclusions) into eight outcome domains, including the nature and frequency of interactions, non-physician clinicians' attitudes toward industry, and the perceived ethical acceptability of interactions. In the research the authors identified, non-physician clinicians reported frequent interactions with the pharmaceutical and infant formula industries. Most non-physician clinicians met industry representatives regularly, received gifts and samples, and attended educational events or received educational materials (some of which they distributed to patients). In these studies, non-physician clinicians generally regarded these interactions positively and felt they were an ethical and appropriate use of industry resources. Only a minority of non-physician clinicians felt that marketing influenced their own practice, although a larger percentage felt that their colleagues would be influenced. A sizeable proportion of non-physician clinicians questioned the reliability of industry information, but most were confident that they could detect biased information and therefore rated this information as reliable, valuable, or useful.
What Do These Findings Mean?
These and other findings suggest that non-physician clinicians generally have positive attitudes toward industry interactions but recognize issues related to bias and conflict of interest. Because these findings are based on a small number of studies, most of which were undertaken in the US, they may not be generalizable to other countries. Moreover, they provide no quantitative assessment of the interaction between non-physician clinicians and industry and no information about whether industry interactions affect patient care outcomes. Nevertheless, these findings suggest that industry interactions are normalized (seen as standard) in clinical practice across non-physician disciplines. This normalization creates the potential for serious risks to patients and health care systems. The researchers suggest that it may be unrealistic to expect that non-physician clinicians can be taught individually how to interact with industry ethically or how to detect and avert bias, particularly given the ubiquitous nature of marketing and promotional materials. Instead, they suggest, the environment in which non-physician clinicians practice should be structured to mitigate the potentially harmful effects of interactions with industry.
Additional Information
Please access these websites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001561.
This study is further discussed in a PLOS Medicine Perspective by James S. Yeh and Aaron S. Kesselheim
The American Medical Association provides guidance for physicians on interactions with pharmaceutical industry representatives, information about the Physician Payments Sunshine Act, and a toolkit for preparing Physician Payments Sunshine Act reports
The International Council of Nurses provides some guidance on industry interactions in its position statement on nurse-industry relations
The UK General Medical Council provides guidance on financial and commercial arrangements and conflicts of interest as part of its good medical practice website, which describes what is required of all registered doctors in the UK
Understanding and Responding to Pharmaceutical Promotion: A Practical Guide is a manual prepared by Health Action International and the World Health Organization that schools of medicine and pharmacy can use to train students how to recognize and respond to pharmaceutical promotion.
The Institute of Medicine's Report on Conflict of Interest in Medical Research, Education, and Practice recommends steps to identify, limit, and manage conflicts of interest
The University of California, San Francisco, Office of Continuing Medical Education offers a course called Marketing of Medicines
doi:10.1371/journal.pmed.1001561
PMCID: PMC3841103  PMID: 24302892
22.  Acceptance and perceived barriers of implementing a guideline for managing low back in general practice 
Background
Implementation of guidelines in clinical practice is difficult. In 2003, the German College of General Practitioners and Family Physicians (DEGAM) released an evidence-based guideline for the management of low back pain (LBP) in primary care. The objective of this study is to explore the acceptance of guideline content and perceived barriers to implementation.
Methods
Seventy-two general practitioners (GPs) participating in quality circles within the framework of an educational intervention study for guideline implementation evaluated the LBP-guideline and its practicability with a standardised questionnaire. In addition, statements of group discussions were recorded using the metaplan technique and were incorporated in the discussion.
Results
Most GPs agree with the guideline content but believe that guideline stipulations are not congruent with patient wishes. Non-adherence to the guideline and contradictory information for patients by other professionals (e.g., GPs, orthopaedic surgeons, physiotherapists) are important barriers to guideline adherence. Almost half of the GPs have no access to recommended multimodal pain programs for patients with chronic LBP.
Conclusion
Promoting adherence to the LBP guideline requires more than enhancing knowledge about evidence-based management of LBP. Public education and an interdisciplinary consensus are important requirements for successful guideline implementation into daily practice. Guideline recommendations need to be adapted to the infrastructure of the health care system.
Trial registration
BMBF Grant Nr. 01EM0113. FORIS (database for research projects in social science) Reg #: 20040116 [25].
doi:10.1186/1748-5908-3-7
PMCID: PMC2275295  PMID: 18257923
23.  Rational Prescribing in Primary Care (RaPP): A Cluster Randomized Trial of a Tailored Intervention 
PLoS Medicine  2006;3(6):e134.
Background
A gap exists between evidence and practice regarding the management of cardiovascular risk factors. This gap could be narrowed if systematically developed clinical practice guidelines were effectively implemented in clinical practice. We evaluated the effects of a tailored intervention to support the implementation of systematically developed guidelines for the use of antihypertensive and cholesterol-lowering drugs for the primary prevention of cardiovascular disease.
Methods and Findings
We conducted a cluster-randomized trial comparing a tailored intervention to passive dissemination of guidelines in 146 general practices in two geographical areas in Norway. Each practice was randomized to either the tailored intervention (70 practices; 257 physicians) or control group (69 practices; 244 physicians). Patients started on medication for hypertension or hypercholesterolemia during the study period and all patients already on treatment that consulted their physician during the trial were included. A multifaceted intervention was tailored to address identified barriers to change. Key components were an educational outreach visit with audit and feedback, and computerized reminders linked to the medical record system. Pharmacists conducted the visits. Outcomes were measured for all eligible patients seen in the participating practices during 1 y before and after the intervention. The main outcomes were the proportions of (1) first-time prescriptions for hypertension where thiazides were prescribed, (2) patients assessed for cardiovascular risk before prescribing antihypertensive or cholesterol-lowering drugs, and (3) patients treated for hypertension or hypercholesterolemia for 3 mo or more who had achieved recommended treatment goals.
The intervention led to an increase in adherence to guideline recommendations on choice of antihypertensive drug. Thiazides were prescribed to 17% of patients in the intervention group versus 11% in the control group (relative risk 1.94; 95% confidence interval 1.49–2.49, adjusted for baseline differences and clustering effect). Little or no differences were found for risk assessment prior to prescribing and for achievement of treatment goals.
Conclusions
Our tailored intervention had a significant impact on prescribing of antihypertensive drugs, but was ineffective in improving the quality of other aspects of managing hypertension and hypercholesterolemia in primary care.
Editors' Summary
Background.
An important issue in health care is “getting research into practice,” in other words, making sure that, when evidence from research has established the best way to treat a disease, doctors actually use that approach with their patients. In reality, there is often a gap between evidence and practice.
  An example concerns the treatment of people who have high blood pressure (hypertension) and/or high cholesterol. These are common conditions, and both increase the risk of having a heart attack or a stroke. Research has shown that the risks can be lowered if patients with these conditions are given drugs that lower blood pressure (antihypertensives) and drugs that lower cholesterol. There are many types of these drugs now available. In many countries, the health authorities want family doctors (general practitioners) to make better use of these drugs. They want doctors to prescribe them to everyone who would benefit, using the type of drugs found to be most effective. When there is a choice of drugs that are equally effective, they want doctors to use the cheapest type. (In the case of antihypertensives, an older type, known as thiazides, is very effective and also very cheap, but many doctors prefer to give their patients newer, more expensive alternatives.) Health authorities have issued guidelines to doctors that address these issues. However, it is not easy to change prescribing practices, and research in several countries has shown that issuing guidelines has only limited effects.
Why Was This Study Done?
The researchers wanted—in two parts of Norway—to compare the effects on prescribing practices of what they called the “passive dissemination of guidelines” with a more active approach, where the use of the guidelines was strongly promoted and encouraged.
What Did the Researchers Do and Find?
They worked with 146 general practices. In half of them the guidelines were actively promoted. The remaining were regarded as a control group; they were given the guidelines but no special efforts were made to encourage their use. It was decided at random which practices would be in which group; this approach is called a randomized controlled trial. The methods used to actively promote use of the guidelines included personal visits to the practices by pharmacists and use of a computerized reminder system. Information was then collected on the number of patients who, when first treated for hypertension, were prescribed a thiazide. Other information collected included whether patients had been properly assessed for their level of risk (for strokes and heart attacks) before antihypertensive or cholesterol-lowering drugs were given. In addition, the researchers recorded whether the recommended targets for improvement in blood pressure and cholesterol level had been reached.
Only 11% of those patients visiting the control group of practices who should have been prescribed thiazides, according to the guidelines, actually received them. Of those seen by doctors in the practices where the guidelines were actively promoted, 17% received thiazides. According to statistical analysis, the increase achieved by active promotion is significant. Little or no differences were found for risk assessment prior to prescribing and for achievement of treatment goals.
What Do These Findings Mean?
Even in the active promotion group, the great majority of patients (83%) were still not receiving treatment according to the guidelines. However, active promotion of guidelines is more effective than simply issuing the guidelines by themselves. The study also demonstrates that it is very hard to change prescribing practices. The efforts made here to encourage the doctors to change were considerable, and although the results were significant, they were still disappointing. Also disappointing is the fact that achievement of treatment goals was no better in the active-promotion group. These issues are discussed further in a Perspective about this study (DOI: 10.1371/journal.pmed.0030229).
Additional Information.
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.0030134.
• The Web site of the American Academy of Family Physicians has a page on heart disease
• The MedlinePlus Medical Encyclopedia's pages on heart diseases and vascular diseases
• Information from NHS Direct (UK National Health Service) about heart attack and stroke
• Another PLoS Medicine article has also addressed trends in thiazide prescribing
Passive dissemination of management guidelines for hypertension and hypercholesterolaemia was compared with active promotion. Active promotion led to significant improvement in antihypertensive prescribing but not other aspects of management.
doi:10.1371/journal.pmed.0030134
PMCID: PMC1472695  PMID: 16737346
24.  A systematic scoping review of adherence to reporting guidelines in health care literature 
Background
Reporting guidelines have been available for the past 17 years since the inception of the Consolidated Standards of Reporting Trials statement in 1996. These guidelines were developed to improve the quality of reporting of studies in medical literature. Despite the widespread availability of these guidelines, the quality of reporting of medical literature remained suboptimal. In this study, we assess the current adherence practice to reporting guidelines; determine key factors associated with better adherence to these guidelines; and provide recommendations to enhance adherence to reporting guidelines for future studies.
Methods
We undertook a systematic scoping review of systematic reviews of adherence to reporting guidelines across different clinical areas and study designs. We searched four electronic databases (Cumulative Index to Nursing and Allied Health Literature, Web of Science, Embase, and Medline) from January 1996 to September 2012. Studies were included if they addressed adherence to one of the following guidelines: Consolidated Standards of Reporting Trials (CONSORT), Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA), Quality of Reporting of Meta-analysis (QUOROM), Transparent Reporting of Evaluations with Nonrandomized Designs (TREND), Meta-analysis Of Observational Studies in Epidemiology (MOOSE) and Strengthening the Reporting of Observational Studies in Epidemiology (STROBE). A protocol for this study was devised. A literature search, data extraction, and quality assessment were performed independently by two authors in duplicate. This study reporting follows the PRISMA guidelines.
Results
Our search retrieved 5159 titles, of which 50 were eligible. Overall, 86.0% of studies reported suboptimal levels of adherence to reporting guidelines. Factors associated with better adherence included journal impact factor and endorsement of guidelines, publication date, funding source, multisite studies, pharmacological interventions and larger studies.
Conclusion
Reporting guidelines in the clinical literature are important to improve the standards of reporting of clinical studies; however, adherence to these guidelines remains suboptimal. Action is therefore needed to enhance the adherence to these standards. Strategies to enhance adherence include journal editorial policies endorsing these guidelines.
doi:10.2147/JMDH.S43952
PMCID: PMC3649856  PMID: 23671390
scoping; systematic; review; adherence; reporting; guidelines
25.  Perceptions and use of the national kidney foundation KDOQI guidelines: a survey of U.S. renal healthcare providers 
BMC Nephrology  2013;14:230.
Background
The National Kidney Foundation (NKF) Kidney Disease Outcomes Quality Initiative (KDOQI) developed guidelines to care for patients with chronic kidney disease (CKD). While these are disseminated through the NKF’s website and publications, the guidelines’ usage remains suboptimal. The KDOQI Educational Committee was formed to identify barriers to guideline implementation, determine provider and patient educational needs and develop tools to improve care of patients with CKD.
Methods
An online survey was conducted from May to September 2010 to evaluate renal providers’ familiarity, current use of and attitudes toward the guidelines and tools to implement the guidelines.
Results
Most responders reported using the guidelines often and felt that they could be easily implemented into clinical practice; however, approximately one-half identified at least one barrier. Physicians and physician extenders most commonly cited the lack of evidence supporting KDOQI guidelines while allied health professionals most commonly listed patient non-adherence, unrealistic guideline goals and provider time-constraints. Providers thought that the guidelines included too much detail and identified the lack of a quick resource as a barrier to clinical implementation. Most were unaware of the Clinical Action Plans.
Conclusions
Perceived barriers differed between renal clinicians and allied health professionals; educational and implementation tools tailored for different providers are needed.
doi:10.1186/1471-2369-14-230
PMCID: PMC4016578  PMID: 24152744
KDOQI; Chronic kidney disease; Guidelines; Survey

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