Childhood interventions: impacts on health, schooling, and socioeconomic outcomes (ongoing)

This project aims first, to gather and summarize existing evidence on the impacts of childhood interventions with health components on health, schooling, and socioeconomic outcomes, both in childhood/adolescence and adulthood . The next phase of the project will seek to assess the impacts of a childhood health program in Portugal on various outcomes, both in the short- and long-run. Results of this project will inform on the importance of investing in prevention and health promotion during the first years of life. 

Judite Gonçalves
Filipe Valadas

Partner and funding:
Fundação Nossa Senhora do Bom Sucesso



Research Grants

Funding body: FCT – Fundação para a Ciência e a Tecnologia 
Project reference: PTDC/ATP-GEO/4101/2012
Starting date: May 3, 2013
Duration in months: 24
Principal contractor: Universidade de Coimbra
Participating institutions: Centro Hospitalar de Lisboa Ocidental, EPE, Centro Hospitalar do Baixo Alentejo, EPE, Centro Hospitalar e Universitário de Coimbra, EPE, Escola Nacional de Saúde Pública – Universidade Nova de Lisboa, Nova School of Business and Economics, Hospital Distrital de Faro, Hospital Júlio de Matos, Hospital Magalhães Lemos, Hospital Professor Doutor Fernando Fonseca, EPE, Centro de Estudos de Geografia e Ordenamento do Território – Faculdade de Letras,, Universidade de Coimbra, Centro de Estudos de Doenças Crónicas – Faculdade de Ciências Médicas, Universidade Nova de Lisboa
Principal investigator: Paula Santana
Principal investigator at Nova School of Business and Economics: Pedro Pita Barros
Mental health is the complex result of multiple biological, psychological and social factors, also involving contextual factors beyond the individual. Empiric evidence suggests that certain characteristics of the environment may influence individual mental health beyond individual characteristics, i.e. the neighborhood/place effect. During the last decade, multilevel analyses have made possible to separate the individual effect from the neighborhood effect on health. The study of the associations between contextual socioeconomic status and mental health is a growing area of social epidemiology. Social environment varies widely across neighborhoods, along the dimensions of deprivation, residential stability (e.g., tenured housing and migration), family structure (e.g., living alone), social cohesion, quality of the built environment and ethnic composition. Furthermore, financial changes can be powerful determinants of health and economic crises are associated with mental disorders and mortality increase.
The National Psychiatric Survey-2009 has shown that Portugal is one of the European countries with a higher prevalence rate of mental disorders. The existing scientific evidence, mainly focused on treatment, supports cost-effective strategies to address this severe problem. There is, however, a lack of a deeper understanding on the impact of the residence local characteristics on mental health and mental disorders, particularly, during an economic crisis.
The goal of this project is to assess the effect of environmental and territorial health determinants on the mental health and on the use of mental health services in times of social and economic crises. This goal integrates specific objectives: 1 To study the associations between the evolution of contextual characteristics of a number of Portuguese municipalities in the last 10 years, and psychiatric morbidity and use of mental health services in these municipalities during the same period; 2 To understand how the mental health of individuals is affected by socioeconomic crises, depending on community support, social capital and urban planning; 3 To propose changes in the physical and social environment that may contribute, in periods of crisis, to promote mental health and reduce psychiatric morbidity of the populations.
The current study final recommendations will be aimed at orienting action, programs and policies with a possible impact on the negative effects on mental health and longevity of the more vulnerable groups to financial crises like the one we are currently experiencing in Portugal and in Europe.
To assess the evolution of the characteristics of the different places of residence we will consider groups of variables: measures of wealth in the municipality (economic activity, employment/unemployment, e.g.), community’s resources (green areas, social support networks, e.g.), accessibility to mental health care, level of safety (number of crimes, e.g.) and quality of lodging (overcrowded, e.g.).
Mental health of the populations will be assessed through: 1) Deaths by suicide (2010-2012, 2000-2002) by municipality; 2) Diagnosis Related Groups (DRGs) for mental disorders (2010-2012 and 2000-2002) by municipality; 3) Number and psychiatric diagnoses of all the catchment areas users with at least one contact (admission or outpatient psychiatric services) during 2012.
Information on 1) and 2) will be obtained through official sources (Serviço Nacional de Estatística and Administração Central do Sistema de Saúde) and will allow the calculation of standardized suicide rates and standardized residents with psychiatric admissions rates and the clusters identification of increased risk, before and during the financial crisis. Finally, information on 3) will be obtained by the medical charts review. Complementing this information, a representative sample of users and non-users (hospitals catchment areas population) will be surveyed with: a) A questionnaire aimed at assessing the relationship between the financial crisis consequences and changes on mental health perception and satisfaction with available resources in the place of residence; b) The Mental Health Inventory-5 to assess mental health perception. Mental health services utilization will be assessed with European Service Mapping Schedule.
Medical charts review will be submitted to the hospitals ethics committees before the start of the protocol. Confidentiality of all the information gathered and anonymization of the databases will be granted.
Therefore, and as already stated, as Mental Health is a multidimensional phenomenon linked to particular environments (places where individuals and groups interact), it requires a multivariate methodological approach, in the field of spatial epidemiology. Thus, after some descriptive approaches, correlation analysis, spatiotemporal clustering, risk areas, multivariate regression models and Geographical Information Systems will be used.

Funding body: FCT – Fundação para a Ciência e a Tecnologia
Project reference: PTDC/IIM-ECO/5165/2012
Starting date: April 1, 2013
Duration in months: 24
Principal investigator: Pedro Pita Barros
Public funding of health care is present in many countries and fiscal austerity characterizes the current times and near future of many European Union countries. The impact of fiscal austerity in the health and health care delivery will be a major issue in in the forthcoming years. This raises challenges in both empirical knowledge and theory. The need for measurement of impacts is clear in some areas, while in others practice is ahead of theory and development of conceptual frameworks is warranted.
The research project proposes to address these impacts in Portugal in three distinct areas: a) use of pharmaceutical products; b) use of hospital services; c) population ability to cope with catastrophic health expenditures. With this project we will produce evidence and arguments to assess and guide policy actions in the health care. We will address 5 themes in the above three areas.
Area a) use of pharmaceutical products
Theme 1: Structural changes in pharmaceutical expenditures in Portugal Pharmaceutical expenditures have grown considerably in Portugal over the last 20 years. The level of pharmaceutical expenditure has been a recurrent target of policies to contain health care costs. Previous works (Barros and Nunes, 2010 and 2011) found that most policies carried out have been largely ineffective in influencing the pace of pharmaceutical expenditures growth. These previous works addressed the first decade of the current century (2001-2010). We want to test the hypothesis of a structural break in the pharmaceutical sector, to identify which policies had the strongest impact, and whether impact was temporary or permanent.
Area b) use of hospital services
Theme 2: Effect of demand pressure on early discharges
Hospitals may react to random demand pressure by discharging patients earlier. The existence of resources constraints generates strong incentives to discharge patients earlier when demand is high. An early discharge, from a clinical point of view, increases the risk of readmission and decreases the benefit from treatment. Overall costs in the health system will be higher and inefficient decisions may be taken.
Theme 3: Use of hospital resources and proximity to death
The effect of population ageing in health expenditures is a much debated issue. The consensus is now that the important feature is proximity to death (Seshamani and Gray, 2004a, 2004b). We want to address this issue in Portuguese hospitals, to assess the impact of ageing in hospital costs, using as proxy the length of stay.
Theme 4: The efficiency of public-private partnerships as an instrument to deliver health care
The existence of pressure for lower public expenditures in the past has led to the search of new funding sources for public equipment. The use of public-privatepartnerships (PPP) was one of these new funding sources. It has come under close scrutiny from both theoretical and empirical viewpoints. Despite the widespread use of PPP in health care (see the report by DLA Piper) there is room for further discussion of two important theoretic aspects: 1) renegotiation of contracts, and 2) how health care providers interact in the (regulated) market for patients, as PPP hospitals and pure public hospitals face different sets of incentives. Technically, this calls for the conceptual framework to mix the delegation literature with mixed oligopoly literature.
Area c) population ability to cope with catastrophic health expenditures
Theme 5: Health expenditures and poverty risk, the role of catastrophic health expenditures
The financial protection against catastrophic health expenditures is receiving increased attention from the literature. Given the poverty level in Portugal, the current crisis may have implications to how well the population can cope with large health expenditures relative to their budget. The issue of financial protection in health was recognized as a challenge to health care systems in the last decade (WHO, 2007; Zu et al., 2007), and out-of-pocket payments are potentially large contributors to substantial drops in standards of living of populations. We address the issue with Portuguese data. The project will measure the evolution over time of the role of private, out-of-pocket, health expenditures in putting households at risk of poverty.
The data to perform the analysis comes from the surveys to household expenditures carried out by Statistics Portugal.

Funding body: WHO – European Center for Healthy Systems & Policies
Starting date: February 16, 2012
Duration in months: 24
Principal investigator: Pedro Pita Barros
Project title: The income gradient of lifestyles for the population aged 50+ in Portugal
Funding body: FCT – Fundação para a Ciência e a Tecnologia
Project reference: PTDC/EGE-ECO/121992/2010
Starting date: January 1, 2012
Duration in months: 24
Principal contractor: Nova School of Business and Economics
Principal investigator: Pedro Pita Barros
This project addresses the issue of inequalities and inequities in health care utilization in the population aged 50+. The elderly tend to be a more vulnerable population, and studies on inequities in health care use in Portugal focus on total population. Linked to existing inequities in the older population are the life-styles. We purport to identify the socio-economic determinants of smoking, drinking and exercising in the 50+ population. A final issue of interest is the health impact of the option to live alone by the elderly. This topic raises some methodological concerns, and needs to account for potential selection.

Funding body: Alto Comissariado da Saúde
Starting date: December 15, 2010
Principal investigator: Pedro Pita Barros
Project title: Share – Health, employment and retirement at 50+: Portugal
Funding body: European Commission
Starting date: December 1, 2009
Duration in months: 24
Principal investigator: Pedro Pita Barros