Teresa Leão

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Inequalities in Diabetes Mellitus and Hypertension : A Parish Level Study in the Northern Region of Portugal Desigualdades na Diabetes Mellitus e Hipertensão Arterial

1. Departament of Social Sciences. Escola Nacional de Saúde Pública. Universidade Nova de Lisboa.... more 1. Departament of Social Sciences. Escola Nacional de Saúde Pública. Universidade Nova de Lisboa. Lisboa. Portugal. 2. Health Department. Northern Region Health Administration. Porto. Portugal. 3. Local Health Unit of Matosinhos. Matosinhos. Portugal.  Autor correspondente: Teresa Leão. teresa.de.leao@gmail.com Recebido: 17 de setembro de 2015 Aceite: 07 de março de 2016 | Copyright © Ordem dos Médicos 2016 Teresa LEÃO1,2,3, Julian PERELMAN1, Manuela FELÍCIO2, Vasco MACHADO2, Graça LIMA2,3 Acta Med Port 2016 Oct;29(10):605-612 ▪ http://dx.doi.org/10.20344/amp.7016

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Facilitating conditions for staff’s confidence to enforce school tobacco policies: qualitative analysis from seven European cities

Implementation Science Communications

Background School staff members’ consistent enforcement of school tobacco policies (STPs) is need... more Background School staff members’ consistent enforcement of school tobacco policies (STPs) is needed to decrease adolescent smoking and exposure to tobacco smoke. Staff’s confidence, indicating their perceived ability to cope with students’ negative responses, explains variations in staff’s STPs enforcement, yet understanding of the determinants for confidence is lacking. We analyzed the conditions in which the staff feel confident in addressing students who violate STPs to support staff’s enforcement. Methods Data consists of 81 semi-structured interviews with the staff members from 26 secondary schools in seven European cities in Belgium, Finland, Germany, Ireland, Italy, The Netherlands, and Portugal. In every city, 3–4 staff members (senior management, teachers, supportive staff) in 3–4 schools (academic–vocational, high–low SES area) were interviewed. Transcripts were analyzed with thematic analysis. Results When staff felt confident in their ability to prevent, diminish, or ha...

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Arguments used by proponents and opponents in Brazil’s regulatory discussions of e-cigarettes and heated tobacco products

Tobacco Control, 2021

ObjectivesTo identify proponents and opponents of the commercialisation and marketing of e-cigare... more ObjectivesTo identify proponents and opponents of the commercialisation and marketing of e-cigarettes and heated tobacco products (HTPs), identify the arguments used on both sides and compare how the arguments have changed over time, we analysed three policy discussions occurring in 2009, 2018 and 2019.MethodsWe conducted a content analysis of one document and six videos from these discussions, provided on the Brazilian Health Regulatory Agency website, or upon request.ResultsThe arguments most used by tobacco companies were related to claims that the use of e-cigarettes and HTPs is less harmful than conventional tobacco. Unions that support its commercialisation also argued that lifting the ban would prevent smuggling and guarantee their quality. On the other side, universities, medical and anti-tobacco institutions argued that such devices may have health risks, including the risk of inducing cigarette smoking. In 2009, most arguments belonged to the ‘health’ theme, while in 2018 ...

Insomnia and nightmare profiles during the COVID-19 pandemic in Portugal: characterization and associated factors

Sleep Medicine, 2022

Objective/Background To describe and characterize insomnia symptoms and nightmare profiles in Por... more Objective/Background To describe and characterize insomnia symptoms and nightmare profiles in Portugal during the first six weeks of a national lockdown due to COVID-19. Patients/Methods An open cohort study was conducted to collect information of the general population during the first wave of SARS-CoV-2/COVID-19 pandemic in Portugal. We analyzed data from 5011 participants (≥16 years) who answered a weekly questionnaire about their well-being. Two questions about the frequency of insomnia and nightmares about COVID-19 were consecutively applied during six weeks (March-May 2020). Latent class analysis was conducted and different insomnia and nightmare profiles were identified. Associations between individual characteristics and both profiles were estimated using odds ratios (ORs) and 95% confidence intervals (CI). Results Five insomnia (No insomnia, Stable-mild, Decreasing-moderate, Stable-severe, Increasing-severe) and three nightmares profiles (Stable-mild, Stable-moderate, Stable-severe) were identified, respectively. Being female, younger, perceiving their income as insufficient and feelings of fear towards COVID-19 were associated with higher odds of insomnia (Women: OR=6.98 95%CI:4.18-11.64; ≥60 years: OR=0.30 95%CI:0.18-0.53); Insufficient income: aOR=8.413 95%CI:3.93-16.84; Often presenting fear of being infected with SARS-CoV-2 infection: aOR=9.13 95%CI:6.36-13.11), and nightmares (Women: OR=2.60 95%CI:1.74-3.86; ≥60 years: OR=0.45 95%CI:0.28-0.74) Insufficient income: aOR=2.60 95%CI:1.20-5.20; Often/almost always presenting fear of being infected with SARS-CoV-2 infection: aOR=6.62 95%CI:5.01-8.74). Having a diagnosis of SARS-CoV-2 virus infection was associated with worse patterns of nightmares about the pandemic. Conclusions Social and psychological individual factors are important characteristics to consider in the development of therapeutic strategies to support people with sleep problems during COVID-19 pandemic.

Costs and cost-effectiveness of youth smoking prevention policies across seven European countries

Tobacco Prevention & Cessation, 2018

BOOK 3 rd ENSP-CNPT INTERNATIONAL CONFERENCE ON TOBACCO CONTROL 2018 14-16 June 2018, Madrid, Spa... more

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Urban rail transport and SARS-CoV-2 infections: an ecological study in Lisbon Metropolitan Area

ABSTRACTIntroductionLarge number of passengers, limited space and shared surfaces can transform p... more ABSTRACTIntroductionLarge number of passengers, limited space and shared surfaces can transform public transportation into a hub of epidemic spread. This study was conducted to investigate whether proximity to railway stations, a proxy for utilization, was associated with higher rates of SARS-CoV-2 infection across small-areas of Lisbon Metropolitan Area (Portugal).MethodsThe number of SARS-CoV-2 confirmed infections from March 2 until July 5, 2020 at parish-level was obtained from the National Epidemiological Surveillance System. We used a Geographic Information System to estimate proximity to railway stations from the six railway lines operating in the area. Then, we fitted a quasi-Poisson generalized linear regression model to estimate the relative risks (RR) and corresponding 95% Confidence Intervals (95%CI).ResultsBetween May 2 and July 5, 2020, there were a total of 17,168 SARS-CoV-2 infections in the Lisbon Metropolitan Area, with wide disparities between parishes.Globally, p...

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A Case-Control Study of Contextual Factors for SARS-CoV-2 Transmission

Frontiers in Public Health, 2021

Background: Knowledge on the settings and activities associated with a higher risk of SARS-CoV-2 ... more Background: Knowledge on the settings and activities associated with a higher risk of SARS-CoV-2 transmission is essential to inform decision-making. We thus designed a case-control study to identify relevant settings for community transmission of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in Portugal.Methods: We evaluated 1,088 cases, identified through the national surveillance system, and 787 community controls, recruited using random digit dialing. Sociodemographic characteristics, individual protective measures, and activities or visited settings were obtained through telephone interview. We report sex-, age-, education-, and citizenship-adjusted odds ratios (aOR) with 95% confidence intervals (95% CI).Results: Household overcrowding (aOR = 1.47; 95% CI 1.14–1.91) and work in senior care (4.99; 1.30–33.08) increased while working remotely decreased the risk of infection (0.30; 0.22–0.42). Going to restaurants/other dining spaces (0.73; 0.59–0.91), grocery stor...

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COVID‐19 transmission and case fatality in long‐term care facilities during the epidemic first wave

Journal of the American Geriatrics Society, 2021

Institutionalized populations experience a higher risk of several infectious diseases especially ... more Institutionalized populations experience a higher risk of several infectious diseases especially in settings with frequent interpersonal close contact and overcrowding. Besides the higher risk of infection, institutionalized people tend to be more vulnerable to its consequences as they are older and present multiple and severe comorbidities. Large proportions of cases and deaths due to COVID19 occurred in long-term care facilities (LTCF) in several countries: in May 2020, 37–66% of COVID-19 fatal cases occurred in LTCF. In Portugal, by November 2020 about 34% of COVID-19 deaths had occurred in these facilities. The heterogeneity of COVID-19 impact raises the hypotheses of transmission inside LTCF merely reflect the infection dynamics in the surrounding community or COVID-19 more severely affect those institutionalized. Thus, we estimated the cumulative incidence and the case fatality rate of SARS-CoV-2 infection in LTCF, considering age-adjusted comparisons to the general population.

Smoking and school absenteeism among 15–16-years-old adolescents: A cross-section analysis on 36 countries

Revue d'Épidémiologie et de Santé Publique, 2018

Introduction Prevention of youth smoking is a cornerstone of tobacco control policies, where scho... more Introduction Prevention of youth smoking is a cornerstone of tobacco control policies, where schools have a crucial role to play. However, the well-known long-term consequences of adolescent smoking may be insufficient to convince education stakeholders to implement tobacco control policies at school level. Although they may be individually aware of public health issues, they may hardly devote much time to efforts for which they will not be rewarded. In this paper, we investigate the link between smoking behaviors and school attendance. Methods We performed logistic regressions on the risk of more than three missed school days, by cause, as function of daily smoking, adjusting for age, sex, socioeconomic status, academic performance, parental involvement, and other risk behaviours. Then, generalized linear models were estimated on the number of missed days, by cause, as function of regular smoking, adjusting for the same covariates. The consistency of results was assessed by replicating the analyses for each sex and age group. Results Daily smoking was significantly linked to school absenteeism, with a 43% excess risk of more than three missed school days per month due to illness (OR = 1.43, 95% CI: 1.37–1.49), and a 86% excess risk due to skipping (OR = 1.86; 95% CI: 1.78–1.95). Daily smoking was also linked to a 26% excess number of monthly missed days due to illness (beta = 0.26; 95% CI: 0.24–0.29), and to a 66% excess number of monthly missed days due to skipping (beta = 0.66; 95% CI: 0.64–0.69). These findings were consistent across age and sex groups. Discussion By showing the link between daily smoking and absenteeism, we argue that smoking may also be upholding school performance, and thus bringing short-term damaging effects to the adolescents.

Cost-effectiveness of tobacco control strategies towards youths across seven European countries: Measurement, challenges and results

Revue d'Épidémiologie et de Santé Publique, 2018

between tobacco users using or not e-cigarettes, with the notable exception of concurrent cannabi... more

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Merging academy and healthcare in the Public Health training of medical students

Public Health Reviews, 2020

BackgroundPublic Health remains central to understand health and its determinants, and Public Hea... more BackgroundPublic Health remains central to understand health and its determinants, and Public Health teams are essential for an integrated collaborative medical practice. However, current teaching of public health to medical students varies in the European Region though an investment in multidisciplinary workforce is recognised essential to deliver high quality public health services. A recent medical education curricula restructuring in the University of Porto Medical School resulted in the inclusion of a Public Health module linking academic teaching to field practice and provided the opportunity to make an initial appraisal of students’ perceptions.Case studyWe analysed final reports (n= 196), debriefing meetings notes (n= 2), and e-mails sent by students (n= 34) regarding the activities they observed or participated at, their contact with Public Health services’ teams, knowledge and critical appraisal, and opinion about the module. Students gained basic knowledge about how epide...

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School tobacco policies and adolescent smoking in six European cities in 2013 and 2016: A school-level longitudinal study

Preventive Medicine, 2020

Assessment of the effectiveness of school tobacco policies (STPs) in reducing adolescent smoking ... more Assessment of the effectiveness of school tobacco policies (STPs) in reducing adolescent smoking remains inconclusive. Previous studies took insufficient account of different dimensions of STPs, the different views of students and staff, and policy changes over time. This study assessed how a multidimensional STP, as perceived by students and staff, was associated with adolescent smoking over time in six European cities. The SILNE and SILNE-R surveys were conducted among students (n = 18,502) and staff (n = 438) in 38 schools in 2013 and 2016. Three dimensions (comprehensiveness, enforcement, and communication) were assessed and we calculated total STP scores. Multilevel logistic regressions estimated associations of STPs with adolescent smoking on and just outside school premises and with weekly smoking. Further analyses estimated associations between 2013 and 2016 STP changes and smoking outcomes in 2016, controlling for STP and smoking prevalence in 2013. On average, there were few increases in STP scores over time. Greater STP enforcement, as perceived by students, was associated with lower odds of weekly smoking (OR:0.93, 95%CI:0.89-0.97) and of smoking on school premises (OR:0.80, 95%CI:0.72-0.90). Higher total STP scores were associated with lower odds of smoking on school premises (OR:0.76, 95%CI:0.67-0.86), but not of smoking just outside premises or smoking weekly. Greater increases in STP scores over time were associated with lower odds of smoking on school premises in 2016 (OR:0.65, 95%CI:0.47-0.89). Well-enforced STPs may help reduce adolescent smoking at school. Schools should be supported in adopting comprehensive policies that also extend to the surroundings of their premises.

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Doubts, Concerns and Fears About COVID-19: What Does the Portuguese Community Want to Know About the Pandemic?

SSRN Electronic Journal, 2020

Enhancing implementation of smoke-free places: A comparative qualitative study across seven European cities

Social Science & Medicine, 2020

Background: Advocacy, resources and intersubjective reasonable arguments are known as factors tha... more Background: Advocacy, resources and intersubjective reasonable arguments are known as factors that contribute to smoke-free (SF) adoption and implementation in Chinese and Anglo-Saxon places. Less is known about how the implementation of smoking bans differs across European places. The aim of this qualitative comparative study is to identify and classify the SF policy implementation processes and types undertaken at the local level in seven European cities according to the views of local bureaucrats and sub-national stakeholders. Method: Semi-structured expert interviews (n = 56) with local decision makers and stakeholders were conducted as qualitative part of the comparative SILNE-R project in Belgium (Namur), Finland (Tampere), Germany (Hanover), the Republic of Ireland (Dublin), the Netherlands (Amersfoort), Italy (Latina), and Portugal (Coimbra). Qualitative interviews were analyzed using the framework analysis. Results: Implementation of SF environments predominantly focuses on indoor bans or youth-related settings. Progressive-hungry (Dublin), moderate-rational (Tampere), upper-saturated (Hanover, Amersfoort), and lower saturated (Namur, Coimbra, Latina) implementation types can be distinguished. These four types differ with regards to their engagement in enhancing SF places as well as along their level of perceived tobacco de-normalization and public smoking visibility. In all municipalities SF environments are adopted at national levels, but are differently implemented at the local level due national policy environments, enforcement strategies and the level of collaboration. Major mechanisms to expand SF regulations were found to be scientific evidence, public support, and the child protection frame. However, counter-mechanisms of closure occur if data on declining prevalence and new youth addiction trends trigger low prioritization. Conclusions: This study found four SF implementation types two mechanisms of progressive expansion and

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‘[…] the situation in the schools still remains the Achilles heel.’ Barriers to the implementation of school tobacco policies—a qualitative study from local stakeholder’s perspective in seven European cities

Health Education Research, 2019

School tobacco policies (STPs) are a crucial strategy to reduce adolescents smoking. Existing stu... more School tobacco policies (STPs) are a crucial strategy to reduce adolescents smoking. Existing studies have investigated STPs predominantly from a school-related ‘insider’ view. Yet, little is known about barriers that are not identified from the ‘schools’ perspective’, such as perceptions of local stakeholders. Forty-six expert interviews from seven European cities with stakeholders at the local level (e.g. representatives of regional health departments, youth protection and the field of addiction prevention) were included. The analysis of the expert interviews revealed different barriers that should be considered during the implementation of STPs. These barriers can be subsumed under the following: (i) Barriers regarding STP legislature (e.g. inconsistencies, partial bans), (ii) collaboration and cooperation problems between institutions and schools, (iii) low priority of smoking prevention and school smoking bans, (iv) insufficient human resources and (v) resistance among smoking ...

Adolescents’ smoking environment under weak tobacco control: A mixed methods study for Portugal

Drug and Alcohol Dependence, 2019

Introduction: Bans on smoking in public places and on sales to minors have been widely implemente... more Introduction: Bans on smoking in public places and on sales to minors have been widely implemented across the globe. However, many countries have either adopted non-comprehensive (i.e., partial) bans and/or weakly enforce those bans. Little is known, from the adolescents' perspective, how this affects their smoking-related perceptions and behaviors. We studied the case of Portugal, where bans are partial and/or weakly enforced. We sought to understand how the bans affect adolescents' access to cigarettes from commercial sources, the visibility of smoking in public places, and smoking locations. Material and methods: We used a mixed methods design on data gathered in 2016. Quantitative, cross-sectional surveys were conducted in six schools (n = 2,444) in Coimbra, Portugal. In two of these schools, qualitative data were collected in eight single-sex focus group interviews (n = 42). Results: Ninety-five percent of the adolescents who tried to buy cigarettes were able to do so from commercial sources, through vending machines, or directly from the vendor. Bans on smoking on school premises and at enclosed public places did not prevent these adolescents from observing smoking outside school gates (84.0%), in cafes and restaurants (97%), or from smoking at cafes, bars, or nightclubs (72.9%). Discussion: Partial and/or weakly enforced policies seem to not prevent adolescents from having access to cigarettes, frequently seeing smoking, and finding ample opportunities to smoke in public places. Adopting and enforcing comprehensive policies are necessary efforts to prevent unfavorable responses and more effectively reduce adolescents' smoking behavior.

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The impact of a public smoking ban on smoking socioeconomic inequalities in a Swiss urban population

European Journal of Public Health, 2018

The visibility of smoking in Europe and its relationship with youth’s positive beliefs about smoking

International Journal of Public Health, 2019

Objectives To determine adolescent-reported visibility of smoking in different public and private... more Objectives To determine adolescent-reported visibility of smoking in different public and private spaces in Europe and associations between smoking visibility and beliefs about the benefits of smoking. Methods We used SILNE-R cross-sectional survey data (2016/2017) of 10,798 14-16-year-old students from 55 secondary schools in seven European cities. Respondents reported for private and public spaces whether they had seen others smoke there in the last 6 months. Beliefs about the benefits of smoking were measured on a 7-item scale; higher scores indicated more positive beliefs. Multilevel linear regression analyses determined associations while controlling for potential confounders and stratifying by smoking status. Results Most students reported observing others smoke in public spaces, especially at train/bus stations (84%). Positive beliefs about smoking of never smokers were positively associated with seeing others smoke in train/bus stations and leisure/sports facilities, but not at home, a friend's home, restaurants or bars, when fully adjusted. Associations were of similar magnitude for ever smokers. Conclusions Smoking in several public places is highly visible to adolescents. Reducing this visibility might weaken positive beliefs that adolescents have about smoking.

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Economic Evaluation of Five Tobacco Control Policies Across Seven European Countries

Nicotine & Tobacco Research, 2019

Introduction Economic evaluations of tobacco control policies targeting adolescents are scarce. F... more Introduction Economic evaluations of tobacco control policies targeting adolescents are scarce. Few take into account real-world, large-scale implementation costs; few compare cost-effectiveness of different policies across different countries. We assessed the cost-effectiveness of five tobacco control policies (nonschool bans, including bans on sales to minors, bans on smoking in public places, bans on advertising at points-of-sale, school smoke-free bans, and school education programs), implemented in 2016 in Finland, Ireland, the Netherlands, Belgium, Germany, Italy, and Portugal. Methods Cost-effectiveness estimates were calculated per country and per policy, from the State perspective. Costs were collected by combining quantitative questionnaires with semi-structured interviews on how policies were implemented in each setting, in real practice. Short-term effectiveness was based on the literature, and long-term effectiveness was modeled using the DYNAMO-HIA tool. Discount rates...

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Alcohol control policies and socioeconomic inequalities in hazardous alcohol consumption: a 22-year cross-sectional study in a Swiss urban population

BMJ Open, 2019

ObjectiveHarmful use of alcohol represents a large socioeconomic and disease burden and displays ... more ObjectiveHarmful use of alcohol represents a large socioeconomic and disease burden and displays a socioeconomic status (SES) gradient. Several alcohol control laws were devised and implemented, but their equity impact remains undetermined.We ascertained if an SES gradient in hazardous alcohol consumption exists in Geneva (Switzerland) and assessed the equity impact of the alcohol control laws implemented during the last two decades.DesignRepeated cross-sectional survey study.SettingWe used data from non-abstinent participants, aged 35–74 years, from the population-based cross-sectional Bus Santé study (n=16 725), between 1993 and 2014.MethodsSES indicators included educational attainment (primary, secondary and tertiary) and occupational level (high, medium and low). We defined four survey periods according to the implemented alcohol control laws and hazardous alcohol consumption (outcome variable) as >30 g/day for men and >20 g/day for women.The Slope Index of Inequality (SI...

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