Antimicrobial resistance (AMR) is a growing concern in human and livestock sectors, also affecting ecosystems and critically threatening future access to effective antimicrobial treatments. In veterinary medicine, ruminants, such as cattle, sheep, goats, buffaloes, and yaks, play vital roles in sustainable food systems, transforming nonedible feedstuff into nutritious products and supporting rural livelihoods and the preservation of ecosystems. However, antimicrobial use contributes to the emergence and spread of drug-resistant bacteria, compromising animal welfare, food safety, and public health. This chapter highlights the impacts AMR has on livestock production and the global efforts, under the One Health framework, that are in place to mitigate this public health crisis. Despite the efforts and commitment of countries, AMR prevalence remains high, with resistance observed in key pathogens. Advances in microbiome research and bioinformatic tools reveal the rumen as botha reservoir for AMR genes and a potential source of novel antimicrobial compounds. Sustainable practices such as organic farming, vaccination, improved farm management, and digital health monitoring are viewed as effective measures to reduce antimicrobial dependence. Global and national initiatives, including awareness campaigns, strengthened surveillance and monitoring, and funding opportunities, are essential to fight AMR in ruminants, ensuring the longevity of effective therapies, the sustainability of agrifood systems, and the protection of public and environmental health. Some key conclusions are: (i) together with reduced antimicrobial use, successful AMR mitigation requires controlling animal-human transmission (and vice-versa) of resistant bacteria; and (ii) the ruminant microbiome can act as an AMR reservoir, and strategies to minimize antimicrobial use may include natural feed additives, improved biosecurity, and precision livestock farming.

Background: Digital health literacy (DHL) is crucial for navigating the increasingly digital healthcare landscape. This study aimed to validate the Portuguese adaptation of the TeHLI (Transactional eHealth Literacy Instrument), a scale measuring four key dimensions of DHL: functional, communicative, critical, and translational. Methods: A rigorous translation and cross-cultural adaptation process was conducted. The adapted TeHLI was applied to a cross-sectional sample of 961 participants residing in Portugal. Construct validity was assessed using Exploratory Factor Analysis (EFA) and Confirmatory Factor Analysis (CFA). Internal consistency was evaluated using Cronbach’s alpha. Results: Cognitive debriefing revealed good comprehension of the items with minor suggestions for refinement. EFA confirmed the four-factor structure, with a slight shift in one item’s loading. CFA demonstrated excellent model fit (CFI = 0.971, TLI = 0.964, RMSEA = 0.055). High Cronbach’s alpha values indicated excellent internal consistency for the overall scale (0.95) and its subscales (0.86-0.90). Conclusions: The Portuguese adaptation of the TeHLI is a valid and reliable instrument for assessing digital health literacy in Portugal. This tool can be used to identify populations in need of support and to evaluate interventions aimed at improving digital health literacy skills, ultimately contributing to better health outcomes.

Background The aim of this study was to evaluate beliefs about and attitudes towards COVID-19 booster vaccination among subjects who had received the complete vaccination schedule but had not received the booster. Methods We conducted a qualitative study using online focus groups made up of participants from all parts of Spain who had received the primary vaccination schedule but had subsequently refused any of the booster doses. Individuals were recruited by snowball sampling. Results The study used 5 focus groups having a total of 30 participants. The thematic analysis identified 10 themes and 32 subthemes. Gynaecological problems and long-term adverse effects were associated with booster hesitancy. Participants perceived the vaccine as less necessary, as they considered it incapable of halting transmission and believed that the risk was much lower than at the onset of the pandemic. Rapid development of the COVID vaccine as compared to that of traditional vaccines, coupled with continuous changes in information, generated distrust and contributed to booster vaccine hesitancy. Conclusions Vaccine hesitancy can appear at any time and with any vaccine despite its evident public health benefits, as is the case of COVID-19 booster doses. Policy-makers should therefore focus on generating trust and responsibility when it comes to booster vaccinations.

IntroductionAntimicrobial resistance (AMR) is a global public health concern that requires a One Health approach. The role of veterinarians in promoting antimicrobial stewardship is essential for successful mitigation of AMR.ObjectiveThis study aimed to design a self-administered questionnaire and evaluate its reliability as a tool to assess veterinarians' knowledge, perceptions, and attitudes regarding AMR and antibiotic prescription and use in animals.MethodsThe questionnaire was developed based on a comprehensive review of relevant literature and by employing collective intelligence methodologies, including focus groups with veterinarians and pharmacists. For the pilot study, veterinarians working in the Northern region of Portugal were recruited. A test-retest was conducted with a 4-week interval. Reproducibility was determined with the intraclass correlation coefficient (ICC; 95% confidence interval) and internal consistency was calculated using Cronbach's alpha.ResultsIn total, 31 (out of 34) veterinarians completed the retest phase of the study. Four sections with scale-items were assessed for reliability, with ICC values ranging from 0.10 (p = 0.285) in Section 2 (AMR) to 0.85 (p < 0.001) in Section 4 (prescription and antibiotic use). The questionnaire achieved Cronbach's alpha coefficient values of 0.81 and 0.78 in test and retest, respectively. Based on ICC values and veterinarians' comments, some items were deleted or reformulated.ConclusionThe developed questionnaire is a reliable instrument capable of capturing veterinarians' knowledge, perceptions, and attitudes on AMR and antibiotic use.

BackgroundTechnology-mediated medication adherence interventions have proven useful, yet implementation in clinical practice is low. The European Network to Advance Best Practices and Technology on Medication Adherence (ENABLE) European Cooperation in Science and Technology Action (CA19132) online repository of medication adherence technologies (MATechs) aims to provide an open access, searchable knowledge management platform to facilitate innovation and support medication adherence management across health systems. To provide a solid foundation for optimal use and collaboration, the repository requires a shared interdisciplinary terminology. ObjectiveWe consulted stakeholders on their views and level of agreement with the terminology proposed to inform the ENABLE repository structure. MethodsA real-time web-based Delphi study was conducted with stakeholders from 39 countries active in research, clinical practice, patient representation, policy making, and technology development. Participants rated terms and definitions of MATech and of 21 attribute clusters on product and provider information, medication adherence descriptors, and evaluation and implementation. Relevance, clarity, and completeness criteria were rated on 9-point scales, and free-text comments were provided interactively. Participants could reconsider their ratings based on real-time aggregated feedback and revisit the survey throughout the study period. We quantified agreement and process indicators for the complete sample and per stakeholder group and performed content analysis on comments. Consensus was considered reached for ratings with a disagreement index of <1. Median ratings guided decisions on whether attributes were considered mandatory, optional, or not relevant. We used the results to improve the terminology and repository structure. ResultsOf 250 stakeholders invited, 117 (46.8%) rated the MATech definition, of whom 83 (70.9%) rated all attributes. Consensus was reached for all items. The definition was considered appropriate and clear (median ratings 7.02, IPR 6.10-7.69, and 7.26, IPR 6.73-7.90, respectively). Most attributes were considered relevant, mandatory, and sufficiently clear to remain unchanged except for ISO certification (considered optional; median relevance rating 6.34, IPR 5.50-7.24) and medication adherence phase, medication adherence measurement, and medication adherence intervention (candidates for optional changes; median clarity ratings 6.07, IPR 4.86-7.17; 6.37, IPR 4.80-6.67; and 5.67, IPR 4.66-6.61, respectively). Subgroup analyses found several attribute clusters considered moderately clear by some stakeholder groups. Results were consistent across stakeholder groups and time, yet response variation was found within some stakeholder groups for selected clusters, suggesting targets for further discussion. Comments highlighted issues for further debate and provided suggestions informing modifications to improve comprehensiveness, relevance, and clarity. ConclusionsBy reaching agreement on a comprehensive MATech terminology developed following state-of-the-art methodology, this study represents a key step in the ENABLE initiative to develop an information architecture capable of structuring and facilitating the development and implementation of MATech across Europe. The debates and challenges highlighted in stakeholders’ comments outline a potential road map for further development of the terminology and the ENABLE repository. International Registered Report Identifier (IRRID)RR2-10.1136/bmjopen-2021-059674

Antimicrobial resistance (AMR) is a global public health problem due to misuse/overuse of antimicrobials. The interplay between humans, animals, and the environment requires a One Health approach for effective AMR control. We focused this research on antimicrobial use in food-producing animals (bovine, caprine, equine, ovine, and swine) to assess the compliance of Organisation for Economic Co-operation and Development (OECD) countries (members, partners, and candidates) with international guidelines: Codex Alimentarius: Code of Practice to Minimize and Contain Foodborne Antimicrobial Resistance, and the Terrestrial Animal Health Code. For this systematic review (PROSPERO CRD42024535461), between February 1 and June 30 of 2024, guidelines were searched on: governmental websites associated with health and veterinary sectors, veterinary organizations specified by the government or included in the country’s National Action Plan for AMR, and the global repository of available guidelines for responsible use of antimicrobials in animal health. Three researchers performed data extraction and AGREE II appraisal was conducted by two researchers. Of the 49 OECD countries, 37 presented guidelines (n = 82) for responsible antimicrobial use in the analyzed species, with bovine and swine being the most represented. The highest number of published guidelines was observed between 2017–2020. The number of clinical and non-clinical guidelines were 43 and 37, respectively, emphasizing the need for veterinarian-directed recommendations. The AMR challenge, the interdependence of countries, and the trade of animal-derived products should encourage national initiatives to develop and implement guidelines for the judicious use of antimicrobials in animal production. Due to OECD countries’ disparities in terms of culture, internal policies, attitudes and perceptions about AMR, and financial resources, this process needs to be gradual and tailored for each case. Therefore, communication and collaboration between countries and stakeholders are essential.

OBJECTIVES:Health literacy constitutes an array of skills and knowledge that has the potential to empower one's ability to actively - and effectively - engage in their own health. Educational interventions can play a fundamental role in improving people's health literacy, which is, in turn, associated with the adoption of healthier lifestyles and a significant predictor of positive health outcomes. This study aimed to analyse the effect of educational interventions on both health literacy and the adoption of healthier lifestyles. STUDY DESIGN:Systematic review. METHODS:The search was performed in PubMed, EMBASE, Scopus and Web of Science in April 2023. The screening was performed by three independent reviewers, following the PRISMA guidelines. All the included articles were critically evaluated through Cochrane's RoB 2 and ROBINS-I quality assessment tools. RESULTS:11290 records were obtained through database searches, of which 12 studies were found to be eligible as they agreed with the inclusion criteria. These 12 interventions included a total of 3407 participants, (n = 2757 who received the educational interventions, n = 650 belonging to the control groups). While the impact of educational interventions on health literacy was explored in all the included studies, lifestyle variables differed from study to study, ranging from nutrition and to physical activity to mental health, social and environmental well-being, among others. CONCLUSIONS:This review provides evidence supporting the effectiveness and relevance of educational interventions containing interactive strategies, in positively changing health literacy levels, lifestyle behaviors such as diet, physical activity, and other health outcomes.

INTRODUCTION:Polypharmacy and Potentially Inappropriate Medication (PIM) pose significant challenges for older adults, frequently leading to adverse health outcomes. While digital health tools offer promise solutions to improve medication management for this population, their integration into primary care settings remains slow. This study aims to explore the perspectives of Portuguese general practitioners (GPs) regarding polypharmacy, PIM, and the adoption of digital health-related tools for medication appropriateness in older adults. METHODS:Five qualitative focus group sessions were conducted with 37 GPs working in Portuguese primary healthcare facilities of the north. The sessions were recorded, and a thematic analysis was performed. RESULTS:The following five themes emerged: factors associated with polypharmacy, challenges in deprescribing, problems related to PIM, strategies to handle polypharmacy, and barriers and facilitators adopting digital health-related tools for medication appropriateness. Eight barriers and nine facilitators were identified. CONCLUSION:This study underscores the complexity of medication management in older adults and highlights the potential of digital health tools to optimize medication use. Tailored interventions and collaborative efforts among all healthcare stakeholders are essential to enhance medication management and improve health outcomes in older adults.

Introduction: Health literacy (HL) is a key determinant of health outcomes, particularly among vulnerable populations such as low-income older adults. Limited HL is associated with poor understanding of medication instructions and lower medication adherence, which can compromise therapeutic success. This study aims to assess the levels of HL and medication adherence among low-income older adults and to analyse the relationship between HL, medication adherence, and other determinants. Methods: A cross-sectional study was conducted among low-income older adults in Portugal's Beira and Serra Estrela Region. HL was assessed using the European Health Literacy Survey Questionnaire (HLS-EU-PT), and medication adherence was measured with the Adherence to Treatment Measure (MAT) scale. Descriptive statistics, Spearman correlations, ordinal logistic regression, and linear regression were used to analyse associations between HL, adherence, and sociodemographic and health factors. Results: Of 196 participants, most had problematic or inadequate HL (87.8%). Medication adherence was relatively high (mean = 5.37, SD = 0.54). HL was positively associated with medication adherence (R = 0.260, p < 0.001), education (R = 0.277, p < 0.001), and ability to pay expenses (R = 0.235, p = 0.002) and negatively with age (R = -0.179, p = 0.019), poor health status (R = -0.237, p = 0.002), and difficulty affording medication (R = -0.389, p < 0.001). Completion of the third cycle of primary education predicted higher HL (OR = 1.939, 95% CI: 0.088-3.790, p = 0.040); the ability to pay expenses predicted better adherence (B = 0.101, 95% CI: 0.014-0.187, p = 0.022). Conclusions: Low HL remains a significant barrier among low-income older adults in Portugal, despite generally high medication adherence. Education and financial stability are key determinants to HL and adherence. Interventions should integrate HL promotion with efforts to reduce socioeconomic barriers and support medication management in the vulnerable populations.

The misuse and/or overuse of antibiotics in animals has been a subject of concern due to the intensification of antimicrobial resistance (AMR). Veterinarians are at the front line of antibiotic prescription and their decision-making process is impacted by several non-clinical factors. The aim of this systematic review was to identify and understand how veterinarians’ attitudes, knowledge, perceptions, and experience influence antibiotic prescription practices. We systematically searched MEDLINE/PubMed, Web of Knowledge, and CAB International databases. Quantitative and mixed methods studies with veterinary graduates were included, with no time restrictions. Articles written in English, Spanish, and Portuguese were considered. Quality assessment was performed with JBI’s cross-sectional critical appraisal tool. Our search retrieved 4722 documents, with 59 being included. Articles’ publication year ranged from 2004 to 2023, with most (n = 55) using a quantitative approach, and the remaining ones (n = 4) using mixed methods. Veterinary practices were categorized into four groups: livestock (n = 24), small animals (n = 14), equine (n = 5), and mixed practice (broader scope; n = 17). Intrinsic factors identified as potentially influencing veterinarians’ antibiotic prescription included: socio-demographic factors (n = 39) and attitudes and concerns: self-confidence (n = 31); need to satisfy clients’ expectations (n = 19); fear (n = 27); lack of knowledge (n = 21). Extrinsic factors were also identified in several studies: clients’ lack of knowledge and/or training regarding AMR, appropriate antimicrobial use, and good production practices (n = 24); substandard hygiene conditions and biosecurity protocols (n = 14); time constraints (n = 4); cost of laboratory tests (n = 12); antibiotic policies and/or guidelines (n = 22); antibiotics cost (n = 20), and withdrawal period (n = 11); animal-related factors (n = 21), namely breeding and animals’ behavior. This systematic review provides an updated and comprehensive understanding of non-clinical factors that can influence veterinarians’ antibiotic prescription practices. High client demand, self-confidence, need to satisfy clients’ expectations, deficient biosecurity, fear, lack of awareness from animal owners and farmers about AMR and appropriate antimicrobial use, and inadequate policies/guidelines were associated with higher antibiotic prescription among veterinarians. Many of the identified factors are potentially modifiable. Within the One Health approach, this can help in the design of interventions focusing on appropriate antibiotic use in animals to tackle AMR.

Irisin is a protein resulting from a proteolytic cleavage of fibronectin type III domain-containing protein 5 (FND5). The ability of irisin to modulate adipocyte and control glucose metabolism in human metabolic diseases gave rise to the hypothesis that irisin could have a pivotal role in aging-related diseases. Although in animal models, increased levels of irisin have been positively associated with better health outcomes, in humans, its role remains controversial. To provide an overview of the main finding on irisin in older adults, a comprehensive search was performed through the MEDLINE-PubMed, Web of Science, Scopus, and Cochrane databases for studies conducted in older adults (≥60 years) published since 2012. After grouping and analyzing the articles based on diseases associated with older adults, the main conclusion of this narrative review is that the included studies did not yield consistent evidence regarding the association between irisin and health or disease in older adults. Further studies are necessary to clarify the effective role of this protein in promoting health and longevity.

Background/Objectives: Older adults should be capable of reasoned judgments regarding their health, lifestyle, and disease management. Therefore, interventions to improve Health Literacy (HL) are essential for empowering older adults to make choices that improve their quality of life. Correct medication use is vital to maintaining and enhancing health outcomes in older adults. This study aimed to identify the most effective HL interventions with impact on medication use among older adults. Methods: A systematic review was conducted using MEDLINE (PubMed) and EMBASE to identify interventional studies evaluating HL interventions that have an impact on medication use in older adults. Results: Three studies satisfied the inclusion criteria. The evidence indicates that HL interventions have positive effects and can be effectively implemented by several healthcare professionals through tailored communication strategies. However, the review underscores a substantial lack of high-quality research on HL strategies aimed at improving medication use in older adults, particularly given the increasing prevalence of chronic diseases and polypharmacy in this population. Conclusions: This systematic review identifies substantial research gaps regarding HL interventions and their impact on medication use among older adults. While the included studies demonstrate encouraging outcomes, further rigorous research is necessary to develop specific HL interventions addressing medication-related challenges in older adults.

Purpose Digital health (DH) has been rapidly expanding over the last years, with new technologies aimed at improving healthcare services quality and effectiveness and patient empowerment. However, DH adoption and usage is not equal to everyone, and is heavily dependent on several individual and contextual factors. Thus, with this study, we aim to explore the main perceptions, barriers, and experiences with DH in Portugal. Methods This study was conducted using a qualitative research design, in the form of focus groups. Participants were recruited through the dissemination of the study via e-mail, through several institutions, and social media posts. The focus group sessions were conducted with six to eight participants, via Zoom videoconference. All the sessions were recorded, transcribed verbatim, and a thematic analysis was performed. Results Thirty-four participants agreed to take part in this study, and five focus group sessions were conducted, until saturation was achieved. After thematic analysis, seven main themes were identified: 1) DH concepts; 2) experiences with DH; 3) health information; 4) advantages of DH; 5) concerns towards DH; 6) barriers to DH access and use; 7) solutions to improve the DH framework. Conclusion Despite the digital health framework improvement throughout the years, a lot needs to be done to make digital health truly accessible to everyone in Portugal. Concerns regarding equitable access, digital health literacy, infrastructure, patient-healthcare professional relationship and AI are some of the many dimensions that must be considered when working towards digital transformation in healthcare.

INTRODUCTION:The implementation of digital health tools and services encounters policy and governance challenges tied to a complex web of stakeholders and influencing factors. This study seeks analyse the digital health framework in Portugal, focusing on digital health policies and interventions. METHODS:Through a multifaceted approach, this study included the conduction of expert interviews, and an extensive assessment of publicly available official documents, thus allowing a thorough analysis of the national digital health framework. To consolidate all the information gathered, a SWOT analysis was subsequently performed. RESULTS:Eight experts involved with digital health in Portugal were interviewed. Seven key themes were identified and discussed alongside the data extracted from document analysis: 1) the digital health context in Portugal; 2) digital health services, tools, and infrastructure in Portugal: strengths and limitations; 3) budget and resources allocation towards digital health in Portugal; 4) digital health development in Portugal: current status and necessary steps; 5) Digital health accessibility and digital health literacy in Portugal; 6) COVID-19 pandemic and its impact on digital [health] tools usage; and 7) comparison of the digital health framework with other countries: lessons to learn. DISCUSSION:As digital health has gained momentum in Portugal over the years, it is crucial to enhance governance and transparency, connect digital infrastructures, and promote data availability. These measures, along with a well-defined strategic vision, are essential for cultivating a robust digital health ecosystem.