# Trend in obesity in an aging society: an estimate of obese elderly in Brazil in 2030.

Rita Nugem, Ronaldo Bordin, R Bordin, Roger Rosa, Rs Santos Rosa, Adriane

Carvalho A Carvalho

► To cite this version:

Rita Nugem, Ronaldo Bordin, R Bordin, Roger Rosa Rs Santos Rosa, Adriane Carvalho A Carvalho. Trend in obesity in an aging society: an estimate of obese elderly in Brazil in 2030.. Proceedings of the 4th IPLeiria's International Health Congress, BMC Health Services Research, 18 (S2), pp.684, 2018, 10.1186/s12913-018-3444-8. doi:10.1186/s12913-018-3444-8

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## MEETING ABSTRACTS

Open Access

<figure><img src="image_1.png" /></figure>

CrossMark

# Proceedings of the 4th IPLeiria's
International Health Congress

Leiria, Portugal. 11-12 May 2018

Published: 13 September 2018

## Keynote lectures

### S1

**The role of practice-based research in stimulating educational innovation in healthcare**

Sandra Hasanefendic (s.hasanefendic@vu.nl)

Vrije Universiteit Amsterdam, De Boelelaan 1105, 1081 HV Amsterdam, the Netherlands

BMC Health Services Research 2018, **18**(Suppl 2):S1

**Background**

Practice-based research is not uncommon in healthcare. In fact, the way nurses and doctors train is through extensive and intensive practice [1]. In other words, practice-based research has been used to gain new knowledge partly by means of practice and the outcomes of that practice [2]. Practice based research networks have also been gaining on importance in healthcare as ways of addressing research questions informed by practicing clinicians. They aim to gather data and improve existing practices of primary care [3], practice-based research is not only about gaining new knowledge via practice and improving existing practices.

**Objective**

In this presentation/paper I explain and highlight the role of practice-based research as an instrument for educational innovation in healthcare sciences.

**Methods**

I used interview excerpts and examples of projects related to healthcare at different universities of applied sciences in the Netherlands and Germany (also known as polytechnics in Portugal) to advance the role of practice-based research in educational innovation. This type of research is an integral part of teaching and curricular assignments in the healthcare settings in the Netherlands and Germany, and particularly at universities of applied sciences. I emphasized how practice-based research can improve and enrich the curricula, while at the same time, building necessary skills of future healthcare professionals and improving practices in already existing healthcare institutions.

**Results**

I show that practice-based research is in fact short term problem-oriented research which serves educational purposes by upgrading students' and teachers' skills and knowledge of the profession and dynamics in the work environment; which also has the potential to improve company products or design solutions and at the same time contribute to local and regional innovation in professions and profession related institutions [4-5]. Its role is multidimensional and dialectic insofar it serves multitude goals and is accomplished in dialogue among relevant stakeholders [6]. Practical suggestions for healthcare educators and practitioners in designing their curricula to incorporate the basic elements of this practice-based research are also offered in this presentation/paper.

**Conclusions**

Practice-based research is more than knowledge acquisition via practice. Its role and goals expand to enriching educational curricula with a more comprehensive engagement of external and professional

stakeholders, at the same time contributing to student soft and professional skill development and solving stakeholder problems or optimizing services and products at local or regional levels.

**References**

1. Westfall JM, Mold J, Fagnan L. Practice-based research—"Blue Highways" on the NIH roadmap. Jama, 2007; 297(4): 403-406.

2. Andrews JE, Pearce KA, Ireson C, Love MM. Information-seeking behaviors of practitioners in a primary care practice-based research network (PBRN). Journal of the Medical Library Association, 2005;93(2):206.

3. Hartung DM, Guise JM, Fagnan LJ, Davis MM, Stange KC. Role of practice-based research networks in comparative effectiveness research. Journal of comparative effectiveness research. 2012;1(1):45-55.

4. Frederik H, Hasanefendic S, Van der Sijde P. Professional field in the accreditation process: examining information technology programmes at Dutch Universities of Applied Sciences. Assessment & Evaluation in Higher Education. 2017, 42(2): 208-225.

5. Hasanefendic S. Responding to new policy demands: A comparative study of Portuguese and Dutch non-university higher education organizations. [Doctoral Thesis]. Vrije Universiteit Amsterdam, the Netherlands. 2018.

6. Hasanefendic S, Heitor M, Horta H. Training students for new jobs: The role of technical and vocational higher education and implications for science policy in Portugal. Technological Forecasting and Social Change. 2016; 113: 328-340.

**Keywords**

Practice-based research, Short term, Problem oriented, Healthcare, Universities of applied sciences.

### S2

**Is sexuality a right for all? Sexual revolution in the old age**

Francisco J Hernández-Martínez (francisco.hernandezmartinez@ulpgc.es)
Universidad de Las Palmas de Gran Canaria, 35001 Las Palmas de Gran Canaria, España

BMC Health Services Research 2018, **18**(Suppl 2):S2

**Background**

"Do not you think your grandmother has sex? What happens with old gays? Why does a kiss between two elders tenderizes us and we do not think it is erotic" (interview, Ricardo Iacub, 2018). It still impacts us, and what do we do with it? Do we let it pass? Do we encourage them?

Throughout the centuries, sex has been postulated as the impulse that gives life to people. This word, of Latin origin, has always aroused much interest in society and in all stages of life; but it must be differentiated from "sexuality", because it contemplates various aspects among which it is found; sex, identities and gender roles, eroticism, pleasure, intimacy, reproduction and sexual orientation [1-6]. Sexuality is a vital dimension that is present in all stages of life, at least since adolescence. It contributes significantly to health and quality of life and is, moreover, a right recognized by international organizations such as the World Health Organization (WHO) [4, 7-9].

<figure><img src="image_2.png" /></figure>
Despite this, old needs had traditionally been considered as a stage in which sexual needs would be absent, in which people are no longer interested or have the capacity to lead an active sexual life [3-8, 11]. Master and Johnson, two famous American sexologists, argued that older people should fight against a false belief, which considers that "*sexual incompetence is a natural component of the aging process*". This belief limits access to sexuality due to fear of failure, to consider that it is no longer correct, that it can be sick or perverse. The same authors pointed out that many of their patients had gone to priests, rabbis, doctors or psychologists and that they had received the answer "*it is logical at their age*" [3, 7, 10].

The studies carried out, in our country and internationally, show that the majority of the elderly, and especially those who have a partner, are still sexually active until very old ages [6-9]. The keys to continue carrying and enjoying a quality sexual life in old age should be recognized and admitted at a social level, and among others, we should start; to be free of prejudices and stereotypes that condemn the elderly to lack of desire, or that associate sexuality in old age to something dirty or morally condemnable. Stop associating youth and sexuality. Do not assume the possible problems or difficulties that may appear as irreversible barriers. Age influences the decrease in sexual activity and interest, but not in satisfaction. It is demonstrated that sex and sexuality play an important role in healthy and full aging [1-3, 6-9, 11]. Taking into account these premises, throughout the presentation will present the results of a study conducted in the Canary Islands among people over 65 years, users of senior centers whose main objective was; obtain data on sexual activity, sexuality and whether age-related pathologies have affected their sexual relations. Against these prejudices, older adults need, want and seek some kind of loving exchange; "*Old people want and need to talk about sex*", and also young people need to think that we have a lifetime to continue enjoying and experimenting with our sexuality.

## References

1. Baudracco CP, Romero M. Derecho e Igualdad para la comunidad trans se llama Ley de Identidad de Género. En Derecho a la Identidad. Ley de Identidad de Género y Ley de Atención Integral de la Salud para Personas Trans. Buenos Aires: Federación Argentina LGBTI; 2011.

2. Uchôa YS, Costa DA, Silva Jr. IAD, Saldanha ST, Silva ES, Freitas WMTM, Soares SS (2016). A sexualidade sob o olhar da pessoa idosa. Rev. Bras. Geriatr. Gerontol. 2016;19(6):939-949.

3. Iacub R. Erótica y Vejez. Perspectivas de Occidente. Ed. Paidós S.A.C.F. Buenos Aires. 2006.

4. Foucault M. Historia de la sexualidad, Buenos Aires: Ed. Siglo Veintiuno; 2010.

5. Grosman CP. et al. Los adultos mayores y la efectividad de sus derechos. Nuevas realidades en el derecho de familia. Rubinzal-Culzoni Editores. Buenos Aires; 2015.

6. Guadarrama R, Ortiz Zaragoza MC, Moreno Castillo YC, González Pedraza AA. Características de la actividad sexual de los adultos mayores y su relación con su calidad de vida. Revista de Especialidades Médico-Quirúrgicas. 2010;15(2):72-79.

7. Hernandez-Martínez FJ, Jiménez-Díaz JF, Rodríguez-de-Vera BC, Quintana-Montesdeoca MP, García-Caballero A, Rodrigues A. Tapersex en ancianos: ¿Existe el placer después de?. En libro de Actos del XX Congreso de la Sociedad Española de Geriatría y Gerontología. Valladolid. 2013.

8. López Sánchez F. Sexualidad y afectos en la vejez. Madrid: Ediciones Pirámide; 2012.

9. Martín Hernández M, Renteria Díaz P, Sardiñas Llerenas E. Estados clínicos y autopercepción de la sexualidad en ancianos con enfoque de género. Revista Cubana de Enfermería, 2009;25(1-2).

10. Masters W, Johnson V. Incompatibilidad sexual humana, Inter Médica, Buenos Aires; 1976

11. Pérez Martínez VT. Sexualidad humana: una mirada desde el adulto mayor. Revista Cubana de Medicina General Integral. 2008;24(1).

## Keywords

Active Aging, Sexuality, Elderly, Sexual activity and benefits.

## S3

### Promoting independent living in frail older adults by improving cognition and gait ability and using assistive products – MIND&GAIT Project

João Apóstolo (apóstolo@esenfc.pt)
The Health Sciences Research Unit: Nursing, Portugal Centre for Evidence Based Practice: A Joanna Briggs Institute Centre of Excellence, Nursing School of Coimbra, 3000-232 Coimbra, Portugal
BMC Health Services Research 2018, **18**(Suppl 2):S3

### Background

Frail older adults are more susceptible to falls, fractures, disability, dependency, hospitalization and institutionalization [1]. Physical and cognitive decline, associated with frailty, potentiate the development of geriatric syndromes and lead to a decrease in self-care, depressive vulnerability and a decrease in quality of life [2]. Adapted physical exercise and cognitive stimulation allow the maintenance of physical and cognitive capacities, which is reflected in an improvement on the functional status of the elderly and in a reduction of associated comorbidities [3].

### Objective

To promote independent living in frail older adults by improving cognition and gait ability and using assistive products.

### Methods

It is planned to develop a combined intervention that will be composed by a digital cognitive stimulation program and an adapted physical exercise program. It is also being developed an auto-blocking kit mechanism for rolling walkers as an assistive product that could be used during the physical exercise program. A randomized-controlled trial will be developed to test the efficacy of the combined intervention in frail older adults. At the same time, a web platform will be developed and it will be used as a repository, providing digital intervention' materials and results.

### Results

Through the implementation of a multidisciplinary strategy, significant benefits are expected in the prevention and maintenance of physical and cognitive decline of the frail older adults. It is hoped that for frail older adults the combined intervention and its digital components would be synonymous of autonomy and improvement of their quality of life, contributing to active aging. The project, being based and tested in clinical practice, will guide health professionals, caregivers and general public to promote the independence of this population.

### Conclusions

Cognitive interventions and physical exercise have impact on cognitive decline, a condition that assumes more importance once it is related with frailty in older adults. This multidisciplinary strategy gives the opportunity to older adults to act actively in their health through the spontaneous performance of cognitive and physical exercises available on the web platform. The components of the combined intervention will allow better reintegration of this population into society of today's world. By promoting research policies among educational institutions and health service delivery institutions, the MIND & GAIT project will make health care available to the frail elderly population more accessible to professionals, caregivers and general public.

### Trial Registration

NCT03390478

### Acknowledgements

The current abstract is being presented on behalf of a research group. It is also part of the MIND&GAIT project Promoting independent living in frail older adults by improving cognition and gait ability and using assistive products, which is a Portuguese project with the support of COMPETE 2020 under the Scientific and Technological Research Support System, in the co-promotion phase. We acknowledge The Health Sciences Research Unit: Nursing (UICISA: E) of the Nursing School of Coimbra, the Polytechnic Institute of Leiria, the Polytechnic of Santarém, Polythechnic of Coimbra and also to other members, institutions and students involved in the project.
## References

1. Apóstolo J, Holland C, O'Connell MD, Feeney J, Tabares-Seisdedos R, Tadros G et al. Mild cognitive decline. A position statement of the Cognitive Decline Group of the European Innovation Partnership for Active and Healthy Ageing (EIPAHA). Maturitas. 2016;83:83-93.

2. Apóstolo J, Cooke R, Bobrowicz-Campos E, Santana S, Marcucci M, Cano A et al. Effectiveness of interventions to prevent pre-frailty and frailty progression in older adults: a systematic review. JBI Database of Systematic Reviews and Implementation Reports. 2018;16(1):140–232.

3. Mewborn CM, Lindbergh CA, Miller LS. Cognitive interventions for cognitively healthy, mildly impaired and mixed samples of older adults: a systematic review and meta-analysis of randomized-controlled trials. Neuropsychology Rev. 2017;27(4):403-439.

## Keywords

Aged, Cognitive decline, Cognitive stimulation, Frailty, Physical exercise.

## S4

### Electronic health records in Portugal

Cristiana Maia (academia@spms.min-saude.pt)
Serviços Partilhados do Ministério da Saúde, 1050-189 Lisboa, Portugal
BMC Health Services Research 2018, **18**(Suppl 2):S4

In the digital transformation Era, there is an increasing need to provide systems capable of offering functionalities that allow the user a quicker and easier access to healthcare related information's. These digital services aim to provide access to more information, allowing the users to make better informed decisions.

In Portugal's National Health Service Portal (SNS Portal www.sns.gov.pt), there are already several digital services available, the Citizen's Area aggregates these services for the user.

Citizen's Area main objectives is to facilitate communication and interaction between Citizens, Professionals and Health Institutions, allowing access to information in an integrated way, providing a better healthcare. Simple and accessible to all users, this area allows personal health information access in one place at any time, thus avoiding unnecessary commuting. This area has access monitoring and permission policy configurations, allowing the Citizen to view access history and configure access permissions to their health information, thus increasing control and management of their own personal health information.

Health Literacy is actively promoted though multiple initiatives, in dedicated areas accessible in SNS Portal and Citizen's Area.

## Keywords

Citizen's Area, SNS Portal, Healthcare, Digital Services, Literacy.

## S5

### Economic crisis and inequalities in the Southern European health systems

Mauro Serapioni (mauroserapioni@ces.uc.pt)
Centro de Estudos Sociais, Universidade de Coimbra, 3000-104 Coimbra, Portugal
BMC Health Services Research 2018, **18**(Suppl 2):S5

## Background

Despite the overall increase in living standards and the introduction of universal health systems, many studies have identified persistent inequalities in all industrialized countries. The Southern European countries, namely Greece, Italy, Portugal and Spain, although the reforms of the 1970s and 1980s introduced universal national health services, social inequalities in health only became a critical issue in the late 1990s. However, the issue of health inequalities became a priority from 2010-2011, when (although with different degrees of severity) the four countries began to feel the first effects of the financial crisis. Various studies have identified the impact of the economic crisis on the most vulnerable population groups, with increasing rates of mental health disorders and a rise in suicides.

## Objective

After a brief contextualization of the welfare state in southern European countries and a characterization of health systems in Greece, Spain, Italy and Portugal, the main health inequalities are described, identifying the potential inequity induced by the reform processes undertaken and the current austerity policies implemented.

## Methods

The study resulted from a non-systematic literature review, based on the Scoping review proposal. A total of 74 publications were analysed.

## Results and Discussion

The analysis has highlighted common characteristics and trends in the Southern European health systems, as well as some significant differences between them. In the four countries, the social gradient (particularly in education, income, and work status) is the principal determinant factor in health inequalities. Another key aspect is the steady increase in out-of-pocket spending in health as a percentage of total health spending in all four countries, markedly in Greece and Portugal. The analysis has identified potential inequalities induced by the reform processes, as result of new relations between the public and private sectors in services provision. Another example of how health systems produce inequalities is the rising proportion of users' health expenses covered by co-payments and user fees. Geographic inequality in health is another critical issue, observed in all four Southern European countries. Finally, the recent debate in the international literature on the relationship between different welfare state regimes and health inequalities will be discussed.

## Conclusions

The crisis and austerity policies have greatly increased the level of dissatisfaction with healthcare provision in these countries.

## Keywords

Health Inequalities, Health Systems, Economic Recession, Southern European Countries.

## S6

### CBmeter- a new medical device for early screening of metabolic diseases

Maria P Guarino<sup>1,2,3</sup>, Gabriel Brito<sup>1,4</sup>, Marlene Lages<sup>1</sup>, Rui Fonseca-Pinto<sup>1,4</sup>, Nuno Lopes<sup>1,4</sup>

<sup>1</sup>Center for Innovative Care and Health Technology, Polytechnic Institute of Leiria, 2411-901 Leiria, Portugal; <sup>2</sup>School of Health Sciences, Polytechnic Institute of Leiria, 2411-901 Leiria, Portugal; <sup>3</sup>Chronic Diseases Research Center, NOVA Medical School, 1150-082 Lisbon, Portugal; <sup>4</sup>School of Technology and Management, Polytechnic Institute of Leiria; 2411-901 Leiria, Portugal

**Correspondence:** Maria P Guarino (maria.guarino@ipleiria.pt)

BMC Health Services Research 2018, **18**(Suppl 2):S6

## Background

Type 2 diabetes mellitus (T2DM) is a highly prevalent disease worldwide which is asymptomatic in about 44% of patients being critical to search for new ways of early diagnosis. Recent studies have demonstrated that the etiology of this disease may be associated with alterations in the function of the carotid body (CB), a chemosensor organ located within the bifurcation of the carotid artery. In animal models of metabolic syndrome, it was observed that the CBs are overactivated, underlying diseases such as obesity, hypertension and T2DM. This discovery provided a new paradigm in the neuroendocrinology field, suggesting that diagnostic function of the CBs has predictive value for the development of metabolic diseases. Despite this fact, it is not common in clinical practice to look at the CBs as organs associated with endocrine dysfunction and we believe this is probably due to the nonexistence of a user-friendly, portable medical device that diagnosis the function of the CBs.

## Objective

The general aim of this work is to develop a novel device that evaluates the function of the carotid bodies - a CBmeter. We are also developing a standard test meal to be used as a physiological dynamic test during CBmeter utilization.
## Methods

This medical device will synchronously assess several physiological variables: heart rate, respiratory rate, blood pressure variation, arterial pulse oximetry and circulating glucose, as well as the physiological responses to hyperoxia and meal ingestion. The results obtained will be analyzed using MatLab, in order to develop an algorithm with predictive value for early diagnosis of metabolic diseases. We are also developing a standard test mixed-meal to assess post-prandial glucose excursions with the CBmeter. The work is currently in the prototype development phase.

## Results

A preliminary pilot-test performed with the prototype revealed that all the proposed variables are assessable with the CBmeter. The standardized test meal used in the pilot-test caused a glucose excursion curve that stabilized 30 minutes after ingestion, being suitable for metabolic evaluation with the CBmeter. Interstitial glucose variation was 16.6mg/dl glucose with a latency time of 21min. Heart rate did not vary significantly after the meal ingestion.

## Conclusions

The CBmeter prototype is currently optimized to be used in a medical device clinical-trial with healthy volunteers. The mixed meal developed has proven to be suited in healthy volunteers to determine variations in CB-related cardiorespiratory parameters.

## Acknowledgements

Project funded by FCT/SAICT-POL/23278/2016

## Keywords

Carotid body, Diabetes, Early diagnosis, Medical device.

## S7

### Help to care for users and caregivers: Help2care

Maria dos Anjos Coelho Rodrigues Dixe¹,² (maria.dixe@ipleiria.pt)

¹Center for Innovative Care and Health Technology, Polytechnic Institute of Leiria, 2411-901 Leiria, Portugal; ²School of Health Sciences, Polytechnic Institute of Leiria, 2411-901 Leiria, Portugal

BMC Health Services Research 2018, **18**(Suppl 2):S7

There are several studies showing that the family members providing care to their relatives need to acquire abilities that enable them to be competent in their performance, having the health care professionals an indispensable role in their training [1]. Empowering caregivers can help in reducing health care costs, improve the quality of life of both user and caregiver [2], their mental health [3] and greater satisfaction with their care [4]. The continued support to caregivers can help them in decision making in less serious health situations and to use fewer health services [5].

The main aims are: to construct assessment instruments to evaluate the patient and caregivers needs and abilities concerning self-care; to develop a support manual accessible to all caregivers; to make videos that demonstrate technics and task procedures to support the caregiver in the caring process; to develop a digital platform where all the developed resources will be available (website and app) to support the care transition from the hospital to the residence integrating professionals from the hospital and from the primary health-care services; to empower health professionals to use the caregivers' and users' self-care empowerment model.

This project will include participation of students, teachers, researchers and stakeholders throughout the project using an action research, where, as the materials are developed, the population target acceptance will be tested, justifying the corrections needed before moving to the next step, using a consistent methodology with an action and learning research process. Population: The population will be: dependent patients diagnosed with a chronic illness, total or partial dependency admitted to the Hospital and require caregiver after hospital discharge; Informal Caregivers whose dependent members of the family present the criteria laid up and Heath professional. To evaluate the patient and caregivers' needs and capacity concerning self-care we will construct them (activity 1). During the pilot test period we will have, two kinds of metrics: Qualitative metrics available on (http://garyperlman.com/quest/). And quantitative

monitoring metrics for the use of the mobile app, including retention rate, churn rate, daily active users (DAU), daily sessions per DAU and stickiness, and also access statistics per module/feature on the app. The mains output will be: A training model of caregivers and users for self-care composed with: a caregiver's. support manual; a digital platform and a manual with the empowerment model to be used by health professionals

## Acknowledgements

The current abstract is being presented on behalf of a research group. It is also part of the Help2care - project: Help to care for users and caregivers, which is a Portuguese project with the support of COMPETE 2020 under the Scientific and Technological Research Support System, in the co-promotion phase. We acknowledge the Polytechnic of Leiria, the Polytechnic of Santarém, Polytechnic of Castelo Branco, Centro Hospitalar de Leiria and also to other members, institutions and students involved in the project.

## References

1. Clarke DJ, Hawkins R, Sadler E, Harding G., McKevitt C, Godfrey M, Dickerson J, Farrin, A.J, Kalra L, Smithard D, Forster. A. Introducing structured caregiver training in stroke care: findings from the TRACS process evaluation study. BMJ Open. 2014;4:1-10.

2. Cheng HY., Chair SY, Chau JP. The effectiveness of psychosocial interventions for stroke family caregivers and stroke survivors: A systematic review and meta-analysis. Patient Education and Counseling. 2014;95:30-44.

3. Legg, LA, Quinn TJ, Mahmood F, Weir CJ, Tierney J, Stott DJ, Smith L.N, Langhorne P. Non-pharmacological interventions for caregivers of stroke survivors. The Cochrane Database of Systematic Reviews. 2014. 10. CD008179. Doi: 10.1002/14651858

4. Bakas T, Farran CJ, Austin JK, Given BA, Johnson EA, Williams LS. Content Validity and Satisfaction With a Stroke Caregiver Intervention Program. Journal of nursing Scholarship. 2009;41(4):368-375.

5. Pierce L, Steiner VL, Khuder SA, Govoni, AL, Horn LJ. The effect of a Web-based stroke intervention on carers' well-being and survivors' use of healthcare services. Disability and Rehabilitation. 2009;31(20):1676-1684.

## Keywords

Transitions of care, Caregivers, Self-care, Users.

## S8

### TeenPower: e-Empowering teenagers to prevent obesity

Pedro Sousa¹,² (pedro.sousa@ipleiria.pt)

¹Center for Innovative Care and Health Technology, Polytechnic Institute of Leiria, 2411-901 Leiria, Portugal; ²School of Health Sciences, Polytechnic Institute of Leiria, 2411-901 Leiria, Portugal

BMC Health Services Research 2018, **18**(Suppl 2):S8

### Background

Adolescent obesity has reached epidemic proportions, being urgent to find effective prevention strategies. The core components of classic prevention programs have been unable to obtain the desired adherence. The solution may involve a more extensive and frequent contact with the healthcare team and the use of alternative communication channels and interacting/dynamic technologies with adolescents. TeenPower is a transdisciplinary practice-based action research project that aims to develop innovative interventions to promote healthy behaviors. This project is promoted by the polytechnics of Leiria, Santarém and Castelo Branco, Município de Leiria (City Council), as well as local schools and primary healthcare stakeholders, key partners in the development phase and in the implementation of the intervention program.

### Objective

The main goal is the development, implementation and evaluation of a program for the promotion of healthy behaviors and prevention of obesity in adolescence, based on e-therapy and sustained by the case management methodology. The project is directed to the cognitive-behavioral empowerment of adolescents, through increased and interactive contact between adolescents and a multidisciplinary healthcare team. The use of Information and Communication Technologies (ICT) in
the intervention can optimize resources and maximize impact, as a
complement to conventional approaches.

## Methods

The project includes the development of three complementary studies: (S1) evaluation of adolescents' health status and cognitive-behavioral indicators, (S2) usability evaluation of the TeenPower platform and mobile app (S3) implementation and adherence evaluation to the TeenPower intervention program. Participants will be recruited from the school groups of Leiria, Santarém and Castelo Branco, aged between 12 and 16, with easy access to internet and smartphone/tablet (inclusion criteria). Intervention include behavioral, nutritional and physical activity counselling (online and face-to-face psychoeducative sessions). The e-therapeutic platform and mobile app (TeenPower) includes educational resources, self-monitoring, social support, interactive training modules and motivational tools. In addition to the case manager, the program will also have the direct support of an interdisciplinary team (nurse, nutritionist, exercise physiologist, among others).

## Results

Expected results includes the delivery of the TeenPower intervention program, including an interactive application (web and mobile); scientific papers, communications and reports; workshops and conferences. We will evaluate adolescents' health status and cognitive-behavioral indicators, evaluate Teenpower usability and program adherence.

## Conclusions

The positive evaluation of the intervention program will stimulate the inclusion of ICT in the promotion of salutogenic behaviors and overweight prevention, creating technological interfaces that will allow customizing the intervention parameters and facilitating the monitoring and tracking.

## Acknowledgements

The current abstract is presented on the behalf of a research group, the TeenPower research team. It is also part of the project TeenPower: e-Empowering teenagers to prevent obesity, co-funded by FEDER (European Regional Development Fund), under the Portugal 2020 Program, through COMPETE 2020 (Competitiveness and Internationalization Operational Program). We acknowledge the Polytechnic Institutes of Leiria, Santarém and Castelo Branco, the Municipality of Leiria (city council), and also other members, institutions and students involved in the project.

## Keywords

Adolescents, Obesity, Health promotion, e-health, Mobile.

S9

# The Early Warning System for Basic School - SAPIE-EB in the promotion of school success, psychological health and career development

Pedro Cordeiro, Paula Paixão

Faculdade de Psicologia e de Ciências da Educação, Universidade de Coimbra, 3000-115 Coimbra, Portugal

Correspondence: Pedro Cordeiro (pedcordeiro@gmail.com)

BMC Health Services Research 2018, **18**(Suppl 2):S9

We present the “Sistema de Alerta Precoce do Insucesso Escolar no Ensino Básico (SAPIE-EB)”, a sophisticated early warning system that ealy flag the students’risk for school failure and ill-being, systematically monitor the students’ progress in the dimensions of and empirically assess the educational impact of the interventions in the dimensions of academic success, psychological health and career development. The SAPIE-EB is a user-friendly system that converts students’ raw data available at schools in knowledge, providing easy-delivered and intuitive reports on students’school failure, dropout and interventions, hereby allowing to deepen the knowledge about their causes and explanatory processes. The SAPIE-EB will be tested in 75 Portuguese basic schools. It is expected, with the implementation of the SAPIE-EB to reduce school retention in about 3% in a

two-year interval period. Longitudinal research will attest the efficacy of the SAPIE-EB, from longitudinal quase-experimental research designs.

## Keywords

Early Warning Systems, SAPIE-EB, School Success, Psychological Health, Career development.

# Oral Communications

O1

# Nursing professionals victims of verbal abuse by their coworkers from the same work unit

Maiara Bordignon, Inês Monteiro

School of Nursing, University of Campinas Campinas, 13083-887

Campinas, São Paulo, Brazil

Correspondence: Maiara Bordignon (bordignonmaiara@gmail.com)

BMC Health Services Research 2018, **18**(Suppl 2):O1

## Background

Violence among professionals of health teams has been exploited over the years with considerable attention to nursing [1-5]. The literature has also highlighted the impact of horizontal violence on the individual, unit and institution, such as, its negative influence on job satisfaction and possible harms to the safety culture, as well as to the wellbeing of professionals [3-5].

## Objective

To present the frequency with which nursing professionals have suffered verbal abuse perpetrated by their coworkers, from the same work unit, during the last year and the professional categories involved in the abuse.

## Methods

A cross-sectional study performed with a sample of 267 nursing professionals - registered nurse, nursing assistant/technician - working in Emergency units in Brazil. The experience of verbal abuse at work suffered by nursing professionals in the last 12 months was accessed using questions of a questionnaire about verbal abuse [6]. Data were described allowing to identify frequencies and professionals involved in the abuse. This study was authorized by institutions and approved by the Ethical Research Board of the university.

## Results

Among the victims of verbal abuse, 23 (15%) nursing professionals reported that the last verbal abuse suffered was from coworkers of the same work unit, excluding abuses perpetrated by a boss or supervisor. At least twenty-one (91%) cases occurred in the emergency units that were part of the study and of these eighteen professionals indicated the perpetrator's profession, revealing that in nine (50%) cases the abuse was perpetrated by a coworker with the same profession, mostly registered nurse-to-registered nurse (5-56%). When the perpetrator's and the victim's profession were different (9-50%), the abuse occurred more frequently from nursing technician-to-registered nurse (3-33%). The presence of the doctor was identified in at least one situation of abuse occurred in the emergency units studied and was directed to a nursing technician. There was no report of verbal abuse perpetrated by other professionals of the non-medical team and who did not participate in the nursing team.

## Conclusions

Our study showed that in almost all instances verbal abuse occurred among the nursing staff professionals themselves. Organizational policies and strategies focusing on violence contributors factors in health care teams need to be structured to prevent violence among professionals, representing a challenge to health management.

## Acknowledgements

Authors are grateful for the funding by grant#2016/06128-7, São Paulo Research Foundation (FAPESP), National Council for Scientific and Technological Development (CNPq) and Coordination for the Improvement of Higher Education Personnel (CAPES), Brazil.
## References

1. Duffy E. Horizontal violence: a conundrum for nursing. Collegian. 1995;2(2):5-17.

2. McKenna BG, Smith NA, Poole SJ, Coverdale JH. Horizontal violence: experiences of Registered Nurses in their first year of practice. J Adv Nurs. 2003;42(1):90-96.

3. Longo J, Cassidy L, Sherman R. Charge nurses' experiences with horizontal violence: implications for leadership development. J Contin Educ Nurs. 2016;47(11):493-499.

4. Purpora C, Blegen MA. Job satisfaction and horizontal violence in hospital staff registered nurses: the mediating role of peer relationships. J Clin Nurs. 2015;24(15-16):2286-94.

5. Armmer F, Ball C. Perceptions of horizontal violence in staff nurses and intent to leave. Work. 2015;51(1):91-7.

6. Bordignon M, Monteiro MI. Apparent validity of a questionnaire to assess workplace violence. Acta Paul Enferm. 2015;28(6):601-8.

## Keywords

Workplace violence, Nurses, Nursing, Emergency Nursing.

## O2

### Social representations of violence on the elderly: an injustice and a badness

Felismina RP Mendes¹,², Otilia Zangão¹, Tatiana Mestre¹

¹Escola Superior de Enfermagem S. João de Deus, Universidade de Évora, 7004-516 Évora, Portugal; ²Centro de Investigação em Desporto, Saúde e Desenvolvimento Humano, Universidade de Évora, 7004-516 Évora, Portugal

**Correspondence:** Otilia Zangão (otiliaz@uevora.pt)

BMC Health Services Research 2018, **18**(Suppl 2):O2

### Background

In contemporary society, ageing is a phenomenon that marks all developed societies. Portugal is one of the most aged countries in Europe. Currently, Portugal shows a life expectancy at birth of 81.3 years, an average value in terms of EU [1]. Social representations allow access to lay forms of thought, fundamental for understanding social phenomena and their consequences, and for the construction of scientific knowledge itself [2]. The Social Representations conduct "the behaviors and the practices and, in this way, justify the positions taken and the behaviors" [3]. Analyzing the social representations of violence on the elderly, from the current and past conceptions and daily practices of the elderly, allows us to have access to the dominant constructions in society about the social phenomenon that is violence and the way it is socially and individually expressed by its main actors.

### Objective

To analyze the social representations of a group of elderly people about violence on the elderly and the reasons why this violence occurs.

### Methods

Exploratory and descriptive research with qualitative approach, supported by Theory of Social Representations. It was attended by 237 elderly people aged 65-96 years, from the project "Ageing Safely in Alentejo" from University of Évora. The Free Speech Association technique was used and data were processed through qualitative data analysis software. All ethical procedures of human research were followed. Thus, all necessary authorizations for the study were requested, such as informed consent to the elderly. All conditions of anonymity and confidentiality of the responses obtained were also guaranteed.

### Results

In social representations of violence on the elderly, the words most evoked by the elderly were injustice, to which were added: mistreatment, badness, bad, lack of respect, sadness, horrible and abandonment. In social representations about the reasons that lead to violence on the elderly, the words such as: lack of respect, lack of education and badness were predominant. These terms refer to the social devaluation of the elderly and their role in today's society, as in the representations about violence.

## Conclusions

The social representations of these elderly people about violence and their reasons points to the stereotypes associated with the prevalent ageism in our society, where the social devaluation of the elderly dominates the daily life conceptions and practices.

## Acknowledgements

This study was carried out under the ESACA - Ageing Safely in Alentejo - Ref: ALT20-03-0145-FEDER-000007, financed by Alentejo 2020, Portugal 2020 and EU.

## References

1. PORDATA. Esperança de vida à nascença: total e por sexo - 2015 [Internet]. 2003 [cited 2017 Out 23]. p. 1-4. Available from: https://www.pordata.pt/Europa/Esperança+de+vida+à+nascença+total+e+por+sexo+1260.

2. Dantas, M., Abrão, F., Freitas, C. & Oliveira, D. Representações sociais do HIV/AIDS por profissionais de saúde em serviços de referência. Revista Gaúcha Enfermagem. [periódico na Internet]. 2014 [cited 2017 Set 05]; 35 (4): 94-100. Available from http://seer.ufrgs.br/index.php/RevistaGauchadeEnfermagem/article/view/45860/3 2387.

3. Mendes, F., Zangão, M., Gemido, M., & Serra, I. Representações sociais dos estudantes de enfermagem sobre assistência hospitalar e atenção primária. Revista Brasileira de Enfermagem. [periódico na Internet]. 2015 [cited 2017 Set 18]; 69 (2): 343-350. Available from http://www.redaly-c.org/pdf/2670/267045808018.pdf.

## Keywords

Social representations, Violence, Elderly, Elderly health, Discrimination.

## O3

### Relationship between the use of new technologies and musculoskeletal symptoms in children and adolescents

Paula C Santos¹,², Sofia Lopes¹,³,⁴, Rosa Oliveira¹, Helena Santos, Jorge Mota², Cristina Mesquita¹,⁴

¹Department of Phisioterapy, School of Allied Health Technologies, Polytechnic Institute of Porto, 4050-313 Porto, Portugal; ²Research Centre in Physical Activity, Health and Leisure, Faculty of Sport, University of Porto, 4050-313 Porto, Portugal; ³Escola Superior de Saúde de Vale de Sousa, 4585-116 Gandra, Portugal; ⁴Centro de Estudos do Movimento e Atividade Humana, Escola Superior de Saúde, Instituto Politécnico do Porto, 4200-072 Porto, Portugal

**Correspondence:** Paula C Santos (paulaclara@ess.ipp.pt)

BMC Health Services Research 2018, **18**(Suppl 2):O3

### Background

Childhood and adolescence are determinants of musculoskeletal development, and the attitudes and habits adopted during these periods can have repercussions in adult life. The increasing use of technologies is becoming more worrying due to the sustained and prolonged postures due to the use of these devices and the consequent impact on musculoskeletal health.

### Objective

This study analyzes the relationship between the use of new technologies with musculoskeletal symptoms (MSS) in children and adolescents.

### Methods

Cross-sectional study with a sample of 460 students aged between 10 and 18 years. Data were collected through a questionnaire that included the Nordic Musculoskeletal Questionnaire.

### Results

98.5% of students reported the used a mobile phone, 84.3% laptop and 52.4% tablet. Only 50.0% of the individuals who used mobile phones, 48.5% of the laptop and 31.1% of the tablet considered having a correct posture during the use of these technologies. We verified that the individuals with MSS showed more times of use of new technologies than individuals without MSS. There were differences in the time (min/day) of mobile phone and laptop use among children and adolescents, respectively 102.6 ± 121.47 vs 205.8 ± 175.89 (p < 0.001) and 74.0 ± 78.08 vs 117.9 ± 127.26 (p < 0.001).
## Conclusions

Most students use new technologies in their daily lives, with less than half of them considering using these technologies in the right posture. It was also verified that individuals with MSS used more times new technologies than individuals without MSS. The time of use of new technologies increases with the age.

## Keywords

New technologies, Musculoskeletal symptoms, Children and adolescents.

## O4

### An ecological approach to fall risk factors for preventive interventions design: a pilot study

Jorge Bravo¹, Hugo Rosado¹, Felismina Mendes³, Catarina Pereira²
¹Nursing Department, São João de Deus Superior Nursing School, University of Évora, 7000-811 Évora, Portugal; ²Health Sciences and Human Development Center, Health and Sports Department, Science and Technology School, University of Évora, 7000-671 Évora, Portugal; ³Health Sciences and Human Development Center, São João de Deus Superior Nursing School, University of Évora, 7000-811 Évora, Portugal

**Correspondence:** Jorge Bravo (jorgebravo@uevora.pt)

BMC Health Services Research 2018, **18**(Suppl 2):O4

## Background

Recent literature reinforces that interventions for fall prevention should include multimodal training [1]. However, even multimodal training tends to focus on exercises separately in single physical, cognitive or environmental hazards variables. An ecological approach to explain phenomena's such as fall occurrence, underlines not only the accumulative effect of isolated variables but also interactions between different variables.

## Objective

To reduce a set of correlated variables to a smaller number that may explain fall occurrence.

## Methods

187 older adults aged 65 to 96 years were assessed for falling risk factors. Principal component analysis (PCA) was performed including data from the 6-minute walk test (6MWT) [2], Gait Scale [3], Fullerton Advanced Balance Scale (FAB) [4], body composition - fat body mass percentage (FBM %), Mini-Mental State Examination (MMSE) [5], Environmental Hazards Scale (EH) [6], health conditions (HC), time up and go test (TUG) [2] and the Epworth Sleepiness Scale (ESS) [7]. Factors with eigenvalues of at least 1.0 were retained and a varimax rotation was used to produce interpretable factors. A binary regression analysis was performed using the forward stepwise (conditional) technique to identify the most significant components explaining fall occurrence. Receiver operating characteristics (ROC) curves were used to assess the discriminative ability of the logistic model.

## Results

Three principal components were identified. In component 1, the dominant variables concerned physical and cognitive fit (6MWT, Gait Scale, FAB, MMSE, TUG), in component 2 dominant variables concerned health and environmental conditions (FBM %, EH, HC), whereas in component 3, the dominant variable concerned alertness (ESS). These components explained cumulatively 37%, 56% and 70% of the variance in fall occurrence. Logistic regression selected components 1 (OR: 0.527; 95% CI: 0.328-0.845) and 2 (OR: 1.614; 95% CI: 1.050-2.482) as predictive of falls. The cut-off level yielding the maximal sensitivity and specificity for predicting fall occurrence was set as 0.206 (specificity = 72.7%, sensitivity = 47.7%, and the area of the ROC curve was computed as 0.660 (95% CI: 0.564-0.756).

## Conclusions

This pilot study showed that multiple correlated variables for fall risk assessment can be reduced to three uncorrelated components characterized by: physical and cognitive fit; health and environmental conditions; and alertness. The first two were the main determinants of falls. Recommendations: Interventions for fall prevention should privilege multimodal training including tasks that work simultaneously physical fitness, cognitive fitness and alertness, considering participant's specific health and environmental conditions.

## Trial Registration

NCT03446352

## References

1. Hafström A, Malmström EM, Terdèn J, Fransson PA, Magnusson M. Improved balance confidence and stability for elderly after 6 weeks of a multimodal self administered balance-enhancing exercise program: a randomized single arm crossover study. Gerontology and geriatric medicine 2016;2:2333721416644149.

2. Rikli RE, Jones CJ. Development and validation of a functional fitness test for community-residing older adults. Journal of aging and physical activity 1999; 7(2): 12961.

3. Tinetti ME. Performance-Oriented Assessment of Mobility Problems in Elderly Patients. Journal of the American Geriatrics Society 1986; 34(2): 119-26.

4. Rose DJ, Lucchese N, Wiersma LD. Development of a multidimensional balance scale for use with functionally independent older adults. Archives of physical medicine and rehabilitation 2006; 87(11): 1478-85.

5. Guerreiro M, Silva AP, Botelho MA, Leitão O, Castro-Caldas A, Garcia C. Adaptação à população portuguesa da tradução do Mini Mental State Examination (MMSE). Revista Portuguesa de Neurologia 1994; 1(9): 9-10.

6. Tinetti ME, Speechley M. Prevention of Falls among the Elderly. New England Journal of Medicine 1989; 320(16): 1055-9.

7. Johns MW. A new method for measuring daytime sleepiness: the Epworth sleepiness scale. sleep 1991; 14(6): 540-5.

## Keywords

Principal component analysis, Falling risk, Physical fitness, Cognitive fitness, Environmental hazards.

## O5

### Relationship between smartphone use and musculoskeletal symptoms in adolescents

Paula C Santos¹,², Cristina Mesquita¹, Rosa Oliveira, Raquel Azevedo, Sofia Lopes¹,³

¹Department of Physiotherapy, School of Allied Health Technologies, Polytechnic Institute of Porto, 4050-313 Porto, Portugal; ²Research Centre in Physical Activity, Health and Leisure, Faculty of Sport, University of Porto, 4050-313 Porto, Portugal; ³North Polytechnic Institute of Health, 4585-116 Gandra, Portugal

**Correspondence:** Paula C Santos (paulaclara@ess.ipp.pt)

BMC Health Services Research 2018, **18**(Suppl 2):O5

## Background

We are currently facing a society of adolescents who are increasingly dependent on technology, in particular the smartphone, and this phenomenon can even lead to limiting situations in which the person's physical well-being is called into question. Intensive use of the smartphone may contribute to a decrease in physical activity and generate musculoskeletal symptoms (MMS).

## Objectives

To verify the existence of a relationship between the use of the smartphone and: 1) MMS; 2) vigorous, moderate and sedentary physical activity

## Methods

An observational, analytical, cross-sectional study was conducted on a sample of 834 adolescents from five schools in the regions of Viseu, Vila Real and Porto. Data collection was performed through online questionnaires through the Qualtrics program, in order to perform the sociodemographic characterization of the sample and to determine behavioral habits related to health, as well as to the use of new technologies. Musculoskeletal symptoms were evaluated through the Portuguese version of the Nordic musculoskeletal questionnaire. (NMQ) and physical activity through the International Questionnaire of Physical Activity (IPAQ).

## Results

The adolescents who used the smartphone for the most time referred MMS in the cervical (p < 0.001), thoracic (p = 0.017), lumbar (p < 0.001), shoulders (p < 0.001), wrists/hands (p = 0.003) and knees (p = 0.013).
Adolescents who practice more vigorous physical activity (p = 0.023) use less smartphone, and those who have more time in sedentary physical activity (p = 0.008) use it more.

## Conclusions

Adolescents who spend more time on smartphones refer more MMS. The use of the smartphone is associated with a more sedentary lifestyle, unlike the adolescents who practice vigorous physical activity that give less use to it.

## Keywords

Smartphone, Physical Activity, Musculoskeletal Symptoms.

## O6

### Functional fitness and cognitive performance in independent older adults - fallers and non-fallers: an exploratory study

Jorge Bravo¹, Hugo Rosado¹, Felismina Mendes², Catarina Pereira³

¹São João de Deus Superior Nursing School, University of Évora, 7000-811 Évora, Portugal; ²Health Sciences and Human Development Center, São João de Deus Superior Nursing School, University of Évora, 7000-811 Évora, Portugal; ³Health Sciences and Human Development Center, Health and Sports Department, Science and Technology School, University of Évora, 7000-671 Évora, Portugal

**Correspondence:** Jorge Bravo (jorgebravo@uevora.pt)

BMC Health Services Research 2018, **18**(Suppl 2):O6

## Background

Actual research reinforces the importance of multimodal exercise programs for fall prevention; however remains unclear which components should be included in exercise programs, considering physical and cognitive components.

## Objectives

This exploratory study aims to identify the associations between functional fitness (FF) and cognitive performance (CP) in independent older adults, regarding fallers and non-fallers.

## Methods

63 males and 124 females (65-96 years) were selected based on the criteria of moderate or high functional independency (≥18 points) determined by responses to the 12-item of Composite Physical Functioning Scale [1]. FF was assessed by the Senior Fitness Test Battery [2]. A composite Z-score was created based on the individual scores for each fitness item. CP was assessed by the Mini-mental State Examination adapted for the Portuguese population [3]. Descriptive statistics were calculated for all outcome measurements and comparisons were performed using independent sample t-Tests. Multiple regression analyses were performed to test associations between FF and CP.

## Results

T-test comparisons showed that females were more flexible than males (p < 0.05). Males were taller and heavier than females (p < 0.05). No differences were observed between these independent fallers and non-fallers sample. Multiple regression analyses were performed to understand the association of FF with CP in fallers and non-fallers. Agility was negatively associated with the MMSE score in fallers and non-fallers; however, after adjusting for gender, age and education, this association was not significant for non-fallers (p < 0.05). Lower body strength showed positive associations (p < 0.05) with the MMSE score exclusively in non-fallers, regardless the adjustments. Likewise, the upper body strength was positively associated with the MMSE score (p < 0.05) in non-fallers after adjusting for age, gender and education (p < 0.05). On the other hand, the upper body flexibility showed negative associations with the MMSE score (p < 0.05) however this association did not remain significant after adjusting for gender, age and education.

## Conclusions

Independent older adults with higher agility scores were more likely to have an improved CP, whether they are fallers or non-fallers. Body strength, particularly improved lower body strength, is associated with higher CP in non-faller older adults, independently of age, gender and education. This exploratory study increases the spectrum of research in multimodal programs by suggesting that agility and strength training should be included in exercise prescription for fall prevention, in order to foment CP.

## Acknowledgements

Study was funded by Horizon 2020, Portugal 2020 (ALT20-030145-FEDER-000007).

## References

1. Rikli RE, Jones CJ. The reliability and validity of a 6-minute walk test as a measure of physical endurance in older adults. Journal of aging and physical activity 1998; 6(4): 363-75.

2. Rikli RE, Jones CJ. Development and validation of a functional fitness test for community-residing older adults. Journal of aging and physical activity 1999; 7(2): 129-61.

3. Guerreiro M, Silva AP, Botelho MA, Leitão O, Castro-Caldas A, Garcia C. Adaptação à população portuguesa da tradução do Mini Mental State Examination (MMSE). Revista Portuguesa de Neurologia 1994; 1(9): 9-10.

## Keywords

Aging, Physical fitness, Accidental falls, Cognitive aging.

## O7

### Association between endurance of the trunk extensor muscles and the risk of falling in community-dwelling older adults

Sofia Flora, Ana Tavares, Joana Ferreira, Nuno Morais
School of Health Sciences, Polytechnic Institute of Leiria, 2411-901 Leiria, Portugal

**Correspondence:** Sofia Flora (sofiaiaflora@gmail.com)

BMC Health Services Research 2018, **18**(Suppl 2):O7

## Background

Falls in the elderly are a serious health problem and the result of the complex interaction between individual and environmental risk factors. Balance is considered a key factor for higher falling risk in this population [1, 2]; thus, assessment and preventive/rehabilitation programs targeting the balance control system are currently a clinical guideline [1]. Programs commonly include strength/power training of the lower limbs and trunk muscles and postural control exercises [1, 3]. Recently it has been shown that the elderly reach premature muscle fatigue during upright stance tasks [2], and that fatigue leads to poor balance control [4]. Muscular endurance hence appears to play an important role in the efficiency of the balance control system, particularly during performance of long lasting functional tasks. However, the association between muscle endurance and balance control measures has been overlooked, especially in the trunk muscles, despite its potential to assist clinicians and researchers to comprehensively screen falling risk factors and tailoring interventions accordingly.

## Objective

The main purpose of this cross-sectional study was to determine the association between endurance of the trunk extensor muscles and the risk of falls in the elderly, considering possible co-factors such as age and BMI.

## Methods

Community-dwelling adults ≥ 65 years were recruited from senior universities in the Centre region of Portugal. Exclusion criteria included severe physical/cognitive limitations that would prevent subjects from performing the testing protocol. Falling risk/balance was assessed using the Berg Balance Scale (BBS, score 0-56). Muscle performance was measured through the trunk extensor endurance test (in seconds). Simple and multiple linear regression analyses, using SPSS (v20), were conducted to predict the effects of muscle endurance, BMI and age on balance control. Statistical significance was set at 0.05.

## Results

Fifty-nine volunteers (44 females, age = 71 ± 5 years, height = 1.60 ± 0.09 m, mass = 71.67 ± 14.35 kg, BMI = 28.02 ± 4.62 kg/m²) were included in the study. The largest correlation was found between the BBS score, and muscle endurance ($\rho$ = 0.379), and BMI ($\rho$ = -0.335). Muscle endurance predicted 7% of the BBS score ($r^2_a$ = 0.070, p = 0.024). When combined with BMI, muscle endurance accounted for ~16% ($r^2_a$=0.162, p = 0.003) of the total variance of the BBS score.
Unsurprisingly, when age was added to the previous model the predictive capacity increased, reaching ~21% ($r^2_a$ = 0.214, p = 0.01).

### Conclusions

Endurance of the trunk extensor muscles and BMI predicted approximately 16% of the BBS score. Since these are modifiable factors, it is recommended that they should be routinely included in the screening of falling risk factors in the elderly and addressed accordingly in preventive programs.

### References

1. Phelan EA, Mahoney JE, Voit JC, Stevens JA. Assessment and management of fall risk in primary care settings. Med Clin North Am. 2015 Mar;99(2):281-93.

2. Pizzigalli L, Micheletti Cremasco M, Mulasso A, Rainoldi A. The contribution of postural balance analysis in older adult fallers: A narrative review. Journal of Bodywork and Movement Therapies. 2016 Apr;20(2):409-17.

3. Granacher U, Gollhofer A, Hortobágyi T, Kressig RW, Muehlbauer T. The Importance of Trunk Muscle Strength for Balance, Functional Performance, and Fall Prevention in Seniors: A Systematic Review. Sports Med. 2013 Apr 9;43(7):627-41.

4. Papa EV, Garg H, Dibble LE. Acute Effects of Muscle Fatigue on Anticipatory and Reactive Postural Control in Older Individuals. Journal of Geriatric Physical Therapy. 2015;38(1):40-8.

### Keywords

Muscle Endurance, Balance, Elderly, Risk of falls, Trunk Extensor Muscles.

## O8

### ICF Core Set for Obstructive Pulmonary Diseases: validation of the environmental factors component through the perspective of patients with asthma

Cristina Jácome<fnref n="1" />,<fnref n="2" />, Susan M Lage<fnref n="3" />, Ana Oliveira<fnref n="2" />, Augusto G Araújo⁴, Danielle AG Pereira<fnref n="3" />, Verônica F Parreira<fnref n="3" />

**Correspondence:** Cristina Jácome (cristinajacome@ua.pt)

BMC Health Services Research 2018, **18**(Suppl 2):O8

### Background

To optimize a patient-oriented approach in asthma management, health professionals need to consider all aspects of the patient's actual context (physical, social and attitudinal). This context can be assessed using the Environmental Factors component of the International Classification of Functioning, Disability and Health (ICF) Core Set for Obstructive Pulmonary Diseases (OPD). The categories included in the Environmental factors component have been selected by respiratory experts, and have been validated from the perspective of physicians, physiotherapists and patients with chronic obstructive pulmonary disease. However, the validation from the perspective of patients with asthma will be essential to allow a more widespread application of the ICF in this population.

### Objective

This study aimed to validate the Environmental factors component of the Comprehensive and Brief versions of ICF Core Set for OPD from the perspective of patients with asthma.

### Methods

A cross-sectional qualitative study was conducted with outpatients with asthma using semi-structured individual interviews. Qualitative data were analysed through the meaning condensation procedure by two researchers with expertise in the ICF.

### Results

Thirty-five participants (26 females; 41±13 years) were included. Eight (35%) categories contained in the Environmental factors component

of the Comprehensive version of the ICF Core Set for OPD and 4 (100%) of those contained in the Brief version were confirmed by the participants. Additionally, 5 second level categories (Products and technology for employment; Flora and fauna; Natural environment and human-made changes to environment, unspecified; Domesticated animals; Support and relationships, unspecified) and 13 third level categories (Food; Drugs; General products and technology for personal use in daily living; General products and technology for employment; Assistive products and technology for employment; Design, construction and building products and technology for gaining access to facilities in buildings for private use; Plants; Animals; Temperature; Humidity; Indoor air quality; Outdoor air quality; Health services) not included in the Core Set were identified.

### Conclusions

The Environmental factors component of the Brief ICF Core Set for OPD was fully supported by the perspective of patients with asthma, contrasting with only one third of the categories of the Comprehensive version. The categories included in the ICF Core Set that were not confirmed by the participants and the additional categories that were raised need to be further investigated in order to develop an instrument tailored to patients' needs. This will promote more patient-centred assessments and rehabilitation interventions.

### Keywords

Asthma, International Classification of Functioning, Disability and Health, Environmental factors, Patient's perspective.

## O9

### Attachment, self-compassion and mental health in the use of the internet to establish intimate relationships

Sónia C Simões<fnref n="1" />,<fnref n="2" />, Vanessa Vieira<fnref n="1" />, Mariana Marques<fnref n="1" />, Laura Lemos<fnref n="1" />

**Correspondence:** Sónia C Simões (soniasimoes@ismt.pt)

BMC Health Services Research 2018, **18**(Suppl 2):O9

### Background

Currently, to our knowledge, there is no research with Portuguese samples comparing the levels of attachment, self-compassion and psychopathological symptoms in subjects who use and do not use the Internet to establish intimate relationships.

### Objective

The present study aimed to investigate how individuals, who use the Internet to establish intimate relationships, differ psychologically from individuals who do not use the Internet for this purpose.

### Methods

We used the following scales: Experiences in Close Relationships (ERP), Self-Compassion Scale (SELFCS), Brief Symptom Inventory (BSI) and a short sociodemographic questionnaire. The sample consisted of 350 individuals of whom 284 used social networks to establish intimate relationships (I) and 66 did not use the Internet for this purpose (NI), with a mean age of 29.90 (SD = 7.41) for the I group and 30.72 (SD = 8.26) for the NI group. The majority of the sample was single in both groups (I: 83.5% vs. NI: 68.2%), heterosexual (I: 79.6% vs. NU: 93.9%), was attending or attended Higher Education (I: 66.5% vs. NI: 60.6%).

### Results

We found that man used more, compared to woman, the Internet to establish intimate relationships, and that the individuals that used most the Internet for this purpose had a higher number of short-term intimate relationships, compared to the group of subjects that did not use the Internet for this purpose. We also found that individuals without a romantic relationship (single, separated/divorced or widowed) were who resorted to this type of online service. Differences between groups regarding attachment, self-compassion and psychopathology were not found. However, it is important to highlight the stronger associations between psychopathological symptoms (global severity index and BSI dimensions) with attachment and self-compassion in the group that did not use the Internet to establish intimate relationships, comparing to the group that reported using the Internet with this intention.

<footnote n="1">¹Centro de Investigação em Tecnologias e Serviços de Saúde, Faculdade de Medicina, Universidade do Porto, 4200-319 Porto, Portugal;</footnote>

<footnote n="2">²Laboratório de Investigação e Reabilitação Respiratória, Escola Superior de Saúde, Universidade de Aveiro, 3810-193 Aveiro, Portugal;</footnote>

<footnote n="3">³Universidade Federal de Minas Gerais, 31270-901 Belo Horizonte, Minas Gerais, Brasil; ⁴Hospital Carlos Chagas, 35900-595, Itabira, Minas Gerais, Brasil</footnote>

<footnote n="1">¹Instituto Superior Miguel Torga, 3000-132 Coimbra, Portugal; ²Centro de Estudos da População, Economia e Sociedade, 4150-171 Porto, Portugal</footnote>
## Conclusions

The results show the importance of deepening the research about the use of Internet to establish intimate relationships, since there are no studies concerning this area in Portugal.

## Keywords

Self-compassion, Attachment, Psychopathology, Intimate relationships, Online dating.

## O10

### The obsessive-compulsive symptomatology: its relation with alexithymia, traumatic experiences and psychopathological symptoms

Sónia C Simões¹,², Timóteo Areosa¹, Helena Espírito-Santo¹, Laura Lemos¹

¹Instituto Superior Miguel Torga, 3000-132 Coimbra, Portugal; ²Centro de Estudos da População, Economia e Sociedade, 4150-171 Porto, Portugal

**Correspondence:** Sónia C Simões (soniasimoes@ismt.pt)

BMC Health Services Research 2018, **18**(Suppl 2):O10

## Background

Alexithymia has been reported more significantly in subjects with obsessive-compulsive disorder (OCD), since they have a hard time recognizing and describing their own emotions. It should also be noted that many individuals with OCD often report experiencing traumatic situations. However, to our knowledge there are no Portuguese studies on the relationship between OCD (or obsessive-compulsive symptomatology), traumatic experiences, and alexithymia, justifying the relevance of this study.

## Objective

The following goals were outlined: 1) To study the relationship between psychopathological symptoms, alexithymia and traumatic experiences in clinical and non-clinical samples; 2) To study and compare the traumatic experiences, the levels of alexithymia, and the psychopathological symptoms in clinical and non-clinical samples; 3) Check the relations of variables such as age, gender, marital status, and literacy with the presence or absence of obsessive-compulsive symptomatology in order to identify potential confounding factors.

## Methods

The total sample comprised 115 individuals aged between 18 and 64 years (M = 31.50; SD = 10.61). For the creation of the 2 groups in comparison, the Maudsley Obsessive Compulsive Inventory (MOCI) cut-off point was used, in which results above 10 indicated the presence of obsessive-compulsive symptomatology. The clinical group had 40 subjects, aged between 18 and 49 years (M = 27.03; SD = 7.68) and the nonclinical group had 75 subjects, aged between 18 and 60 years (M = 33.89; SD = 11.21). The research protocol included: MOCI, Traumatic Experiences Checklist (TEC), Toronto Alexithymia Scale and the Brief Symptom Inventory.

## Results

The clinical sample presented more psychopathological symptomatology and higher values of alexithymia compared to the non-clinical sample. No differences were found between groups in the presence of traumatic experiences, but the clinical sample presented higher scores of sexual abuse and trauma in the family of origin. Finally, there was a greater number of statistically significant associations and of a stronger magnitude in the non-clinical sample among the studied variables, compared to the clinical sample, especially according to the TEC.

## Conclusions

It was verified that traumatic experiences and alexithymia, in particular, might be factors associated with the onset of obsessive-compulsive symptomatology, being a future study area to understand if they will also be risk factors for developing OCD.

## Keywords

Obsessive-compulsive symptomatology, Traumatic experiences, Alexithymia.

## O11

### Loss of group immunity against measles

João MG Frade¹,², Carla Nunes³, João R Mesquita⁴, Maria SJ Nascimento⁵, Guilherme Gonçalves¹

¹Multidisciplinary Unit for Biomedical Research, Institute of Biomedical Sciences Abel Salazar, University of Porto, 4050-313 Porto, Portugal;

²Center for Innovative Care and Health Technology, Polytechnic Institute of Leiria, 2411-901 Leiria, Portugal; ³Public Health Research Centre, National School of Public Health, Nova University, 1600-560 Lisboa, Portugal; ⁴Agrarian Superior School, Polytechnic Institute of Viseu, 3500-606 Viseu, Portugal; ⁵Laboratory of Microbiology, Department of Biological Sciences, Faculty of Pharmacy, University of Porto, 4050-313 Porto, Portugal

**Correspondence:** João MG Frade (joao.frade@ipleiria.pt)

BMC Health Services Research 2018, **18**(Suppl 2):O11

## Background

Vaccination coverage rates higher than 95% contribute to the so-called group immunity effect with regard to measles vaccination [1]. However, to guarantee such immunity, it is important that those vaccine coverage rates also correspond to levels of seropositivity of measles antibodies (specific IgG antibodies levels > 150 mIU/ml) higher than 95% [2].

## Objective

This study intends to evaluate from which moment, after having been vaccinated with MMR II (triple viral vaccine against mumps, measles and rubella), 95% of the individuals have specific IgG antibodies (Anti-Measles-IgG) <150 mIU/ml.

## Methods

A cross-sectional study was conducted on 190 individuals, born in Portugal after 1990, with records of vaccine history documented in the Individual Record of Vaccination (IRV) and in the Individual Health Bulletin (IHB). Specific IgG antibodies to measles virus (Anti-Measles-IgG) were measured using the commercial immunoassay Siemens Enzygnost®Anti-Measles Virus/IgG.

## Results

Data were grouped into three birth cohorts: born between 1990 and 1993, born between 1994 and 1995 and born between 2001 and 2004. It was found that those born between 2001 and 2004 were those that presented the highest levels of protection against measles, less than 2% of these individuals had levels of protection below the 150 mIU/ml. The cohort born between 1994 and 1995 was the one that presented the lowest protection against the disease, in which more than 50% of the individuals were below the protection threshold (150 mIU/ml). The cohort born between 1990 and 1993 is an intermediate cohort, where more than 50% of individuals are above protection threshold, but with a significant percentage of seronegative individuals. ANOVA analysis and Tukey's multiple comparison analysis showed a statistically significant difference among the 3 birth cohorts (p < 0.001). The use of mathematical modelling showed that at the end of 9 years, after individuals have received MMR II, more than 95% individuals no longer presented specific IgG antibodies against measles virus (Anti-Measles-IgG) above 150 mIU/ml (p < 0.0001).

## Conclusions

The time elapsed since the last MMR II vaccination seems to be associated with protection against measles. Nine years after MMR II, more than 95% of individuals are seronegative for the Specific IgG antibodies to measles virus.

## References

1. Gonçalves G, Frade J Nunes C, Mesquita JR, Nascimento MSJ, Persistence of measles antibodies, following changes in the recommended age for the second dose of MMRvaccine in Portugal. Vaccine 33, 2015: 5057-63.

2. Gonçalves G, Nunes C, Mesquita JR, Nascimento MSJ, Frade J. Measles antibodies in cord blood in Portugal. Possible consequences for the recommended age of vaccination. Vaccine 34, 2016: 2750-57.
**Keywords**

Immunity, Measles, Vaccination.

**O12**

**Code Stroke in an emergency department - evaluation of results after 7 years of protocol implementation**

Ilda Barreira¹, Matilde Martins², Leonel Preto², Norberto Silva¹, Pedro Preto³

¹**Serviço de Urgência**, Unidade Local de Saúde do Nordeste, 5301-852 Bragança, Portugal; ²**Departamento de Enfermagem**, Escola Superior de Saúde, Instituto Politécnico de Bragança, 5300-146 Bragança, Portugal; ³**Serviço de Ortotraumatologia**, Unidade Local de Saúde do Nordeste, 5301-852 Bragança, Portugal

**Correspondence:** Leonel Preto (leonelpreto@ipb.pt)

BMC Health Services Research 2018, **18**(Suppl 2):O12

**Background**

Fibrinolysis reduces mortality and disability after an ischemic stroke, and its benefits are documented with level of evidence I [1]. The major goal of the Code Stroke (CS) is to treat the eligible cases by fibrinolysis, within the therapeutic window of 4.5 hours after symptom onset [2]. Thus, an emergency department must operate efficient mechanisms to receive, diagnose, treat or transfer patients with stroke [3].

**Objective**

The main objective was to evaluate the results of the CS protocol implementation in an Emergency Department (ED) of a hospital in the North of Portugal. As secondary objectives we aimed to: (I) Characterize the patients in sociodemographic and clinical variables; (II) Calculate the activation rate of CS protocol and the rate of fibrinolysis.

**Methods**

Retrospective descriptive analysis, using data from the Manchester triage system and other secondary source of information, of all patients with ischemic stroke, haemorrhagic stroke, and transient ischemic attack (TIA) admitted to the Emergency Department between January 1, 2010 and December 31, 2016. Socio-demographic data, care times, cardiovascular risk factors and other clinical variables were collected. The statistical analysis was performed by ANOVA, at 0.05 significance level.

**Results**

In the 7 years analysed, 1200 patients with cerebrovascular disease were admitted in the ED. Among these patients, 63.0% presented ischemic stroke, 17.3% haemorrhagic stroke and 19.8% TIA. The population was predominantly male (54.8%) and had a mean age of 77.4 (± 11.2) years. Stroke code was activated 431 times, covering 37.2% (n = 282) of ischemic stroke, and have received thrombolytic therapy 18.4% (n = 52) of these patients. Door-to-needle time was, in average, 69.5 minutes. Mean (± SD) NIHSS (National Institutes of Health Stroke Scale) score was 14.8 (± 5.2) before treatment, decreasing to 11.8 (± 6.0) at two hours post-fibrinolysis (p < 0.05). For all patients (N = 1,200), we obtained the following prevalence of risk factors: Hypertension (64.7%), dyslipidaemia (30.3%), diabetes (26.5%), atrial fibrillation (23.3%), obesity (12.9%), smoking (6.3%) and ischemic heart disease (5.9%). The 24-hour mortality rate was 0.9% for ischemic stroke, 10.6% for haemorrhagic stroke, and 0% for TIA.

**Conclusions**

High rates of activation protocol were obtained for acute ischemic stroke, but only 52 patients met the criteria for fibrinolysis. The high age and comorbidity of patients with ischemic disease and its origin, predominantly rural, may have influenced the therapeutic window and the eligibility criteria for fibrinolysis.

**References**

1. Jauch EC, Saver JL, Adams HP, Bruno A, Connors JJ, Demaerschalk BM, et al. Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2013;44(3):870-947.

2. Baldereschi M, Piccardi B, Di Carlo A, Lucente G, Guidetti D, Consoli D, et al. Relevance of prehospital stroke code activation for acute treatment measures in stroke care: a review. Cerebrovasc Dis. 2012;34(3):182-90.

3. Alonso de Leciña M, Egido JA, Casado I, Ribó M, Dávalos A, Masjuan J, et al. Guidelines for the treatment of acute ischaemic stroke. Neurologia. 2014;29(2):102-22.

**Keywords**

Stroke, Emergency Service Hospital, Fibrinolysis, Outcome and Process Assessment.

**O13**

**SEMantic and PRAgmatic assessment platform for school-age children**

Dulce Tavares, Eileen S Kay

Escola Superior de Saúde de Alcoitão, 2649-506 Alcabideche, Portugal

**Correspondence:** Dulce Tavares (mdtavares@essa.pt)

BMC Health Services Research 2018, **18**(Suppl 2):O13

**Background**

Semantic and pragmatic skills are developed throughout life and are essential in the development of school and social learning. Upon entering school, learning to read and write is developed in two large areas of knowledge. The first implies capacities of recognition and decoding of written symbols of the word and vocabulary development and the second allows the understanding of what is read through inferential capacities and non-literal interpretation. Often, students with reading comprehension difficulties go unnoticed. It is easier to detect a child who reads slowly, syllable by syllable, or with mistakes than those who read fluently but without understanding the content. These difficulties only become evident when questions are asked about the text and when it is necessary to understand the questions of subjects such as mathematics or science. Thus, success to reach the National Curricular Plan can be compromised.

**Methods**

Material was developed to evaluate semantic and pragmatic skills in school-aged children. In semantics, aspects of syntagmatic and paradigmatic relations (lexical field, synonymy and antonyms) and paronymy are evaluated. In pragmatics, competences are evaluated such as inferences, comprehension of idioms and proverbs. This material will be placed on a platform that can be consulted and used by different professionals working with children. The items that constitute this material took into account the stages of language development and school level. The lexicon used is in the domain of European Portuguese.

**Results**

The 756 children who were assessed attended public and private schools in Portugal. The results show an increasing evolution of the lexical competences of the children, with significant differences between the different age groups in all tests. There were no significant differences between female and male except in the paronym test. Regarding the socio-professional level of the child's origin, it is verified that it is a differentiating factor of lexical competence because significant differences in all tests were observed regardless of the age of the child.

**Conclusions**

The authors concluded that it is of great importance to analyse lexical competence regarding the aspects of its organization, as it enables students to deal with academic tasks successfully, improving literacy as well as to be able to act in a systematic and productive way in the intervention with children with language disorders. The complexity and innovation of the pragmatic skills assessment (in European Portuguese) leads to this work to continue in development.

**Keywords**

Semantic, Pragmatics, Assessment, School age.
## O14

**Quality of Life in Portugal – what factors can determine the QoL in people with Intellectual Disabilities and a great need of supports?**

António Rodrigo, Sofia Santos, Fernando Gomes
Faculty of Human Kinetics, University of Lisbon, 1495-687 Cruz Quebrada, Portugal

**Correspondence:** António Rodrigo (antoniorodrigo92@gmail.com)

BMC Health Services Research 2018, **18**(Suppl 2):O14

**Background**

In Portugal, the Quality of Life (QoL) concept has become increasingly relevant, leaving aside a vision that only focus on the person's limitations to one that emphasizes the quality of interactions between personal characteristics and environmental demands, within a socioecological model. This new paradigm changes the approach to evaluation and planning individualized supports, regarding adults with Intellectual and Developmental Disability (IDD). Research shows an emerging interest in analysing what personal and environmental factors have impact in QoL of persons with IDD. Therefore, our main goal is to analyse how individual characteristics influence QoL of people with intellectual disability with greater need of supports.

**Methods**

The Portuguese version of the Escala San Martín, that focus on 8 QoL domains: Self-determination, Emotional Well-Being, Physical Well-Being, Material Well-Being, Rights, Personal Development, Social Inclusion and Interpersonal Relations was applied to 293 individuals with intellectual disabilities, over 18 years-old (32.31 ± 8.29), 128 females and 165 males. All participants were institutionalized. The dependent variables were the domains/QoL total scores and the independent variables were gender, diagnosis, age, comorbidities and tacking medication. A comparative study was carried out using either independent samples t-tests or the one-way analyses of variance (ANOVA).

**Results**

When comparing gender, age and medication consumption, no significant differences were found, with all groups presenting similar mean QoL scores. Regarding comorbidities, significant differences were found when comparing physical well-being (p < 0.001), rights (p < 0.001) and social inclusion (p = 0.001) domains, with higher mean QoL scores to those without comorbidities. Significant differences were also found regarding diagnosis, in all domains except for the material well-being. Higher mean scores were found in individuals with a mild intellectual disability diagnosis, when compared to those with severe or profound ID diagnosis.

**Conclusions**

The information about personal factors with impact in QoL will help to meet challenges and will allow a more adjusted person-centred planning. Discussion and implications for practice will be presented.

**Keywords**

Individualized supports, Intellectual and Developmental Disability, Quality of Life, Escala San Martín.

## O15

**Relationship between the levels of functional capacity and family functionality and depression in the elderly**

Andréia WB Silva, Akemi Izumi, Giovanna G Vietta, Márcia R Kretzer
Universidade do Sul de Santa Catarina, 88137-270 Palhoça, Santa Catarina, Brasil

**Correspondence:** Andréia WB Silva (andreiawb@hotmail.com)

BMC Health Services Research 2018, **18**(Suppl 2):O15

**Background**

Depression is one of the most prevalent mental health problems among the elderly [1]. Functional limitations and changes in family dynamics characterize important risk factors for the onset of depression [1,2].

**Objective**

To analyse the relation between levels of functional capacity and family functionality and depression in the elderly.

**Methods**

A cross-sectional study was conducted including one hundred and thirty-eight (138) elderly individuals. The presence of depression, the levels of capacity to perform Basic Activities of Daily Living (BADL) and Instrumental Activities of Daily Living (IADL) and family functionality were assessed, respectively, by the Geriatric Depression Scale (GDS), Katz Index of Independence in Activities of Daily Living, Lawton Scale and family APGAR. The Statistical Package for Social Sciences (SPSS) version 18.0 was used to enter and analyse data (p < 0.05). The present study was approved by the Research Ethics Committee of UNISUL.

**Results**

The most prevalent characteristics were the age between 60 and 69 years (62.3%), the female gender (52.9%), the white ethnicity (87.0%), having accomplished up to 8 years of schooling (75.8%), and being retired (80.4%). 67.4% of the elderly did not have a spouse, and 14.5% lived alone. Depression presented a prevalence in 43.5% of the participants, of whom 88.3% were mildly depressive and 11.7% were severely depressive. There was a high frequency of hypertension (64.5%), Diabetes Mellitus (37.7%), osteoarthritis (39.1%), heart failure (28.3%), chronic obstructive pulmonary disease (15.9%) and asthma (9.4%). When evaluating functional capacity, 1.4% and 12.3% of the participants were classified as dependent to perform BADL and IADL, respectively. Family dysfunction was observed in 12.3% of the elderly (5.1% moderate dysfunction and 7.2% high dysfunction). When testing associations between depression and sociodemographic characteristics, the results showed statistical differences when comparing gender and marital status. Women were 1,538 times more likely to have depression than men (p = 0.031), and individuals who had a spouse were 1,580 times more likely to suffer from the disease (p = 0.018). When associating depression with other comorbidities, arterial hypertension was 1.652 times more prevalent (p = 0.024). Statistical differences were also identified with heart failure (PR = 1.941, p = 0.001) and asthma (PR = 1.923, p = 0.012). The functional capacity for BADL and IADL did not differ statistically. Family dysfunction was significantly associated with depression, which was 1,969 times more frequent in dysfunctional families (p = 0.003).

**Conclusions**

Depression in the elderly is associated with the female gender, having a spouse, cardiovascular and respiratory morbidities and family dysfunction.

**References**

1. Lima AMP, Ramos JLS, Bezerra IMP, Rocha R, Batista HHMT, Pinheiro WR. Depressão em idosos: uma revisão sistemática da literatura. Rev Epidemiol Controle Infecç. 2016;6(2):97-103.

2. Bretanha AF, Fachinni LA, Nunes BP, Munhoz TN, Tomazi E, Thumé E. Sintomas depressivos em idosos residentes em áreas de abrangência das Unidades Básicas de Saúde da zona urbana de Bagé, RS. Rev Bras Epidemiol. 2015;18(1):1-12.

**Keywords**

Depression in the elderly, Functional capacity, Family functionality.

## O16

**Microbiological evaluation of hotel units swimming pools**

Diana Assembleia, Teresa Moreira, António Araújo, Cecilia Rodrigues, Marlene Mota, Manuela Amorim

Escola Superior de Saúde, Instituto Politécnico do Porto, 4200-072, Porto, Portugal

**Correspondence:** Manuela Amorim (mas@ess.ipp.pt)

BMC Health Services Research 2018, **18**(Suppl 2):O16
**Background**

Swimming pools are currently operated by public and private entities for the development of sports, recreational and therapeutic activities [1]. For this reason, it is essential to guarantee the chemical and microbiological quality of the pool water, since they may be the origin of several pathologies [2].

**Objective**

The present research aimed to analyse data from the microbiological evaluation of indoor and outdoor swimming pool waters of Hotel Units of Mainland Portugal and Madeira in the year 2016, in order to verify the water quality.

**Methods**

A cross-sectional descriptive study was performed using database records from a northern laboratory. The microbiological parameters studied to characterize the indoor and outdoor swimming pool waters included CFU/mL of viable microorganisms at 37°C/24h, CFU/100mL of total coliforms, CFU/100mL of *Escherichia coli*, CFU/100mL of *Enterococcus spp.*, CFU/100mL of *Pseudomonas aeruginosa*, CFU/100mL of total *Staphylococcus* and CFU/100mL of coagulase producers *Staphylococcus*. The samples were characterized as conforming and non-conforming according to the reference intervals indicated in Regulatory Circular nº 14/DA of 21/08/2009 of Direção Geral de Saúde [1].

**Results**

Of the total of indoor pools (n = 610) analysed, 25.09% (n = 153) were classified as non-conforming, being the microorganisms viable at 37 °C the most frequent cause of nonconformities (n = 105), followed by total coliforms and total *Staphylococcus* (n = 42 each). For the outdoor pools (n = 1982), 29.92% (n = 593) were also classified as non-conforming, once more being microorganisms viable at 37 °C the most frequent cause of nonconformities (n = 420), followed by total coliforms (n = 154).

**Conclusions**

Indoor swimming pools have a lower frequency of nonconformities compared to outdoor swimming pools. The ambient temperature and the presence of soils around the pool influence the microbiological quality of the water [2]. These results also suggest that water treatment is not effective, indicating water pollution, being hygienic care other factor that influence the microbiological quality of the water [3]. The determination of these parameters is useful when microbiological monitoring is carried out constantly.

**References**

1. Direcção-Geral da Saúde. Normativa Circular Nº 14/DA de 21/08/2009. Programa de Vigilância Sanitária de Piscinas; 2009.

2. Rebelo H, Rodrigues R, Grossinho J, Almeida C, Silva M, Silva C, et al. Avaliação da qualidade da água de piscinas: estudo de alguns parâmetros bacteriológicos e físico-químicos. Boletim Epidemiológico Observações. 2014, 3(4):3-5.

3. World Health Organization. Guidelines for safe recreational water environments. Swimming pools and similar environments. Geneva: World Health Organization; 2006.

**Keywords**

Microbiological evaluation, Microbiological quality, Swimming pool waters, Fecal contamination indicators.

O17

**Normative values of functionality and quality of life of the portuguese healthy older people**

Cátia Paixão¹, Sara Almeida¹,², Alda Marques¹,²

¹Respiratory Research and Rehabilitation Laboratory, School of Health Sciences, University of Aveiro, 3810-193 Aveiro, Portugal; ²Institute for Research in Biomedicine, University of Aveiro, 3810-193 Aveiro, Portugal

**Correspondence:** Alda Marques (amarques@ua.pt)

BMC Health Services Research 2018, **18**(Suppl 2):O17

**Background**

The older population is increasing worldwide [1]. Since the average life expectancy is currently 71.4 years at birth and the healthy life

expectancy is only 63.1 years, there is a need to enhance the focus on public health to promote health and healthy ageing [2, 3]. Measures of functionality and health-related quality of life (HRQoL) have been identified as predictors of healthy aging [4-6]. However, to interpret results from those measures, and compare them within a population or across populations, normative data are necessary [7-9].

**Objective**

To establish age and gender-related normative values for the Five Times Sit to Stand Test (5 STS), 10 Meter Walk Test (10MWT), and World Health Organization Quality of Life-Bref (WHOQoL-Bref) for Portuguese healthy older people.

**Methods**

An exploratory cross-sectional study was conducted. Participants were recruited from the community. Functionality was assessed with the 5STS [4, 10] and 10MWT [5, 11] and Health-related Quality of Life (HRQoL) with the WHOQoL-Bref (scores: 0-20 and 0-100) [6]. Descriptive statistics was used to determine normative scores by age decades (60-69; 70-79; 80-89 years) and gender. Differences between age and gender were explored with multiple comparison tests using the Bonferroni correction.

**Results**

118 older people (76.2 ± 8.9yrs; n = 79, 66.9% female) participated in this study. Mean scores of 5STS (9.4 ± 3.5s; 13.0 ± 4.9s; 16.7 ± 6.7s), 10MWT (5.4 ± 2.1s; 6.5 ± 3.1s; 12.4 ± 5.9s) increased with age. Mean scores of the different domains of the WHOQoL-Bref 0-20 scale: physical health (15.9 ± 2.6; 15.1 ± 2.2; 13.6 ± 2.3), psychological (15.6 ± 2.6; 15.0 ± 2.3; 13.9 ± 1.9), social relationships (15.8 ± 2.8; 14.6 ± 2.4; 13.5 ± 2.4), environment (16.4 ± 2.3; 16.0 ± 2.3; 15.1 ± 1.6) decreased with age. Similar findings were observed in the WHOQoL-Bref 0-100 scale: physical health (74.6 ± 16.4; 69.3 ± 13.5; 60.4 ± 14.2), psychological (72.6 ± 16.4; 68.4 ± 14.5; 61.8 ± 12.1), social relationships (73.6 ± 17.6; 66.4 ± 15.2; 59.6 ± 15.2) and environment (77.6 ± 2.3; 74.9 ± 14.6; 69.4 ± 10.2). Females showed worst results in all measures. Mean scores of most measures were significantly different among age decades and gender (p < 0.05).

**Conclusions**

This study provided normative values of 5STS, 10MWT and WHOQoL-Bref for the Portuguese healthy older people. These data may improve the utility of these measures for health professionals to screen people and develop tailored interventions to improve functionality and HRQoL in this population. Normative values of WHOQoL-Bref will also allow identifying vulnerable groups and describing the profile of HRQoL in Portuguese healthy older people living in the community.

**Acknowledgements**

This work was partial supported by Programa Operacional de Competitividade e Internacionalização (COMPETE), through Fundo Europeu de Desenvolvimento Regional (FEDER) and Fundação para a Ciência e Tecnologia (FCT) under the project UID/BIM/04501/2013.

**References**

1. WHO. Global health and aging. Geneva: World Health Organization. 2011.

2. Ageing H. Keystone for a Sustainable Europe-EU Health Policy in the Context of Demogr aphic Change. European Comission. 2007.

3. Fuchs J, Scheidt-Nave C, Hinrichs T, Mergenthaler A, Stein J, Riedel-Heller SG, et al. Indicators for healthy ageing—a debate. International journal of environmental research and public health. 2013;10(12):6630-44.

4. Marques A, Almeida S, Carvalho J, Cruz J, Oliveira A, Jácome C. Reliability, Validity, and Ability to Identify Fall Status of the Balance Evaluation Systems Test, Mini-Balance Evaluation Systems Test, and Brief-Balance Evaluation Systems Test in Older People Living in the Community. Arch Phys Med Rehabil. 2016;97(12):2166-73.

5. Marques A, Cruz J, Quina S, Regêncio M, Jácome C. Reliability, Agreement and Minimal Detectable Change of the Timed Up & Go and the 10-Meter Walk Tests in Older Patients with COPD. COPD: Journal of Chronic Obstructive Pulmonary Disease. 2016;13(3):279-87.

6. Huang T, Wang W. Comparison of three established measures of fear of falling in community-dwelling older adults: psychometric testing. Int J Nurs Stud. 2009;46(10):1313-9.

7. Rothstein JM, Echternach JL. Primer on measurement: an introductory guide to measurement issues, featuring the American Physical Therapy
Association's standards for tests and measurements in physical therapy practice: Amer Physical Therapy Assn; 1993.

8. Bohannon RW, Andrews AW. Normal walking speed: a descriptive meta-analysis. Physiotherapy. 2011;97(3):182-9.

9. Mitrushina M, Boone KB, Razani J, D'Elia LF. Handbook of normative data for neuropsychological assessment: Oxford University Press; 2005.

10. Bohannon R. Reference values for the five-repetition sit-to-stand test: a descriptive meta-analysis of data from elders. Percept Mot Skills. 2006;103(1):215-22.

11. Bohannon R. Comfortable and maximum walking speed of adults aged 20-79 years: reference values and determinants. Age Ageing. 1997;26(1):15-9.

## Keywords

Normative values, Functionality, Quality of Life, Portuguese healthy older people.

## O18

### Relationship between balance and functionality, gait speed, physical activity and quality of life in community-dwelling older people

Sara Almeida¹,², Cátia Paixão¹, Alda Marques¹,²

¹Respiratory Research and Rehabilitation Laboratory, School of Health Sciences, University of Aveiro, 3810-193 Aveiro, Portugal; ²Institute for Research in Biomedicine, University of Aveiro, 3810-193 Aveiro, Portugal

**Correspondence:** Alda Marques (amarques@ua.pt)

BMC Health Services Research 2018, **18**(Suppl 2):O18

### Background

Balance is a modifiable risk factor for falls which represent a major public health problem for healthy ageing [1]. Predictors of healthy ageing in older people (i.e., functionality, gait speed, physical activity (PA) and health-related quality of life (HRQoL)) have been correlated with balance measures [2-5]. However, most balance measures do not assess the different components of balance hindering the design of interventions. To overcome this difficulty the Balance Evaluation System Test (BESTest) [6] and its short versions [7, 8] (new comprehensive measures of balance) were developed. Nevertheless, the relationship between the BESTest [6] and its short versions [7, 8] with functionality, gait speed, physical activity and health-related quality of life older people living in the community is still unknown.

### Objective

To explore the relationship between the BESTest, Mini-BESTest and Brief-BESTest with functionality, gait speed, PA and HRQoL in community-dwelling older people.

### Methods

An exploratory cross-sectional study was conducted. Community-dwelling older people (> 60 yrs) were recruited. Balance was assessed with the BESTest, Mini-BESTest and Brief-BESTest, functionality with the 5STS [9], gait speed with the 10MWT [10], PA with the Brief-PA questionnaire [11] and HRQoL with the WHOQoL-Bref [12]. Descriptive statistics was used to characterize the sample. Correlations were explored with the Spearman correlation coefficient. By convention, the interpreting size of a correlation coefficient was negligible (0.00-0.30), low (0.30-0.50), moderate (0.50-0.70), high (0.70-0.90) and very high (0.90-1.00) correlation [13].

### Results

One hundred and eighteen older people living in the community (76.2 ± 8.9 years; n = 79, 66.9% female) participated in this study. On average participants were overweight, with high body mass index (male: 26.9 ± 4.2 kg/m²; female: 26.8 ± 4.3 kg/m²) and fat-free mass (male: 29.5 ± 6.3 %; female: 37.6 ± 6.2%). BESTest, Brief-BESTest and Mini-BESTest were I) low and negatively correlated with intense (-0.34; -0.37; -0.32, respectively) and moderate (-0.37; -0.37; -0.35, respectively) PA; II) moderate and negatively correlated with the 5STS (-0.51; -0.61; -0.59, respectively); III) moderate to high and negatively correlated with the 10MWT (-0.69; -0.77; -0.78) and IV) negligible to moderate and positively correlated with the WHOQoL-Bref domains (I-Physical health 0.46; 0.57; 0.53; II-Psychological 0.47; 0.52; 0.53; III-Social relationships 0.32; 0.36; 0.28; IV-Environment 0.46; 0.51; 0.46).

## Conclusions

This study shows that there is a relationship between the BESTest and its short versions with functionality, gait speed and HRQoL in community-dwelling older people. Higher correlations were found in the short versions, especially with functionality measures. This is useful for clinical practice since these versions are simpler, require less material and are quicker to apply.

## Acknowledgements

This work was partially supported by Programa Operacional de Competitividade e Internacionalização (COMPETE), through Funfo Europeu de Desenvolvimento Regional (FEDER) and Fundação para a Ciência e a Tecnologia (FCT) under the project UID/BIM/04501/2013.

## References

1. WHO. Falls: fact sheet. Geneva; 2016.

2. Iwakura M OK, Shibata K, Kawagoshi A, Sugawara K, Takahashi H, et al. Relationship between balance and physical activity measured by an activity monitor in elderly COPD patients. Int J Chron Obstruct Pulmon Dis. 2016;11:1505-14.

3. Ozcan A DH, Gelecek N, Ozdirenc M, Karadibak D. The relationship between risk factors for falling and the quality of life in older adults. BMC Public Health. 2005;5:90.

4. Spagnuolo D JS, Iwama Å, Dourado V. Walking for the Assessment of Balance in Healthy Subjects Older than 40 Years. Gerontology. 2010;56(5):467-73.

5. Nilsagård Y AM, Carling A, Vesterlin H. Examining the validity and sensitivity to change of the 5 and 10 sit-to-stand tests in people with multiple sclerosis. Physiotherapy Research International. 2017;22(4):e1681.

6. Horak F, Wrisley D, Frank J. The Balance Evaluation Systems Test (BESTest) to Differentiate Balance Deficits. Phys Ther. 2009;89(5):484-98.

7. Franchignoni F, Horak F, Godi M, Nardone A, Giordano A. Using psychometric techniques to improve the Balance Evaluation Systems Test: the mini-BESTest. Journal of rehabilitation medicine. 2010;42(4):323-31.

8. Padgett P, Jacobs J, Kasser S. Is the BESTest at its best? A suggested brief version based on interrater reliability, validity, internal consistency, and theoretical construct. Phys Ther. 2012;92(9):1197-207.

9. Goldberg A, Chavis M, Watkins J, Wilson T. The five-times-sit-to-stand test: validity, reliability and detectable change in older females. Aging Clin Exp Res. 2012;24(4):339-44.

10. Peters D, Fritz S, Krotish D. Assessing the Reliability and Validity of a Shorter Walk Test Compared With the 10-Meter Walk Test for Measurements of Gait Speed in Healthy, Older Adults. J Geriatr Phys Ther. 2013;36(1):24-30.

11. Marshall A, Smith B, Bauman A, Kaur S. Reliability and validity of a brief physical activity assessment for use by family doctors. Br J Sports Med. 2005;39(5):294-7.

12. Kluthcovsky A, Kluthcovsky F. O WHOQOL-bref, um instrumento para avaliar qualidade de vida: uma revisão sistemática. Revista de Psiquiatria do Rio Grande do Sul. 2009;31(3).

13. Mukaka M. A guide to appropriate use of Correlation coefficient in medical research. Malawi Med J. 2012;24(3):69-71.

## Keywords

Correlations, Balance, Healthy ageing predictors, Older people.

## O19

### Trends of hospitalization for chronic obstructive pulmonary disease in Brazil from 1998 to 2016

Bárbara O Gama, Andréia WB Silva, Fabiana O Gama, Giovanna G Vietta, Márcia R Kretzer
University of Southern Santa Catarina, Campus Pedra Branca, 88137-270 Palhoça, Santa Catarina, Brazil

**Correspondence:** Bárbara O Gama (barbara.oenning@hotmail.com)

BMC Health Services Research 2018, **18**(Suppl 2):O19

### Background

Chronic Obstructive Pulmonary Disease (COPD) is a major public health problem. In Brazil, it is the fifth largest cause of hospitalization
in the public health system when analysing patients over 40 years of age.

**Objective**

To analyse the trend of hospitalization for COPD in Brazil from 1998 to 2016.

**Methods**

Trend analysis of hospitalization for COPD were based on data from the "Sistema de Informação Hospitalar do Departamento de Informática do Sistema Único de Saúde" (DATASUS). Simple linear regression analysis, p < 0.05. Approved by the Ethics Committee of the Universi-dade do Sul de Santa Catarina (UNISUL).

**Results**

In the period, 3,403,536 hospitalizations for COPD were analysed in Brazil, with a strong tendency to reduce rates (β= -6,257, p < 0.001), from 166.2/100,000 inhabitants in 1998 to 56.7/100,000 inhabitants in 2016. Among the Brazilian regions, there were higher hospitalization rates in the southern region, 461.8/100,000 inhabitants in 1998 and 133.1/100,000 inhabitants in 2016, followed by the central-west region, 222.2/100,000 inhabitants for 61,6/100,000 inhabitants. The region with the lowest rates of hospitalization was the northeast, with 69.6/100,000 inhabitants at 36.7/100,000 inhabitants. There largest decreases in the southern region (β= -19.4). The trend is decreasing in both sexes, with the largest reduction in male (β = -6,976), which has the highest admission rates at the beginning and end of the period (180.7 and 60.6/100.000 inhabitants, respectively). All age groups analysed showed a significant reduction tendency, with the largest decreases in the age groups above 60 years. In the age group of 80 years or more, there was reduction from 3370.1/100,000 in 1998 to 1535.3/100,000 inhabitants in 2016 (β = -101,198). In females, the reduction was from 2089.1/100,000 inhabitants to 548.4/100,000 inhabitants (β = -84,372).

**Conclusions**

The trend of hospitalization for COPD in Brazil is decreasing. The southern region has the highest rates, as does the male sex. The age groups of 60 and older in both sexes present the highest rates of hospitalization, with increase proportional to the increase in age. The results indicate a change in the profile of this disease, which can be attributed to a greater coverage of the family health strategy, better monitoring of diagnosed cases, and free access to medicines dispensed by the SUS (Sistema Único de Saúde), which reduce exacerbations of the cases.

**Keywords**

Chronic Obstructive Pulmonary Disease, Hospitalization, Trends.

O20

Temporal trend of hospitalization for acute myocardial infarction in the southern Brazilian states from 2008 to 2016

Jessica M Okabe, Bárbara O Gama, Pedro F Simão, Márcia Kretzer, Giovanna G Vietta, Fabiana O Gama
University of Southern Santa Catarina, Campus Pedra Branca, 88137-270 Palhoça, Santa Catarina, Brazil

Correspondence: Jessica M Okabe (jessica.okabe@gmail.com)

BMC Health Services Research 2018, **18**(Suppl 2):O20

**Background**

Acute Myocardial Infarction (AMI) is responsible for high hospitalization rates in Brazil Southern regions and represents one of the major causes of morbidity and mortality.

**Objective**

To analyse the temporal trend of hospitalization for AMI in the southern Brazilian states from 2008 to 2016.

**Methods**

Ecological study of time series of hospitalization for AMI, with data from the Hospital Information System provided by the Department of Informatics of the Single System (CID 10 - code I 21.9) in the resident population of the States of Paraná (PR), Santa Catarina (SC) and Rio Grande do Sul (RS), according to sex and age group. Simple linear regression was performed, with p < 0.05. Study approved by the Research Ethics Committee of the Southern University of Santa Catarina.

**Results**

In the analysed period, there were 154,828 hospitalizations in the South region. There was an upward trend in rates, with an average annual increase of 4,261 hospitalizations per AMI/100,000 inhabitants. At the beginning of the period a rate of 82.65/100,000 inhabitants was registered and at the end a rate of 118.67/100,000 inhabitants. The same trend was observed in the three southern states. Paraná presented a rate of 15.57/100,000 in 2008, to 24.89/100,000 in 2016 (β = 1.064; p = 0.002). In Santa Catarina the rate ranged from 17.11/100,000 in 2008 to 28.23/100,000 in 2016 (β = 1.159; p < 0.001). Rio Grande do Sul presented the highest rates among states, from 21.98/100,000 in 2008 to 30.57/100,000 in 2016 (β = 1.156; p < 0.001). Both sexes had an upward trend (male β = 15.732; p < 0.001; female β = 8.553; p < 0.001), with a variation from 279.32 (2008) to 418.46/100,000 inhabitants (2016) among men; and from 165.76 to 238.05/100,000 inhabitants among women. It was observed that the age groups between 40-49 years and 70-79 years, in both sexes, presented an upward tendency of hospitalization rates. In the male age group between 40 and 49 years, the increase in hospitalization rate was 368.56/100,000 in 2008 to 475.21/100,000 in 2016 (β = 10.553; p = 0.01). Between 70-79 years there was an increase of 10791.40/100,000 to 12458.46/100,000 in this same period (β = 160.084; p = 0.04). In the female age group between 40-49 years the increase in hospitalization rate was from 168.11/100,000 in 2008 to 210.63/100,000 in 2016 (β = 5.184; p = 0.02). And between 70-79 years there was an increase from 4452.09/100,000 to 5130.12/100,000 in this same period (β = 78.868; p = 0.02).

**Conclusions**

The study showed an upward trend in hospitalization rates for AMI in the Southern Region, by sex and age groups above 30 years for both sexes. Males present the highest rates.

**Keywords**

Acute myocardial infarction, Trend, Hospitalization.

O21

Temporal trend of the incidence of tuberculosis in the state of Santa Catarina from 2001 to 2015

Rafaela F Abreu, Bárbara O Gama, Pedro F Simão, Giovanna G Vietta, Márcia Kretzer, Fabiana O Gama
University of Southern Santa Catarina, Campus Pedra Branca, 88137-270 Palhoça, Santa Catarina, Brazil

Correspondence: Rafaela F Abreu (rafaelafujii@hotmail.com)

BMC Health Services Research 2018, **18**(Suppl 2):O21

**Background**

World Health Organization (WHO) declared Tuberculosis (TB) as a global public health emergency. TB control is a priority in Brazil.

**Objective**

To analyse the temporal trend of incidence of Tuberculosis in the State of Santa Catarina from 2001 to 2015.

**Methods**

Ecological study of time series of TB incidence trends selected from the SINAN (Information System for Notifiable Diseases) of the Ministry of Health in the population residing in the State, by sex, age group and macro-regions. Simple linear regression was performed, p < 0.05. Study approved by the Research Ethics Committee of the Southern University of Santa Catarina.

**Results**

From 2001 to 2015, 30,213 TB cases were confirmed in Santa Catarina, with a steady trend in incidence rates, with 31.2/100,000 inhabitants in 2001 and 32.0/100,000 inhabitants in 2015 (p = 0.27). The male gender presented the highest rates, showing a strong tendency to increase, with an increase of 0.456 per year, ranging from 42.24/100,000 inhabitants in 2001 to 47.55/100,000 inhabitants, in the year 2015 (p < 0.001). In the male groups, aged from 0 to 19 years and from 20 to 29 years, a significant trend occurred in the increase of incidence rates, with an increase of 0.159 and 0.606, respectively, of the rate (p = 0.02) per year. The age group from 40 to 49 years, in turn, showed a decreasing trend, with a reduction of 1.292 in the
incidence rate per year (p = 0.001). In females, there was a reduction of 0.802 in the rate per year in the age group of 20 to 29 years (p = 0.003). The macro-regions of the Midwest, Foz do Rio Itajaí and Plat- eau Norte presented a reduction in TB incidence rates. In the macro- regions of Greater Florianópolis and South, the trend was increasing (p < 0.05).

### Conclusions

TB incidence rates in Santa Catarina are stationary. Growing trend in males. Growing trend in the male age groups up to 29 years and de- creasing between 40 and 49 years. Decreasing trend in the female age group from 20 to 29 years. Macro-regions located in the coastal range have an increasing tendency and the macro-regions located in the Centre West of the State, a decreasing trend.

### Keywords

Tuberculosis, Trend, Incidence.

## O22

### Trauma, impulsivity, suicidality and binge eating

Ana C Ribeiro, Mariana Marques, Sandra Soares, Pedro Correia, Cidália Alves, Paula Silva, Laura Lemos, Sónia Simões
Instituto Superior Miguel Torga, 3000-132 Coimbra, Portugal

**Correspondence:** Ana C Ribeiro (anaclaudia_aac@hotmail.com)

BMC Health Services Research 2018, **18**(Suppl 2):O22

### Background

Binge eating is a public health problem with physical and psycho- logical effects, throughout life. Several studies explored the associ- ation between some variables (e.g. shame) and binge eating symptoms, but it is important to continue exploring the contribution of other correlates.

### Objective

Explore the association and the predictive role of traumatic experi- ences, impulsivity and suicidality with/to binge eating symptoms.

### Methods

421 subjects from the general population and college students (women, n = 300, 71.3%) completed the Traumatic Events Checklist, the Binge Eating Scale, the Barratt Impulsiveness Scale and the Suicidality Scale.

### Results

The values of punctual prevalence of binge eating symptoms were similar to those from recent national studies, having found a severe severity of 2.6% in the total sample (3.3% in women). In both gen- ders, suicidality total score and the body mass index (BMI) associated with binge eating total score. Only in women this score correlated with sexual and family trauma total scores and with the total score of traumatic events. If in men suicidality total score associated with family trauma total score and with the total score of traumatic events; in women that score also correlated with sexual trauma total score. In men, binge eating total score associated to attentional im- pulsivity (one of the first order impulsivity factors) and, in women, to all the first order impulsivity factors (attentional impulsivity, motor and non-planning), and with all the second order impulsivity factors (psychological attention, cognitive instability, motor, self-control and cognitive complexity), with the exception of perseverance. In women, attentional impulsivity particularly associated with sexual and family trauma total scores and with the total score of traumatic experiences. In women, the BMI, suicidality and attentional impulsivity total scores were the binge eating total score predictors.

### Conclusions

In a sample from the general population and college students, we found that it is salient and of importance for future interventions, mainly in women, the predictive role of BMI, suicidality and atten- tional impulsivity scores to binge eating symptoms, with traumatic events (a more distal correlate) revealing significant associations, but not predicting these symptoms.

### Keywords

Traumatic events, Impulsiveness, Suicidality, Binge eating.

## O23

### Computerised respiratory sounds during acute exacerbations of chronic obstructive pulmonary disease

Ana Oliveira¹,²,³, Patrícia Rebelo²,³, Lídia Andrade⁴, Carla Valente⁴, Alda Marques²,³

¹Faculty of Sports, University of Porto, Porto,4200-450 Portugal;

²Respiratory Research and Rehabilitation Laboratory, School of Health Sciences, University of Aveiro, 3810-193 Aveiro, Portugal; ³Institute for Research in Biomedicine, University of Aveiro, 3810-193 Aveiro, Portugal;

⁴Pulmonology Department, Baixo Vouga Hospital Center, 3810-501 Aveiro, Portugal

**Correspondence:** Ana Oliveira (alao@ua.pt)

BMC Health Services Research 2018, **18**(Suppl 2):O23

### Background

Timely treatment and adequate monitoring of acute exacerbations of chronic obstructive pulmonary disease (AECOPD) have shown to re- duce hospital admissions and recovery time, while improving pa- tients' quality of life [1]. Nevertheless, this is challenging as AECOPD diagnosis/monitoring relies exclusively on patients' reports of symp- toms worsening [2]. AECOPD are characterised by an increased air- way inflammation and obstruction, abnormal bronchial mucus and air trapping, which results in changes in lung acoustics [2,3]. Thus, changes in respiratory mechanics related with AECOPD may be suc- cessfully monitored by respiratory sounds, namely adventitious re- spiratory sounds (ARS, crackles and wheezes) [3]. Nevertheless, little is known on ARS changes during the time course of AECOPD.

### Objective

To evaluate ARS changes during the time course of AECOPD.

### Methods

25 non-hospitalised patients with AECOPD (16 males, 70.0 ± 9.8yrs, FEV1 54.2 ± 20.6% predicted) were enrolled. Patients were treated with pharmacological therapy. ARS at anterior and posterior right/left chest were simultaneously recorded at hospital presentation (T1) and at weeks 3 (T3) and 8 (T8). ARS (no. of crackles and wheeze occupation rate-%Wh) were processed, per respiratory phase, using validated algo- rithms [4,5]. Differences were examined with Friedman and Cochran tests and both tests were corrected with Bonferroni corrections.

### Results

Significant differences were found in no. of inspiratory crackles (0.6 [0.1-2.2] vs. 0.5 [0.1-2.5] vs. 0.3 [0.0-0.9]; p = 0.008) in T1, T3 and T8 at posterior chest, namely participants presented more inspiratory crackles (p = 0.013) at T1 than at T8. Similar results were found for in- spiratory %Wh (0.0 [0.0-12.3] vs. 0.0 [0.0-0.0] vs. 0.0 [0.0-0.0]; p = 0.019), namely, participants presented significantly more inspiratory %Wh at T1 than at T3 (p = 0.006). A significant higher number of par- ticipants presenting inspiratory wheezes was found at T1 than at T3 at the anterior chest (%Wh: 10 vs. 2 vs. 5; p=0.017) and a trend to significance was found at posterior chest (%Wh: 10 vs. 3 vs. 4; p = 0.052). No differences were found for the remaining variables.

### Conclusions

Crackles and wheezes seem to be sensitive to monitor the course of AECOPD. Inspiratory crackles seem to persist until 15 days after the exacerbations (i.e., approximate time needed to resolve AECOPD [6]) whilst inspiratory %Wh significantly decreased after this period. This information may allow further advances in the monitoring of patients with COPD across all clinical and non-clinical settings, as respiratory sounds are simple, non-invasive population-specific and available by nearly universally means. Further studies with larger samples and in- cluding data collected before the AECOPD are needed to confirm these findings.

### References

1. Wilkinson TM, Donaldson GC, Hurst JR, Seemungal TA, and Wedzicha JA. Early therapy improves outcomes of exacerbations of chronic obstructive pulmonary disease. Am J Respir Crit Care Med 169: 1298-1303, 2004.

2. The Global Initiative for Chronic Obstructive Lung Disease. Global Strategy for Diagnosis, Management, and Prevention of 543 Chronic
Obstructive Pulmonary Disease—2017 Report. The 544 Global Initiative for Chronic Obstructive Lung Disease, Inc.; 2017.

3. Gavriely N, Nissan M, Cugell DW, Rubin AH. Respiratory health screening using pulmonary function tests and lung sound analysis. Eur Respir Rev. 1994;7(1):35-42.

4. Pinho C, Oliveira A, Jácome C, Rodrigues JM, Marques A. Integrated approach for automatic crackle detection based on fractal dimension and box filtering. IJRQEH. 2016;5(4):34-50.

5. Taplidou SA, Hadjileontiadis LJ. Wheeze detection based on time-frequency analysis of breath sounds. Comput Bio Med. 2007;37(8):1073-83.

6. Seemungal TA, Donaldson GC, Bhowmik A, Jeffries DJ, Wedzicha JA. Time course and recovery of exacerbations in patients with chronic obstructive pulmonary disease. Am J Respir Crit Care Med. 2000; 161(5): 1608-1613.

**Keywords**

Chronic Obstructive Pulmonary Disease, Acute exacerbations, Computerised respiratory sounds, Crackles, Wheezes.

## O24

### Trauma, self-disgust and binge eating

Sandra Soares, Mariana Marques, Ana C Ribeiro, Pedro Correia, Cidália Alves, Paula Silva, Helena E Santo, Laura Lemos
Instituto Superior Miguel Torga, 3000-132 Coimbra, Portugal

**Correspondence:** Sandra Soares (sandra.soares.93@hotmail.com)
BMC Health Services Research 2018, **18**(Suppl 2):O24

### Background

Binge eating disorder is finally recognized in the current Diagnostic and Statistical Manual of Mental Disorders-5. Additionally, international and national studies explored correlate binge eating symptoms, but it is important to evaluate the role of other variables for these symptoms, in the general population.

### Objective

Explore the association and predictive role of traumatic experiences and of self-disgust with/in binge eating symptoms, exploring, also, the possible mediation role of self-disgust in the relation between traumatic experiences and those symptoms.

### Methods

421 subjects from the general population and college students (women, n = 300, 71.3%) completed the Traumatic Events Checklist, the Binge Eating Scale and the Multidimensional Self-disgust scale.

### Results

We found binge eating (BE) values similar to those from other national studies: mild to moderate BE (women: 6.3%; men: 5.0%) and severe BE (women: 3.3%; men: 0.8%). In men, BE total score positively correlated with defensive activation, cognitive-emotional and avoidance dimensions (self-disgust). Body mass index (BMI) positively correlated with BE total score and defensive activation (self-disgust) and negatively with family trauma. In women, BE total score positively associated with all self-disgust dimensions. Sexual trauma, family trauma, total of traumatic events and BMI positively associated with BE total score and all the self-disgust dimensions. In a hierarchical multiple regression analysis, BMI, total of traumatic events and the cognitive-emotional of self-disgust predicted BE total score. The cognitive-emotional (self-disgust) dimension mediated totally the relation between traumatic events and the BE total score.

### Conclusions

In a sample from the general population and college students, BE values were similar to those from national studies. In women, sexual trauma, family trauma and total traumatic experiences (and all self-disgust dimensions) associated with BE. A higher BMI was associated with higher BE levels. In future interventions focusing on BE, in women,

it seems important to consider the role of cognitive-emotional self-disgust in the relation between BE occurrence and distal traumatic events.

**Keywords**

Traumatic events, Self-disgust, Binge eating.

## O25

### New paediatric screening procedures: health promotion in primary care

Marisa Lousada¹,², Ana P Mendes³,⁴, Helena Loureiro¹,⁵, Graça Clemêncio⁶, Elsa Melo¹,⁵, Ana RS Valente¹
¹School of Health Sciences, University of Aveiro, 3810-193 Aveiro, Portugal; ²Center for Health Technology and Services Research, University of Aveiro, 3810-193 Aveiro, Portugal; ³Health Sciences School, Polytechnic Institute of Setúbal, 2914-503 Setúbal, Portugal; ⁴Centro Interdisciplinar de Investigação Aplicada em Saúde, Polytechnic Institute of Setúbal, 2914-503 Setúbal, Portugal; ⁵Health Sciences Research Unit: Nursing, Nursing School of Coimbra, 3046-851 Coimbra, Portugal; ⁶ACES Baixo Vouga, 3804-502 Aveiro, Portugal

**Correspondence:** Marisa Lousada (marisalousada@ua.pt)

BMC Health Services Research 2018, **18**(Suppl 2):O25

### Background

Screening procedures do not identify the specific disorder but allow a quick identification of children who may need a detailed assessment in speech therapy. Screening instruments are usually performed by different health professionals (e.g. pediatricians, nurses). The Child Health Program for primary care in Portugal determined that all 5-year-old children should be screened by nurses and general practitioners to conclude if they present a typical development suitable to school requirements. This screening is usually implemented through the Mary Sheridan test and there is no speech-language screening test used in primary care. Recently a Speech and Language Screening was validated for Portuguese children in kindergartens with excellent levels of specificity, sensitivity and reliability. RALF aims to quickly identify (5 minutes) children who may be at risk of speech-language impairment and need to be referred to a in depth assessment by a Speech-Language Therapist.

### Objectives

This study aims to implement a new screening procedure in primary health care contributing to best practices. Specifically, the study aims to identify children with speech-language disorder that are undiagnosed due to the absence of a known condition such as neurological, hearing or cognitive impairment.

### Methods

Ethical approval was granted by the Ethics Committee (UICISA) (ref.14/2016). A sociocultural questionnaire characterizing child and family background was fulfilled by caregivers to collect information about the child's background (e.g., mother language; neurological, hearing, cognitive disorder) and child's family background. Subject selection criteria included: Portuguese as native language and absence of a language disorder secondary to a known condition. The sample comprised 37 children whose parents returned informed consents. The screening was applied by 10 nurses in the Global Health Examination of 5 years old children in 2 health care centres.

### Results

Twenty-one percent of children failed the screening. This illustrates the high level of speech-language difficulties (without any other associated condition) and is consistent with previous research studies. The children that failed the screening were already been referred to speech-language services for a detailed assessment.

### Conclusions

This study highlights the importance of the implementation of a screening procedure in primary health care contributing to best practices.
**Acknowledgements**

Study supported by FEDER through POCI-01-0145-FEDER-007746 and FCT via CINTESIS, R&D Unit (ref. UID/IC/4255/2013).

**Keywords**

Screening, Speech and language, Health promotion.

**O26**

**Practices on using wearables during aquatic activities**

Henrique P Neiva¹,², Luís Fail¹, Mário C Marques¹,², Maria H Gil¹,², Daniel A Marinho¹,²

¹Department of Sport Sciences, University of Beira Interior, 6201-001 Covilhã, Portugal; ²Research Center in Sports Sciences, Health Sciences and Human Development, 6201-001 Covilhã, Portugal

**Correspondence:** Henrique P Neiva (henriquepn@gmail.com)

BMC Health Services Research 2018, **18**(Suppl 2):O26

**Background**

Several studies described the use of different sensors to detect the daily activity, movement and sleep patterns and physical activities [1]. These are easily available for all those who are interested in tracking physical activity and progresses to improve physical fitness and health-related parameters [1]. However, little is known about the people's knowledge about this equipment and specially in some specific activities that have some restrictions, for instance those performed in-water.

**Objective**

The purpose of this study was to characterize Portuguese practices on the use of wearable technology during aquatic activities.

**Methods**

Swimming pools from the interior region of Portugal were selected randomly and their users completed a questionnaire consisting of 33 questions. The first part focused on the characterization of their motivations and usual in-water activities, and the second focused on their views on the value of the wearable technology, its use and suggestions for future development of those devices according to aquatic activities.

**Results**

Ten swimming pools were accessed, and 418 questionnaires were filled by people ranging from 18 to 79 years-old. About 79% of these subjects have heard about wearables for sport, but 65% never used them during exercise. At the time of the inquiries, 24% still used and 11% gave up using it mainly because of lack of interest or because the devices did not work well underwater. Among the non-users, most reported that they did not have the opportunity (53%), considering that they are not useful (17%), or complaining about the financial cost (15%). However, most of them (74%) would be interested in trying this type of equipment during aquatic activities. Interestingly, 71% did not consider doing more exercise after they have the equipment. From those subjects using wearables, only a few (n = 24) used during in-water exercise.

**Conclusions**

For future, the devices should be more comfortable, be more reliable, be water resistant, with longer battery life. Besides the usual feed-backs provided, they also would like to see some technical corrections evidenced by that technology. People seemed to know about the existence of wearables to monitor physical activity but are still reluctant because of their underwater reliability, cost, and opportunity to try them. These results evidenced a need for improving these technological devices according to subjects needs and the activities performed. Some suggestions were made according to the future development of these devices to use during in-water exercitation.

**Acknowledgements**

NanoSTIMA: Macro-to-Nano Human Sensing Towards Integrated Multimodal Health Monitoring and Analytics, NORTE-01-0145-FEDER-000016, co-financed by FEDER-NORTE2020.

**References**

1. Chambers R, Gabbett TJ, Cole MH, Beard A. The use of wearable microsensors to quantify sport-specific movements. Sports Med. 2015, 45(7): 1065-1081.

**Keywords**

Technology, In-water activities, Sensors.

**O27**

**Does the recall of caregiver eating messages exacerbate the pathogenic impact of shame on eating and weight-related difficulties?**

Sara Oliveira, Cláudia Ferreira

Cognitive and Behavioural Centre for Research and Intervention, University of Coimbra, 3000-115 Coimbra, Portugal

**Correspondence:** Sara Oliveira (sara.oliveira.uc@gmail.com)

BMC Health Services Research 2018, **18**(Suppl 2):O27

**Background**

It has been recognized the central role of caregiver eating messages - restriction of food intake and pressures to eat - on later individual's eating behaviour, body image and weight status [1-3]. Additionally, shame is a painful emotion [4] also associated with the development and maintenance of body image and eating-related difficulties [5, 6], namely inflexible eating and concerns and maladaptive attitudes regarding body weight and shape [7].

**Objective**

The main aim of the present study was to test whether recalling caregiver eating messages [3] moderates the association of external shame [8] with inflexible eating rules [7] and with concerns and maladaptive attitudes regarding body weight and shape [9,10].

**Methods**

The sample comprised 479 Portuguese women, aged between 18 and 60 (M = 25.66; SD = 8.50), who completed validated self-report measures. The relationship between the study variables was accessed by Pearson product-moment correlation and the moderator effect was tested through path analysis.

**Results**

Results revealed that caregiver restrictive/critical messages played a significant moderator effect on the relationships of external shame with inflexible eating rules, and with concerns and maladaptive attitudes regarding body weight and shape. These findings suggested that caregiver restrictive/critical eating messages exacerbated the impact of shame on these psychopathological outcomes, with the tested model accounting for 17% and 29% of the variance of inflexible eating rules and body weight and shape concerns, respectively. In addition, pressure to eat caregiver messages was not correlated with all variables examined. A graphical representation of the moderation analyses allowed to understand that, for the same levels of external shame, women who recall more caregiver restrictive/critical eating messages tend to adopt more inflexible eating rules and present greater concerns and maladaptive attitudes regarding body weight and shape.

**Conclusions**

These findings appear to offer important clinical and investigational implications, highlighting the importance of the development of efficient parental intervention approaches as a refuge against maladaptive eating regulation strategies.

**References**

1. Abramovitz BA, Birch LL. Five-year-old girls' ideas about dieting are predicted by their mothers' dieting. J Am Diet Assoc. 2000; 100: 1157-1163. doi: 10.1016/S0002-8223(00)00339-4.

2. Birch LL, Fisher JO. Mother's child-feeding practices influence daughters eating and weight. Am J Clin Nutr. 2000; 71: 1054-1061.

3. Kroon Van Diest A, Tylka T. The Caregiver Eating Messages Scale: Development and psychometric investigation. Body Image. 2010; 7:317-326. doi: 10.1016/j.bodyim.201006.002.

4. Gilbert P. What is shame? Some core issues and controversies. In: Gilbert P, Andrews B, editors. Shame: Interpersonal behavior, psychopathology and culture. New York: Oxford University Press; 1998. pp. 3-38.

5. Goss K, Gilbert P. Eating disorders, shame and pride: A cognitive behavioural functional analysis. In: Gilbert P, Miles J, editors. Body shame: Conceptualization, research & treatment. Hove, UK: Brunner Routledge; 2002. pp. 219-255.
6. Hayaki J, Friedman M, Brownell K. Shame and severity of bulimic symptoms. Eat Behav. 2002; 3:73-83. doi:10.1016/S1471-0153(01)00046-0.

7. Duarte C, Ferreira C, Pinto-Gouveia J, Trindade I, Martinho A. What makes dietary restraint problematic? Development and validation of the Inflexible Eating Questionnaire. Appetite. 2017; 114:146-154. doi: 10.1016/j appet.2017.03.034.

8. Matos M, Pinto-Gouveia J, Gilbert P, Duarte C, Figueiredo C. The Other As Shamer Scale - 2: Development and validation of a short version of a measure of external shame. Personal Individ Differ. 2015; 74:6-11. doi: 10.1016/j.paid.2014.09.037.

9. Fairburn CG, Beglin SJ. Assessment of eating disorders: interview of self report questionnaire? Int J Eat Disord. 1994; 16(4):363-370. doi:10.1002/1098-108X(199412).

10. Machado PP, Martins C, Vaz AR, Conceição E, Bastos AP, Gonçalves S. Eating Disorder Examination Questionnaire: psychometric properties and norms for the Portuguese population. Eur Eat Disord Rev. 2014; 22(6):448-453. doi:10.1002/erv.2318.

Keywords

Caregiver eating messages, External shame, Inflexible eating rules,
Eating disordered, Women.

O28

How does shame mediate the link between a secure attachment
and negative body attitudes in men?

Sara Oliveira, Cláudia Ferreira

Cognitive and Behavioural Centre for Research and Intervention,
University of Coimbra, 3000-115 Coimbra, Portugal

Correspondence: Sara Oliveira (sara.oliveira.uc@gmail.com)

BMC Health Services Research 2018, **18**(Suppl 2):O28

Background

Shame is a painful self-conscious and universal emotion [1] regarded
as a central feature of the development and maintenance of body
image difficulties [2]. Additionally, it's known the association between
attachment style and body concerns, among women [3]. Particularly,
a secure attachment may promote a more favourable body image
[4]. However, few studies have focused on mechanisms that may ex-
plain body image difficulties in men.

Objective

The present study tested a model which hypothesized that the im-
pact of a secure attachment on the engagement in negative male
body attitudes, namely attitudes towards their muscularity and body
fat [5, 6], is carried by general feelings of shame [7], while controlling
the effect of body mass index.

Methods

The sample comprised 133 men, aged between 18 and 60 years old (M = 28.83; SD = 10.24), who completed validated self-report measures. The relationship between the study variables was accessed by Pearson product-moment correlation and the mediator effect was conducted through path analysis.

Results

The tested path model explained 22% and 49% of negative male at-
titudes towards their muscularity's and low body fat's variance, re-
spectively. Results demonstrated that a secure attachment presented
a significant direct effect on attitudes towards body fat, and an indir-
ect effect through external shame on attitudes towards muscularity.
In fact, these findings seem to suggest that men who were secure in
attachment tend to experience less general feelings of shame and,
consequently, presented low negative body attitudes, namely in
regards to their muscularity and body fat.

Conclusions

These data support the relevance of addressing shame experiences
when working with men with body image related-difficulties, espe-
cially in a context of early adverse experiences in their attachment.

References

1. Gilbert P. What is shame? Some core issues and controversies. In: Gilbert P, Andrews B, editors. Shame: Interpersonal problems, psychopathology and culture. New York: Oxford University Press; 1998. pp.3-3.

2. Goss K, Gilbert P. Eating disorders, shame and pride: A cognitive behavioural functional analysis. In Gilbert P, Miles J, editors. Body shame: Conceptualization, research & treatment. Hove, UK: Brunner Routledge; 2002. pp. 219-255.

3. Sharpe TM, Killen JD, Bryson SW, Shisslak CM, Estes LS, Gray N, et al. Attachment style and weight concerns in preadolescent and adolescent girls. Int J Eat Disord. 1998; 23(1):39-44.

4. Cash T. Cognitive-behavioral perspectives on body image. In: Cash T, Pruzinsky T, editors. Body image: A handbook of theory, research, and clinical practice. New York: The Guilford Press; 2002. pp.38-36.

5. Tylka TL, Bergeron D, Schwartz JP. Development and psychometric evaluation of the Male Body Attitudes Scale (MBAS). Body Image. 2005; 2(2):161-175. doi: 10.1016/j.bodyim.2005.03.001.

6. Ferreira C, Oliveira S, Marta-Simões J. Validation and psychometric proper-
ties of Portuguese Version of Male Body Attitudes Scale-Revised (MBAS-
R). Manuscript in preparation, 2017.

7. Matos M, Pinto-Gouveia J, Gilbert P, Duarte C, Figueiredo C. The Other As Shamer Scale - 2: Development and validation of a short version of a measure of external shame. Personal Individ Differ. 2015; 74:6-11. doi:10.1016/j.paid.2014.09.03.

Keywords

Secure attachment, External shame, Negative body attitudes, Men.

O29

Potential contamination of tourniquets used in peripheral
venipuncture: preliminary results of a scoping review

Anabela S Oliveira¹, Pedro Parreira¹, Nádia Osório², Paulo Costa¹, Vânia
Oliveira¹, Fernando Gama³, João Graveto¹

¹Health Sciences Research Unit: Nursing, Nursing School of Coimbra, Coimbra, 3046-851, Portugal; ²Coimbra Health School, Polytechnic Institute of Coimbra, Coimbra, 3046-854, Portugal; ³Coimbra Hospital and University Centre, 3000-075 Coimbra, 3000-075, Portugal

Correspondence: João Graveto (jgraveto@esenfc.pt)

BMC Health Services Research 2018, **18**(Suppl 2):O29

Background

Peripheral venipuncture constitutes one of the most frequent and in-
vasive clinical procedures performed in healthcare settings [1-2]. In
order to stop blood flow and promote vascular distension, the use of
a tourniquet five to ten centimetres above the desired puncture site
is recommended [3]. The irregular management of these specific
medical devices, without complying with guidelines, constitutes a
risk of microorganism dissemination [4-5].

Objective

To map the available evidence on the microbiological contamination of tourniquets used in peripheral venipuncture, identifying recurrent practices in their manipulation.

Methods

Scoping review based on the principles advocated by Joanna Briggs Institute [6]. The analysis of relevance of the articles, the extraction and synthesis of data was performed by two independent reviewers. The search strategy included all articles published until November 2017, written in Portuguese, Spanish, French and English.

Results

An initial total of 2,052 articles derived from the search conducted. Through Endnote software, 998 duplicates were removed. The remaining 1,054 articles were screened by title and abstract. Of these, 33 articles were included for full-text analysis by two independent reviewers. During this process, the reference lists of all included articles were screened, which resulted in the inclusion of 3 new articles. Ten studies were excluded due to absence of microbiological data inclusion and 6 were excluded due to lack of full-text access and author's reply. Overall, a total of 1,337 tourniquets belonging to nurses, nursing assistants, doctors, phlebotomists and lab workers were analysed for microorganism contamination. A small number of studies verified that the same tourniquets were used continuously by professionals between 3 days to 104 weeks. Preliminary results evidenced contamination rates varying between 9% and 100%, composed by diverse microorganisms such as *Staphylococcus aureus*, *Escherichia coli*, *Pseudomonas aeruginosa*,
Enterococcus and Acinteobacter baumannii. Several of the included studies described conflicting practices during tourniquet manipulation by health professionals, especially when focused on domains such as hand hygiene before and after tourniquet use, glove usage during venipuncture, tourniquet cleaning and disinfecting, sharing tourniquets with other professionals and storage conditions. The most cited reason for tourniquet replacement in clinical settings was due to their loss by health professionals.

## Conclusions

As a contribution to clinical practice, it is expected that the mapping of the available scientific evidence regarding the potential contamination of these devices will appear as an informative contribution that supports the analysis of current practices in this field, promoting the implementation of quality assurance systems in health institutions.

## Acknowledgements

This protocol is part of the project "Transfer of technological innovations to nursing practice: a contribution to the prevention of infections", funded from the European Regional Development Fund, by the Operational Program Competitiveness and Internationalization of PORTUGAL 2020.

## References

1. Marsh N, Webster J, Mihala G, Rickard C. Devices and dressings to secure peripheral venous catheters: A Cochrane systematic review and meta-analysis. International Journal of Nursing Studies. 2017;67:12-19.

2. Oliveira AS. Intervenção nas práticas dos enfermeiros na prevenção de flebites em pessoas portadoras de cateteres venosos periféricos: um estudo de investigação-ação [PhD thesis]. Universidade de Lisboa; 2014.

3. Veigar B, Henriques E, Barata F, Santos F, Santos I, Martins M et al. Manual de Normas de Enfermagem: Procedimentos Técnicos. 2nd ed. Administração Central do Sistema de Saúde, IP; 2011.

4. World Health Organization. Decontamination and reprocessing of medical devices for healthcare facilities. Geneva, Switzerland: WHO Document Production Services; 2016.

5. Costa P. Gestão de material clínico de bolso por enfermeiros: fatores determinantes e avaliação microbiológica [Masters dissertation]. Nursing School of Coimbra; 2017.

6. Peters M, Godfrey C, McInerney P, Baldini Soares C, Khalil H, Parker D. Chapter 11: Scoping Reviews. In: Aromataris E, Munn Z, ed. by. Joanna Briggs Institute Reviewer's Manual [Internet]. The Joanna Briggs Institute; 2017 [cited 14 December 2017]. Available from: https://reviewersmanual.joannabriggs.org/.

## Keywords

Tourniquets, Contamination, Peripheral venipuncture.

## O30

### Effects of a community-based food education program on nutrition-related knowledge in middle-aged and older patients with type 2 diabetes: a RCT

Carlos Vasconcelos<fnref n="1" />,<fnref n="2" />, António Almeida<fnref n="1" />, Maria Cabral³, Elisabete Ramos³,⁴, Romeu Mendes<fnref n="1" />,³,⁵

**Correspondence:** Romeu Mendes (romeuduartemendes@gmail.com)

BMC Health Services Research 2018, **18**(Suppl 2):O30

### Background

Peripheral Diabetes imposes an unacceptably high human, social and economic cost, especially on aging populations. Nutrition-related knowledge is of crucial importance to make healthier food choices, contributing for type 2 diabetes (T2D) control and related comorbidities prevention.

### Objective

To analyse the effects of a food education program (FEP) on the nutrition-related knowledge (NRK) in middle-aged and older patients with T2D.

### Methods

Forty-two individuals between 50 and 80 years old with T2D were recruited in primary health care institutions, to participate in Diabetes em Movimento®, a community-based exercise program (3 exercise sessions per week; 75 minutes each; during 9 months), developed in Vila Real, Portugal. Participants were randomized into two groups: a control group (CG; N = 19; exercise program only) and an experimental group (EG; N = 23; exercise program plus a FEP). The FEP was 16 weeks long and, on each week, a different nutrition-related theme was addressed. Each theme was driven through a theoretical session (15 minutes) and dual-task exercise strategies integrated in Diabetes em Movimento®'s sessions. The NRK was evaluated, before and after the 9-month intervention, using the Portuguese reduced version of Nutritional Knowledge Questionnaire (from 0 to 56 points; higher score, better knowledge).

### Results

Thirty-six participants completed the study (CG, N = 16; EG, N = 20). The baseline score was 30.19 ± 6.10 (CG) vs. 29.40 ± 6.16 points (EG). After the intervention, the score was 31.31 ± 7.40 (CG) vs. 35.20 ± 5.68 points (EG). A significant time*group interaction effect was identified (p = 0.001; η²p = 0.290). Considering the FEP's sessions adherence level (< 50% vs. ≥ 50%), a significant time*group interaction effect was also identified (baseline, 29.78 ± 7.84 [< 50%] vs. 29.09 ± 4.76 [≥ 50%]); after intervention, 32.78 ± 5.93 [50%] vs. 37.18 ± 4.85 [≥ 50%]; p = 0.004, η²p = 0.370).

### Conclusions

A community-based easy-to-implement food education program was effective in increasing NRK of middle-aged and older patients with type 2 diabetes and may contribute to better food choices. Program's adherence levels play a major role on knowledge acquisition.

### Trial Registration

NCT02631902

### Keywords

Type 2 diabetes; Food education program; Nutrition-related knowledge; Community-based intervention.

## O31

### Perception of oral antidiabetic agents adverse events and their impact on Health Related Quality of Life in type 2 diabetic patients

Rui S Cruz<fnref n="1" />, Luiz M Santiago<fnref n="2" />, Carlos F Ribeiro³

**Correspondence:** Rui S Cruz (ruic@estescoimbra.pt)

BMC Health Services Research 2018, **18**(Suppl 2):O31

### Background

Currently, drug therapy with oral antidiabetic agents, is capable of inducing normoglycemia levels able to decrease the risk of complications associated with diabetes mellitus. However, it is also known that the various existing oral antidiabetic agents may trigger a large number of adverse events, either alone or in combination. Some of these tolerability and security issues related to the oral antidiabetic are reported by patients and can influence negatively or satisfaction with treatment or glycaemic control, or the therapeutic adherence and maintenance. It is therefore very important the role of patients in monitoring adverse events related to the use of the oral antidiabetic drugs in order to optimize treatment and improve the quality of life of patients with type 2 diabetes (DM2).

### Objective

The aim of this study was to determine the prevalence of adverse events associated with use of oral antidiabetics and assessing their impact on Health-related Quality of Life (HRQoL) of diabetic patients tracked in primary health care.

### Methods

A total of 357 DM2 patients were enrolled in observational and cross-sectional study, recruited in six Health Care Centres/Family Health Units (FHU) of the central region of Portugal. Data collection

<footnote n="1">¹University of Trás-os-Montes e Alto Douro, 5000-801 Vila Real, Portugal;</footnote>

<footnote n="2">²Polytechnic Institute of Viseu, 3504-510 Viseu, Portugal; ³Instituto de Saúde Pública, Universidade do Porto, 4050-600 Porto, Portugal; ⁴Faculty of Medicine, University of Porto, 4200-319 Porto, Portugal; ⁵Public Health Unit, ACES Douro I - Marão e Douro Norte, 5000-524 Vila Real, Portugal</footnote>

<footnote n="1">¹Coimbra Health School, Polytechnic Institute of Coimbra, 3046-854</footnote>

<footnote>Coimbra, Portugal; ²Faculty of Medicine, University of Coimbra, 3004-504</footnote>

<footnote>Coimbra, Portugal; ³Department of Pharmacology and Experimental</footnote>

<footnote>Therapeutics, Faculty of Medicine, University of Coimbra, 3004-504</footnote>

<footnote>Coimbra, Portugal</footnote>
comprised three questionnaires to measure the prevalence of adverse events, the diabetes health profile (DHP-18) and EQ-5D-3L.

## Results

Results showed that the highest prevalence of adverse events is in the DipeptidylPeptidase-4 Inhibitors followed by Metformin+Sitagliptin (fixed dose) and Metformin+Vildagliptin (fixed dose) therapeutic classes. We also found that all correlations between different variables were statistically significant (p < 0.001).

## Conclusions

Thus, we conclude that patients who show a greater number of adverse events tend to have poorer health profiles, worse general health and also lower health-related quality of life.

## Keywords

Diabetes Medication, Therapy, Quality of Life.

## O32

### Third stage of waterbirth: observational study

Joyce CS Camargo<sup>1,2</sup>, Vitor Varela<sup>3</sup>, Elisabete Santos<sup>3</sup>, Natalcia M Araújo<sup>2</sup>, Kelly CMP Venâncio<sup>4</sup>, Manuela Néné<sup>5</sup>, Maria CLR Grande<sup>6</sup>
<sup>1</sup>Abel Salazar Institute of Biomedical Sciences of the University of Porto, 4200-135 Porto, Portugal; <sup>2</sup>School of Arts, Sciences and Humanities, University of São Paulo, 03828-000 São Paulo, Brazil; <sup>3</sup>São Bernardo Hospital, 2910-445 Setúbal, Portugal; <sup>4</sup>College of Nursing, University of São Paulo, 05403-000 São Paulo, Brazil; <sup>5</sup>Escola Superior de Saúde da Cruz Vermelha Portuguesa, 1350-125 Lisboa, Portugal; <sup>6</sup>Faculty of Psychology and Educational Sciences, University of Porto, 4200-135 Porto, Portugal

**Correspondence:** Joyce CS Camargo (joyce@usp.br)

BMC Health Services Research 2018, **18**(Suppl 2):O32

## Background

The placental-delivery, in waterbirth (WB), usually occurs while maternal wellbeing is monitored through clinical aspects, heart-rate and blood-pressure, as well as water-coloration. Adequate care should be taken in this period, with prevention of postpartum-haemorrhage(HPP), which is the main cause of maternal death in developing countries, and approximately ¼ of all maternal deaths worldwide [1].

## Objective

To verify the outcome of the labour's third stage at the Waterbirth-Project (PWB), in Setúbal, at São Bernardo's Hospital located in Portugal. Study's question: *What's the maternal outcome of childbirth's 3rd stage in PWB?*

## Methods

Observational-study, cross-sectional, descriptive based on ethical guidelines (CNPD-9885/2015) approved by the hospital, where delivery room's infrastructure, protocol's definition and technical and scientific training of the obstetric-team began in 2006. The PWB occurred between 2011-2014. 153 women, with a single pregnancy, gestational age ≥ 37 weeks with low-risk prenatal care participated in the PWB, signed an informed consent form about study's benefits and risks, resulting in 90 waterbirths. Data were collected from the specific PWB forms in April 2016. Data management was developed in Excel® and SPSS® version 16.0 programs.

## Results

In the PWB, 51.1% of women had placental waterbirth vs 48.9% out-of-water. The active management occurred in 7.7% vs 86.7% of physiological management, 92.3% of the women had physiological blood loss, and 7.7% had increased bleeding, controlled with uterotonics. These results corroborate with evidence: Swiss study [2], with 89 WB vs 279 out-of-water births, 57% had physiological defect in the water and the 3rd-Stage was significant (p < 0.01) in PA; English study [3] with 5,192 WB, with third physiological stage, 86.1% of which 55.8% were in water. For 3rd-Stage's management [4]: 1. Active: administration of uterotonic (oxytocin [1], 1st choice) after birth, timely clamping of the umbilical cord and controlled cord traction. 2. Physiological: Spontaneous relief assisted by gravity and/or maternal effort. In order to evaluate PPH in WB, in addition to the clinical state of the puerperium, the coloration of the comparison to wine is analysed: 50-100 ml blood loss to the pink-Chablis; from 150-250 ml to bleed and 500-750 ml to Merlot-wine [5] or, study-site midwife's

puts-hand below the surface of the water horizontally. If visible hand, haemorrhage ≤ 500mL, if hand not-visible, haemorrhage > 500mL.

## Conclusions

The 3rd-Stage's management in WB is safe and according to the experience of the PWB, no adverse events were related to it. More studies are needed to support good clinical practices based on scientific evidence.

## References

1. OMS. Recomendações da OMS para a prevenção e tratamento da hemorragia pós-parto. In: Saúde OMd, editor. 2014. p. 48.

2. Zanetti-Dallenbach RA, Lapaire O, Maertens A, Holzgreve W, Hosli I. Water birth, more than a trendy alternative: a prospective, observational study. Arch Gynecol Obstet. 2006;274(6):355-65.

3. Burns EE, Boulton MG, Cluett E, Cornelius VR, Smith LA. Characteristics, interventions, and outcomes of women who used a birthing pool: A prospective observational study. Birth. 2012;39(3):192-202.

4. ICM, FIGO. Prevention and Treatment of Post-partum Haemorrhage: New Advances for Low Resource Settings International Confederation of Midwives (ICM). International Federation of Gynaecology and Obstetrics (FIGO); 2006.

5. Harper B. Gentle Birth Choices. Revised Edition ©2005 Barbara Harper ed: Inner Traditions Bear and Company; 2005 August 09, 2005.

## Keywords

Childbirth's 3rd stage, Placental-delivery, Postpartum-haemorrhage, Waterbirth, Midwifery.

## O33

### Aqua apgar in waterbirth: cross-sectional study

Joyce CS Camargo<sup>1,2</sup>, Vitor Varela<sup>3</sup>, Elisabete Santos<sup>3</sup>, Maria AJ Belli<sup>2</sup>, Maryam MJ Trintinália<sup>2</sup>, Manuela Néné<sup>4</sup>, Maria CLR Grande<sup>5</sup>
<sup>1</sup>Abel Salazar Institute of Biomedical Sciences of the University of Porto, Portugal; <sup>2</sup>School of Arts, Sciences and Humanities, University of São Paulo, 03828-000 São Paulo, Brazil; <sup>3</sup>São Bernardo Hospital, 2910-445 Setúbal, Portugal; <sup>4</sup>Escola Superior de Saúde da Cruz Vermelha Portuguesa, 1350-125 Lisboa, Portugal; <sup>5</sup>Faculty of Psychology and Educational Sciences, University of Porto, 4200-135 Porto, Portugal

**Correspondence:** Joyce CS Camargo (joyce@usp.br)

BMC Health Services Research 2018, **18**(Suppl 2):O33

## Background

Waterbirth (WB) is the complete underwater fetal expulsion [1,2] with much discussion [3] about it. Aqua Apgar [4] is an index that evaluates the newborn's vitality (NB) while still submerged in water until life's first minute, developed by Cornelia Enning.

## Objective

To know the neonatal outcome of the Waterbirth Project (PWB) at a Setubal's (Portugal) Hospital, São Bernardo. Study's Question: *What is the neonatal outcome of new-borns born in PWB?*

## Methods

Cross-sectional study, observational, descriptive based on ethical guidelines (CNPD-9885/2015) approved by the hospital, whose delivery-room's infrastructure, protocol's definition and obstetric-team's technical and scientific training began in 2006. The PWB occurred between 2011-2014. 153 women with single pregnancy, gestational age ≥ 37 weeks with low-risk prenatal care participated in the PWB and signed an informed consent form about study's benefits and risks, resulting in 90 waterbirth. Data were collected from the specific PWB form in April 2016. Data management was developed in Excel® and SPSS® version 16.0 programs.

## Results

The 1st minute's Aqua Apgar and the 5th minute's Apgar were superior to 7 in all the cases, with an average of 9.4 at the 1st minute and 9.9 at the 5th minute. A cross-sectional-study in Sydney [5] observed minor Apgar and may be due to disregarding that water-born NB manifest their vitality by moving the legs and arms, opening and closing their eyes and mouth and swallowing [4]. A cohort study in the UK [6] corroborates our study that NB of aquatic birth were less likely to have a low Apgar score in the 5th minute. The use of Aqua
Apgar in our study allowed a coherent outcome in the NBs who is
kept submerged in water until life's first minute, with a soft transition
to extra uterine life and with no negative repercussions on heart rate
and absence of complication or neonatal hospitalization.

Conclusions

This study provides evidences that may support clinical decisions re-
garding delivery in water. Further studies on Aqua Apgar should be
conducted to support evidence-based practices.

References

1. Nutter, E., Meyer, S., Shaw-Batista, J. & Marowitz, A. (2014). Waterbirth: an integrative analysis of peer - reviewed literature. Journal of Midwifery & Women's Health. 59, (3), 286-319.

2. Cluett ER, Burns E. Immersion in water in labour and birth. Cochrane Database Syst Rev 2009;(2):CD000111.

3. ACOG. American College of Obstetricians & Gynecologists. (2014). Immersion in water during labor and delivery (Committee Opinion No. 594). Retrieved from http://www.acog.org/ Resources_And_Publications/ Committee_Opinions/ Committee_on_Obstetric_Practice/Immersion_in_ ater_During_Labor_and_Delivery 4.Garland D. Revisiting Watermirth: an attitude to care. 2011. Published by Palgrave Macmillan. ISBN 10: 0230273572 / ISBN 13: 978023273573

5. Bovbjerg M L; Cheyney M; Everson C. (2016). Maternal and Newborn Outcomes Following Waterbirth: The Midwives Alliance of North America Statistics Project, 2004 to 2009 Cohort. J Midwifery Womens Health. Jan-Feb;61(1):11-20. doi: 10.1111/jmwh.12394. Epub 2016 Jan 20.

6. Dahlen HG, Dowling H, Tracy M, Schmied V, Tracy S. (2013). Maternal and perinatal outcomes amongst low risk women giving birth in water compared to six birth positions on land. A descriptive cross sectional study in a birth centre over 12 years. Midwifery;29(7):759-64.

Keywords

Aqua Apgar, Waterbirth, Midwifery, Apgar, Childbirth.

O34

Portuguese centenarians from Oporto and Beira Interior:
distinctive health profiles?

Daniela Brandão¹,², Oscar Ribeiro¹,³, Rosa M Afonso¹,⁴, Constança Paúl¹,⁵
¹Center for Health Technology and Services Research, 4200-450 Porto,
Portugal; ²Faculty of Medicine, University of Porto, 4200-319 Porto,
Portugal; ³University of Aveiro, 3810-193 Aveiro, Portugal; ⁴University of
Beira Interior, 6201-001 Covilhã, Portugal; ⁵Institute of Biomedical
Sciences Abel Salazar, University of Porto, 4050-313 Porto, Portugal

**Correspondence:** Daniela Brandão (danielafsb BRANDÃO@gmail.com)

BMC Health Services Research 2018, **18**(Suppl 2):O34

Background

In Portugal, the number of centenarians almost tripled over the last
decade from 589 centenarians in 2001 to 1526 in 2011 [1], and re-
cent projections point to the existence of 3,393 centenarians in 2013
[2]. Reaching the age of 100, though an important landmark, does
not necessarily indicates successful aging as it is often accompanied
by severe health and functional constraints. Understanding health
trajectories of these long-lived individuals and studying the prevalence of diseases that are the most common causes of death is important for conveniently addressing their current caregiving needs.

Objective

The aim of this study is to present an overview of the sociodemo-
graphic and health-related characteristics of two distinct samples of
Portuguese centenarians (predominantly rural vs. predominantly urban)
and acknowledge potential dissimilarities.

Methods

A sample of 241 centenarians was considered (140 from the PT100 Oporto Centenarian Study and 101 from the PT100 Beira Interior Centenarian Study). Sociodemographic information, nature and number of diseases, functionality and physical health variables were collected.

Results

In both samples, most centenarians were female (89.3% in Oporto,
and 86.1% in Beira Interior), and widowed (76.4% in Oporto, 91.1% in

Beira Interior), and lived in the community (57.9% in Oporto, 49.0%
in Beira Interior). Higher levels of basic activities of daily living (BADL)
and instrumental activities of daily living (IADL) dependency were
found in the Oporto sample, as well as a higher percentage of bed-
ridden centenarians (61.0% in Oporto vs. 38.1% in Beira Interior). Sen-
sorial impairments and incontinence were the most frequent
conditions reported in both samples; however, lower percentages of
age-related illnesses were found in the Beira Interior sample. Consid-
ering the three most lethal diseases among the elderly population
(heart disease, non-skin cancer and stroke), 60.0% of centenarians in
Oporto escaped these conditions, whereas in Beira Interior this per-
centage increases to 85.4%.

Conclusions

This study provides a general overview about the health profile of
Portuguese centenarians in two types of communities: one rural and
with low population density, and another in an urban context. Our
findings raise important differences between centenarians from the
two samples, which reinforce the heterogeneity of this population,
and the importance of environmental factors in how such an ad-
vanced age was achieved. Findings highlight the need for potentially
distinctive health promotion initiatives in these two settings.

Acknowledgements

This work was supported by the Portuguese Foundation for Science and Technology (FCT) [PhD Grant for the first author - SFRH/BD/101595/2014]. The PT100 Oporto Centenarian Study was supported by the Portuguese Foundation for Science and Technology (FCT; Grant Pest - C/SAU/UI0688/ 2011 and C/SAU/UI0688/2014).

References

1. National Statistical Institute of Portugal, (INE). Censos - Resultados definitivos. Região Norte - 2011. Lisboa: Instituto Nacional de Estatística; 2012.

2. National Statistical Institute of Portugal (INE). Projeções de População Residente 2015-2080. Lisboa: Instituto Nacional de Estatística; 2017.

Keywords

Centenarians, Health, Functionality, Diseases, Portugal, Morbidity.

O35

Implementation of an educational program to promote functionality in medical wards: quasi-experimental study

João Tavares¹,², Joana Grácio³, Lisa Nunes³

¹Nursing School of Coimbra, Coimbra, 3046-851, Portugal; ²Coimbra Education School, Polytechnic Institute of Coimbra, 3030-329, Portugal;

³Coimbra Hospital and Universitary Centre, 3000-075 Coimbra, 3000-075, Portugal

**Correspondence:** João Tavares (enf.joaotavares@hotmail.com)

BMC Health Services Research 2018, **18**(Suppl 2):O35

Background

Functional decline, diminished performance in at least one activity of daily living, is often of 30 to 60% among hospitalized older adults (OA) [1]. Quality nursing care is essential to prevent functional decline. A “new” theoretically based philosophy of care has been proposed: the Function Focused Care (FFC), which is geared toward optimization of function and physical activity during all personal/care related activities that occur throughout the hospital stay [2]. The FFC has demonstrated better outcomes at discharge and post-acute periods.

Objective

To evaluate the effect of an educational program for nurses in pro-
moting the FFC among hospitalized OA.

Methods

This is a prospective quasi-experimental study developed in four in-
ternal medical units. These units were randomly selected in two units
for case (intervention) and two for control. Participants were 117 OA
and 94 registered nurses (RN). Intervention consisted in the develop-
ment and implementation of an educational program about FFC to
RN, lasting 10 hours, and a maintenance program, during 5 months.
Further details about the program can be found in Tavares et al [3]. Implementation of FFC activities by RN was assessed through the FFC Behaviour Checklist, which was completed by the researchers through non-participant observation [4]. The measures for patients were the functional decline (DF) assessed by the Katz Index: difference between baseline and discharge (t0), discharge and follow-up of 3 months (t1) and baseline and follow-up (t2). For comparison of the case and control groups, an independent t-test was calculated.

## Results

The patient's sociodemographic and clinical characteristics showed no statistical differences between groups. The provision of FFC mean was 0.46 ± 0.22, indicating that RN promoted only 46% of total possible FFC activities. Significant statistical differences were found between case and control group (t(91)= -2.85; p= 0.01), with means of 0.52 ± 0.24 and 0.39 ± 0.19, respectively. No statistical difference was found between the promotion of FFC and the functional decline at t0 (U = 30.5, p = 0.15), t1 (t(38.82) = 6.293; p< 0.15) or t2 (t(83) = 2.49, p = 0.44).

## Conclusions

Promotion of functionality is very low, which could be explained by the lack of impact in FD prevention. However, in the case group, more FFC activities were developed. These results suggest a positive impact of the educational program in OA care. The FFC can be seen as a challenge and opportunity for change, innovation, and creativity, in order to improve the effectiveness, efficiency, and quality of care of hospitalized OA.

## References

1. Hoogerduijn JG, Schuurmans MJ, Duijnstee MSH, De Rooij SE, Grypdonck MFH. A systematic review of predictors and screening instruments to identify older hospitalized patients at risk for functional decline. J Clin Nurs. 2007;16(1):46-57.

2. Burket TL, Hippensteel D, Penrod J, Resnick B. Pilot testing of the function focused care intervention on an acute care trauma unit. Geriatr Nurs. 2013;34(3):241-246.

3. Grácio J, Tavares JP de A, Nunes L, Silva R. Programa educacional para enfermeiros: eficácia de duas estratégias formativas. In: XI Congresso Internacional Galego-Português de Psicopedagogia, 2017; Braga: Universidade do Minho. Instituto de Educação. Centro de Investigação em Educação Universidade Minho, 2017; 540-541.

4. Tavares JP de A, Grácio J, Nunes L. Functional Focused care: content validity of Functional Focused Care Behavior Checklist. Eur Geriatr Med. 2016;7(supplement 1):S1-S282.

## Keywords

Function focused care, Older adults, Hospitalization functionality, Educational program.

## O36

### Self-reported data and its relation to the standard and validated measures to predict falls

Anabela C Martins, Catarina Silva, Juliana Moreira, Nuno Tavares Physiotherapy Department, Coimbra Health School, Polytechnic Institute of Coimbra, 3026-854 Coimbra, Portugal

**Correspondence:** Anabela C Martins (anabelamartins@estescoimbra.pt)
BMC Health Services Research 2018, **18**(Suppl 2):O36

### Background

According to National Institute for Health and Care Excellence quality standards, the assessment of fall risk and preventing falls should be multifactorial and include self-reported questions like fall history, fear of falling (FoF), self-perception of functional ability, environment hazards, gait pattern, balance, mobility and muscle strength [1]. Concerning the self-reported data, some studies described subjectivity and difficulty in extracting reliable information when using such methods. History and number of previous falls are often used as golden standard in fall risk assessment studies [2]; however, these questions are source of misjudgement, in part, due to difficulty for an older person remember exactly how many times he/she had fallen in a past period of time.

## Objective

The study aimed to compare self-reported questions and standard and validated measures for screening risk of fall to verify the confidence of the self-reported data.

## Methods

506 community-dwelling adults aged 50+ years old (mean age 69.56 ± 10.29 years old; 71.7% female) were surveyed regarding demographics, history of fall, FoF, sedentary lifestyle, use of upper-extremities to stand up from a chair, by self-reported questionnaire; analysis of gait, balance and muscle strength, by standard and validated measures for screening risk of fall - 10 meters walking speed test [3], Timed Up & Go test [4] and 30 second sit to stand test [4], respectively. Independent samples t tests were performed to compare groups.

## Results

33.2% of the sample reported at least one fall in the last year (fallers), 50% reported FoF, 46.4% sedentary lifestyle, 31.8% needed their upper extremities assistance to stand from a chair. Fallers demonstrated lower scores of gait velocity (p < 0.001), lower extremities strength (p < 0.001) and balance (p = 0.034) compared with non-fallers; who reported sedentary lifestyle also showed lower scores of gait velocity (p < 0.001), lower extremities strength (p = 0.001) and balance (p < 0.001) compared with non-sedentary. Simultaneously, who assumed FoF showed lower scores of gait velocity (p < 0.001), lower extremities strength (p < 0.001) and balance (p < 0.001) compared with who had no FoF. Finally, those who use the upper-extremities to stand up from a chair showed lower scores of gait velocity (p < 0.001), lower extremities strength (p < 0.001) and balance (p < 0.001) compared with those who do not.

## Conclusions

The findings suggest that self-reported data like history of falls, sedentary lifestyle, FoF and use of upper extremities to stand up from a chair, obtained by simple questions, have emerged as reliable information on risk factors for falling and can be used to complete the fall risk screening.

## Acknowledgements

Authors would like to thank all participants and centres, clinics and other entities hosting the screenings. Financial support from project FallSensing: Technological solution for fall risk screening and falls prevention (POCI-01-0247-FEDER-003464), co-funded by Portugal 2020, framed under the COMPETE 2020 (Operational Programme Competitiveness and Internationalization) and European Regional Development Fund (ERDF) from European Union (EU).

## References

1. NICE, National Institute for Health and Care Excellence. Falls in older people: assessing risk and prevention. Clinical Guideline, 2013 Available at: nice.org.uk/guidance/cg161 (faltam dados à referência)

2. Garcia AG, Dias JMDD, Silva SLA, Dias RC. Prospective monitoring and self-report of previous falls among older women at high risk of falls and fractures: a study of comparison and agreement. Braz J Phys Ther. 2015; 19(3).

3. Fritz S & Lusardi M. White paper: "walking speed: the sixth vital sign". J Geriatr Phys Ther. 2009; 32(2): 2-5.

4. Stevens JA. The STEADI tool kit: a fall prevention resource for health care providers. IHS Prim Care Provid. 2016, 39: 162-6.

## Keywords

Self-reported data, Fall Risk Assessment, Community dwelling adults.

## O37

### Life after falling: which factors better explain participation in community dwelling adults?

Juliana Moreira, Catarina Silva, Anabela C Martins
Physiotherapy Department, Coimbra Health School, Polytechnic Institute of Coimbra, 3026-854 Coimbra, Portugal

**Correspondence:** Juliana Moreira (juliana.moreira@estescoimbra.pt)
BMC Health Services Research 2018, **18**(Suppl 2):O37
## Background

Participation is defined by World Health Organization (WHO), as the person's involvement in a life situation [1]. There are few studies exploring the association between participation restriction and being older, exhibiting more depressive moods, poor mobility, and a lack of balance confidence [2,3].

## Objective

The objective of this study was to identify which factors, namely, age, functional capacity and self-efficacy for exercise have the best association with participation.

## Methods

A sample of 168 community-dwelling adults (age ≥50 years), mean age 70.45 ± 10.40 years old (78.6% female), with history of at least one fall in the previous year, participated in the study. Measures included demographic variables, functional capacity, assessed by six functional tests: Grip strength, Timed Up and Go (TUG), 30 seconds Sit-to-Stand, Step test, 4 Stage Balance “modified” and 10 meters Walking Speed and two questionnaires (Self-efficacy for exercise and Activities and Participation Profile related to Mobility - PAPM). Descriptive and correlational statistics were performed to analyse data.

## Results

Fifty-nine percent of participants presented restrictions in participation (34.8% mild restrictions, 17.4% moderate restrictions and 6.8% severe restrictions). Participation showed a strong correlation with 10 meters walking speed (r = -0.572) and TUG (r = 0.620) for a significance level p < 0.001. A moderate correlation was found between participation and 30 seconds Sit-to-Stand (r = -0.478), Step test (r = -0.436), Grip strength (r = -0.397), 4 Stage Balance test “modified” (r = -0.334), as well as, Self-efficacy for exercise (r = -0.401) and age (r = 0.330), for a significance level p < 0.001.

## Conclusions

This study suggests that participation of individuals with history of fall is associated with functional capacity, self-efficacy for exercise and age. Previous studies have showed comparable findings [4,5,6], however, admitting the strong association between participation and 10 meters Walking Speed and TUG, it is essential to include these instruments in a comprehensive evaluation of the individuals who have suffered a fall in the past year to predict participation restrictions. The performance assessed, in few minutes, by these tests, will gather information about balance and mobility impairments, that associated with a quick assess of Self-efficacy for exercise [7] will outline the quality of life of persons with history of falls.

## Acknowledgements

Authors would like to thank all participants and centres, clinics and other entities hosting the screenings. Financial support from project FallSensing: Technological solution for fall risk screening and falls prevention (POCI-01-0247-FEDER-003464), co-funded by Portugal 2020, framed under the COMPETE 2020 (Operational Programme Competitiveness and Internationalization) and European Regional Development Fund (ERDF) from European Union (EU).

## References

1. WHO, World Health Organization. International Classification of Functioning, Disability, and Health. Geneva: Classification, Assessment, Surveys and Terminology Team, 2001

2. Liu J. The severity and associated factors of participation restriction among community dwelling frail older people: an application of the International Classification of Functioning, Disability and Health (WHO-ICF). BMC Geriatrics, 2017, 17:43.

3. Desrosiers J, Robichaud L, Demers L, Ge'linas I, Noreau L, Durand D. Comparison and correlates of participation in older adults without disabilities. Archives of Gerontology and Geriatrics, 2009, 49: 397-403.

4. Anaby D, Miller WC, Eng JJ, Jarus T, Noreau L, Group PR. Can personal and environmental factors explain participation of older adults? Disability and Rehabilitation, 2009;31(15):1275-82.

5. Rubio E, Lázaro A, Sánchez-Sánchez A. Social participation and independence in activities of daily living: across sectional study. BMC Geriatrics, 2009, 9:26.

6. Tomioka K, Kurumatani N, Hosoi H. Social Participation and the Prevention of Decline in Effectance among Community-Dwelling Elderly: A Population-Based Cohort Study. PLoS ONE, 2015, 10(9).

7. Martins AC, Silva C, Moreira J, Rocha C, Gonçalves A. Escala de Autoeficácia para o Exercício: validação para a população portuguesa. Conversas de Psicologia e do Envelhecimento Ativo, 2017, 126-141

## Keywords

Participation, Community-dwelling adults, Falls, Functional capacity, Self-efficacy for exercise.

## O38

### History of fall and social participation profile among community dwelling older adults: is there any relation with frailty phenotype?

Mónica Calha, Anabela C Martins
Physiotherapy Department, Coimbra Health School, Polytechnic Institute of Coimbra, 3026-854 Coimbra, Portugal

Correspondence: Mónica Calha (monicacalha@gmail.com)

BMC Health Services Research 2018, **18**(Suppl 2):O38

## Background

Ageing population is a worldwide phenomenon. The number of older frail people increases rapidly, which leads to a substantial impact on the economic, social and health systems. Cardiovascular Health Study data [1] estimated that, in a population with 65 years or more, 6.3% of aged adults have the frailty phenotype. According to Fried *et al.*, frailty is a vulnerable condition characterized by the decline of biological reserves [2,3]. This happens due to deregulation of multiple physiological systems, which puts the individuals at risk by reducing the organism resistance to stressful factors, with a subsequent loss of functional homeostasis. One of the most significant aspects described in the literature is the fact that frailty is an important risk factor for falls. It is estimated that one in every three adults over 65 years fall each year. The frailty syndrome also compromises the social participation of aged adults.

## Objective

To understand if adults with 65 years or over with frailty phenotype have history of falls in the period of the previous 12 months prior to the study and worst social participation, when compared to the ones who don't have this phenotype.

## Methods

A sample of 122 community-dwelling adults (age ≥65 years), mean age 72.22 ± 6.44 years old (63.9% female), with history of at least one fall in the previous year participated in this cross-sectional study. Data were collected by a demographic, clinical and history of falls questionnaire, functional tests and the Activities and Participation Profile related to Mobility (PAPM).

## Results

We verified that there are statistically significant differences in the history of falls between no-frailty (n = 24; mean number of falls = 1.92) and frailty/pre-frailty (n = 31; mean number of falls = 3.06) individuals (p = 0.036), as well as in the social participation score of both groups, with worse profile among the frailty/pre-frailty (0.821), when compared to no-frailty (0.276) (p = 0.000).

## Conclusions

Adults with 65 years or over who present frailty or pre-frailty phenotype, when compared to no-frailty ones, have higher rate of falls in the previous 12 months and more restrictions in social participation. Physiotherapists benefit from this knowledge to understand needs of this population and to plan interventions focus on prevention of falls and strategies to promote participation as promising outcomes.

## References

1. Etman, A., Burdorf, A., Van der Cammen, T.J.M., Mackenbach, J.P., Van Lenthe, F.J. (2012). Socio-demographic determinants of worsening in frailty among community-dwelling older people in 11 European countries. Journal of Epidemiology and Community Health; 66(12):1116-1121.
2 Eyigor, S., Kutsal, Y.G., Duran, E., et al. (2015). Frailty prevalence and related factors in the older adult - FrailTURK Project. American Aging Association; 37(3):1-13.

3 Tarazona-Santabalbina, F.J., Gómez-Cabrera, M.C., Pérez-Ros, P., et al. (2016). A Multicomponent Exercise Intervention that Reverses Frailty and Improves Cognition, Emotion, and Social Networking in the Community-Dwelling Frail Elderly: A Randomized Clinical Trial. Journal of the American Medical Directors Association; 17(5):426-433.

### Keywords

Community dwelling adults, Frailty phenotype, Risk of falls, Social participation.

## O39

### Sexual assistance through the eyes of sex workers: one path to improve sexual lives of people with disabilities

Ana R Pinho¹, Fernando A Pocahy², Conceição Nogueira¹

¹Center for Psychology, Faculty of Psychology and Education Sciences, University of Porto, 4200-135 Porto, Portugal; ²Universidade do Estado do Rio de Janeiro, 20550900 Rio de Janeiro, Brazil

**Correspondence:** Ana R Pinho (mipsi20699@fpce.up.pt)

BMC Health Services Research 2018, **18**(Suppl 2):O39

### Background

Historically, people with disabilities have been seen as asexual and their sexual rights were often neglected. Nowadays, some progresses have been made but they still face multiple stereotypes and barriers that limit their social and sexual lives. Sexual assistance is a way of sexual expression in which trained individuals provide sexual services to clients with disabilities, improving their well-being in relation to sexuality. However, in Portugal the only way to access commercial sex is through sex workers who have no training to attend disabled clients.

### Objective

To understand if sex workers see training as a useful aspect to be taken into account for improving psychological and sexual health of clients with disabilities and themselves.

### Methods

An explorative study of qualitative approach, with 13 sex workers interviews analysed using the thematic analysis method proposed by Braun and Clarke (2006) [1].

### Results

From the analysis of the interviews four themes have emerged. Sex workers theme focus on the life experiences and motivations to attend clients with disabilities. Clients theme characterizes who are the people with disabilities seeking commercial sex. Search for sex work theme deepens knowledge about how they get in touch with sex workers. Finally, the attendance theme explains the dynamics of the relationship established and the many obstacles they overcome in order to express their sexuality through commercial sex.

### Conclusions

The main conclusions provide evidence of the use of commercial sex by people with disabilities who seek in this service sexual and emotional satisfaction. Certain relationship specificities tend to be experienced with feelings of embarrassment on the part of professionals. Based on the experiences and obstacles sex workers observed when working with people with disabilities, measures were pointed out to improve the psychological and sexual health of those involved in the situation, which highlights the need for training to serve this group of clients, as well as the need for legalization of sex work.

### References

1. Braun V, Clarke V. Using thematic analysis in psychology. Qualitative Research in Psychology. 2006; 3: 77-101.

### Keywords

Sexual health, Sexual Assistance, Sex Work, Clients with Disabilities.

## O40

### Results of an intervention program for men who batter women: perceptions of accompanied men

Anne CLG Silva, Elza B Coelho

Department of Public Health, Federal University of Santa Catarina, 88040-900 Florianópolis, Santa Catarina, Brazil

**Correspondence:** Anne CLG Silva (anne_clg@hotmail.com)

BMC Health Services Research 2018, **18**(Suppl 2):O40

### Background

In intimate partner violence, man is the main perpetrator of violence, and it is essential to include him in interventions to decrease violence, because he can take responsibility for violence, seeking new forms of expression. However, intervention with men is criticized, such as: using resources that could be targeted to victims; the imposition of re-education measures rather than punitive measures; consider that men do not change their behaviour [1]. Nevertheless, it is within the framework of evaluation that we find one of the major shortcomings of batterer intervention programs, since the effects of participation of men in that, have been receiving little analysis [2].

### Objective

This research aims to analyse the results of a batterer intervention program from the perspective of man accompanied by the program.

### Methods

It is a case study conducted in a batterer intervention program with 86 men. It was used the Centres for Disease Control and Prevention Follow Up Questionnaire, adapted to be used in Brazil. Data were analysed according to content analysis techniques. This project was approved by the Human Research Ethics Committee of the Infantile Hospital Joana de Gusmão. Subjects were asked to agree through an informed consent.

### Results

When asked about changes occurred after 3 months of follow-up in the program some men reported having not noticed any changes, which indicates that the program is not effective to all participants and the importance of longer follow-ups. However, most men cited changes in the way they act and perceive the division of tasks between men and women, thus participation in the program can be the starting point for rethinking and building new ways of expressing masculinity. And the changes cited go beyond the scope of the marital relationship, encompassing the relationship with the children, the abandonment of addictions and the desire to seek school education.

### Conclusions

According to the data, attention to perpetrators of violence has a positive influence not only in the behaviour towards the partner, but also on the relationship with children and the abandonment of addictions. Although longer follow-ups - including the couple - are needed, the batterer intervention program may be a tool to decrease violence against women.

### References

1. Antezana AP. Intervenção com Homens que Praticam violência contra seus cônjuges: reformulações teórico-conceituais para uma proposta de
intervenção construtivista-narrativista com perspectiva de gênero. Nova Perspectiva sistêmica, 2012; 42:9-27.

2. Toneli MJF; Lago MCS; Beiras A; Climaco DA, organizadores. Atendimento a homens autores de violência contra as mulheres: experiências latino-americanas. Florianópolis: UFSC/CFH/NUPPE; 2010.

**Keywords**

Violence against women, Batterer intervention, Men, Program evaluation.

O41

Effectiveness of a reminiscence program on cognitive frailty, quality of life and depressive symptomatology in the elderly attending day-care centres

Isabel Gil¹, Paulo Costa², Elzbieta Bobrowicz-Campos², Rosa Silva³, Maria L Almeida¹, João Apóstolo⁴

¹Nursing School of Coimbra, 3046-851 Coimbra, Portugal; ²Health Sciences Research Unit: Nursing, Nursing School of Coimbra, 3046-851 Coimbra, Portugal; ³Universidade Católica Portuguesa, Institute of Health Sciences, 4200-374 Porto, Portugal; ⁴Health Sciences Research Unit: Nursing, Portugal Center for Evidence-Based Practice: A JBI Centre of Excellence, 3046-851 Coimbra, Portugal

**Correspondence:** Isabel Gil (igil@esenfc.pt)

BMC Health Services Research 2018, **18**(Suppl 2):O41

**Background**

Reminiscence is a therapeutic intervention based on the account of personal experiences that allows access to significant life events. Evidence suggests that this intervention is particularly beneficial for the elderly with neurocognitive disorders [1], especially with regard to psychosocial variables. In Portugal, this intervention is underused, and there is a need to study its applicability and efficacy.

**Objective**

To evaluate the effect of a reminiscence-based program (RBP) [2] on cognitive frailty, quality of life and depressive symptomatology in elderly people attending day-care centres. Evaluate professional's satisfaction with the program and identify obstacles in its implementation.

**Methods**

A quasi-experimental study with one group was carried out in four day-care centres in the central region of Portugal. The framing sample included 69 older adults aged ≥ 65 years. Of those, 28 (average age of 79.33 ± 7.35 years and average education of 3.29 ± 1.86 years) participated in the 7-week RBP, twice a week. Outcomes of interest were cognitive frailty indicators measured through the Montreal Cognitive Assessment (MoCA); quality of life measured using the short version of World Health Organization Quality of Life Scale-module for older adults (WHOQOL-OLD-8); and depressive symptomatology measured by the 10-item Geriatric Depression Scale (GDS-10). In addition, the eight professionals conducting the study were asked to identify obstacles to the successful implementation of the program, and to evaluate its structure, themes, contents, and the involvement of the elderly in each session.

**Results**

RBP was shown to have positive effects on the MoCA and WHOQOL-OLD-8 score (p < 0.05). Improvement in the GDS-10 score was observed; however, it was statistically non-significant. The structure of the program sessions was considered as mostly clear and perceptible (94%), and themes and contents as mostly pleasant and appropriate (94%). Positive feedback was obtained regarding the program capacity to involve the elderly in the activities proposed (87.5%). However, according to the professionals' opinion, there is a need for ampler capacitation of the teams implementing RBP, better articulation with the institutions regarding the used space and activities schedule, and better articulation with the elderly to guarantee their commitment to the program.

**Conclusions**

Reminiscence was shown to be effective in improving cognition and quality of life, as well as potentially effective in decreasing depressive symptomatology. Therefore, it presents a therapeutic potential, contributing to the improvement of the care provided. It is also worth

mentioning the good acceptance of the program which, however, implies the qualification of the professional teams for its implementation.

**Acknowledgements**

This study was developed within the context of the project "664367/FOCUS" (funded under the European Union's Health Programme (2014-2020)) and project ECOG (funded by the Nursing School of Coimbra).

**References**

1. Thorgrimsen L, Schweitzer P, Orrell M. Evaluating reminiscence for people with dementia: a pilot study. The Arts in Psychotherapy. 2002;29(2):93-97.

2. Gil I, Costa P, Bobrowicz-Campos E, Cardoso D, Almeida M, Apóstolo J. Reminiscence therapy: development of a program for institutionalized older people with cognitive impairment. Revista de Enfermagem Referência. 2017;4(15):121-132.

**Keywords**

Reminiscence, Elderly, Cognition, Quality of life, Depressive symptomatology.

O42

Development and validation of a reminiscence group therapy program for older adults with cognitive decline in institutional settings

Isabel Gil¹, Paulo Costa², Elzbieta Bobrowicz-Campos², Rosa Silva³, Daniela Cardoso⁴, Maria Almeida¹, João Apóstolo⁴

¹Nursing School of Coimbra, 3046-851 Coimbra, Portugal; ²Health Sciences Research Unit: Nursing, Nursing School of Coimbra, 3046-851 Coimbra, Portugal; ³Universidade Católica Portuguesa, Institute of Health Sciences, 4200-374 Porto, Portugal; ⁴Health Sciences Research Unit: Nursing, Portugal Center for Evidence-Based Practice: A JBI Centre of Excellence, 3046-851 Coimbra, Portugal

**Correspondence:** Isabel Gil (igil@esenfc.pt)

BMC Health Services Research 2018, **18**(Suppl 2):O42

**Background**

Research has evidenced the positive impact of non-pharmacological therapies aimed at elderly people with cognitive decline in the institutional setting. Reminiscence Therapy (RT) emerges in this category as an enabling strategy, which favours moments of happiness, dignity and life purpose [1]. Nonetheless, studies centred in RT are limited in Portugal, with a clear absence of structured interventional programs, emerging the need to develop and validate well-defined and replicable RT programs [2].

**Objective**

We intend to construct and validate a RT program directed to elderly people with cognitive decline, to be implemented in institutional settings by healthcare professionals.

**Methods**

Guidelines for complex interventions development from the Medical Research Council were followed [3]. The program was conceptualized in four distinct phases: Phase I (Preliminary), the initial conceptualization of the program design and supportive materials; Phase II (Modelling), consisting in the conduction of interviews and focus groups with healthcare specialists; Phase III (Field Test), aiming at the evaluation of each program session; and Phase IV (Consensus Conference), to synthesize the contributions and analyse challenges that emerged in preceding phases.

**Results**

Based on the contributions of experts, healthcare professionals and the institutionalized elderly, a RT program divided into two strands was formed. The main strand includes 14 sessions, performed twice a week. The maintenance strand included seven weekly sessions. Each thematic session is related to the participants' life course, with a maximum duration of 60 minutes. The 4-phase conceptualization process resulted in the creation of a digital platform with audio-visual contents to aid professionals during each session; inclusion of an introductory section that contextualizes the therapeutic potential of RT; introduction of complementary activities that can be developed additionally in the institutional settings; reinforcement of multisensory stimulation throughout