Julian Perelman

Universidade NOVA de Lisboa | NOVA · National School of Public Health

Background Proton-pump-inhibitors (PPIs) are overprescribed, posing challenges to patients and healthcare systems. In Portugal, the public National Health Service (NHS) provides universal coverage and reimburses medication regardless of prescription origin, i.e., public or private. This study aimed to compare PPIs outpatient prescription patterns a...

Introduction Cannabis use among adolescents is a public health concern, because of its association with the use of other illicit drugs, mental health disorders, and social problems. Most studies show that adolescents from low socioeconomic status (SE) background are more likely to use cannabis, but the causes of SE inequalities remain to be underst...

Background Historically, women’s roles were predominantly associated with motherhood, leading to significant career interruptions and lower incomes compared to men. As gender roles have evolved, as did labor policies protecting parents, it would be expected that income penalties in women and income premiums in men would attenuate, especially in the...

Background Proton pump inhibitors (PPI) are frequently overprescribed, posing challenges to patients and healthcare systems. In Portugal, the publicly funded National Health Service (NHS) provides universal coverage and reimburses the cost of medications regardless of the prescription origin. If private practices may benefit from longer consultatio...

Background Air pollution, specifically particulate matter with a diameter of 2.5 micrometers (PM2.5), is the primary environmental health risk in Europe. Exposure to PM2.5 increases the risk of cardiovascular diseases, including AMI, resulting in high direct costs associated with in-patient treatment. This study aims to estimate the avoidable and a...

Background Severe mental health disorders directly affect quality of life but may also indirectly relate to physical diseases and their prognosis. We test this hypothesis for the specific case of acute myocardial infarction (AMI), postulating a longer in-patient stay and an excess in-hospital mortality among patients suffering psychiatric comorbidi...

Background Parenthood may affect men’s and women’s personal lives, professional careers, and well-being differently. In the last decades, structural modifications in gender norms, the labor market, and family-supporting policies have occurred, but with cross-country variations, even within European borders. This study aimed to update the estimates...

Background The intense childrearing years often coincide with the heightened work demands and responsibilities of the career-building years. We aimed to evaluate the association between family-life stage and men’s and women’s experience of work and private demands, and the conflict between these demands. Methods We evaluated 3532 mothers and 731 f...

Background Portugal faces a shortage of primary care workforce resulting in an increase in patients without Family Physician (FP). While expanding the patient list per FP may help, it could also result in excessive workloads, compromising Consultation Times (CT) and quality of care. Furthermore, it is important to study the role of the primary heal...

Background Incentivizing healthcare professionals through pay-for-performance (P4P) schemes has become an essential strategy to enhance healthcare quality and efficiency. In Portugal, a P4P framework was put in place in Primary Health Care (PHC). Understanding how these incentives influence healthcare delivery is crucial for optimizing P4P effectiv...

Objectives In the context of rapid transformations in family structures, understanding how household composition can affect adults' health behaviours is crucial, particularly when considering the potential role of such close social relationships in shaping those behaviours. This paper documents how household structure relates to individual health b...

Background Teleworking (TW) has recently shifted from a marginal into a common practice. Yet, concerns have been raised regarding potential work-health negative effects, related to the reduced socialization, and extended working hours with computers at home, possibly offset by reduced commuting time or better individual work-life balance. This pape...

Background Changing dietary patterns is essential to reducing the substantial environment impact of agriculture and food production systems. We performed a cross-country comparison of dietary patterns and their associated environmental impact in Europe, including by sociodemographic factors. Methods We analyzed pooled cross-sectional dietary recor...

The magnitude of the impact of technological innovations on healthcare expenditure is unclear. This paper estimated the impact of high-technology procedures on public healthcare expenditure for patients with ischemic heart disease (IHD) in Portugal. The Blinder–Oaxaca decomposition method was applied to Portuguese NHS administrative data for IHD di...

Introduction Worldwide, demographic ageing is a major social, economic and health challenge. Despite the increase in life expectancy, elderly often live with multiple chronic conditions, exposing them to multiple medications. Concerns have been raised about the growing issue of inappropriate long-term usage of proton-pump inhibitors (PPI), which ha...

Background: The evidence indicates a high prevalence of malnutrition, such as stunting and overweight, among Iranian children. Yet, this prevalence may not be equally distributed across socioeconomic groups, so that non-targeted policies may be ineffective. This paper aimed to measure the socioeconomic patterning of children's stunting and overweig...

Background Coupled with its impact on quality of life, non-communicable Diseases (NCD) may degrade both the quality and quantity of the workforce, and stunt economic growth and productive employment. However, there is limited information about the social costs of NCDs to identify priorities in resource allocation, particularly in regard to retireme...

Background Least favored people experience poorer health than those with higher socioeconomic (SE) status. These inequalities are mainly due to disparities in noncommunicable diseases (NCD). Over the last decades, Portugal experienced important SE challenges, including the recession, making it fundamental to assess how health inequalities have been...

Background: Price erosion of generic medicines over time as a result of existing pricing policies in combination with increasing operational costs of these products due to high inflation, undermine long-term sustainable competition in European off-patent medicines markets. Therefore, the aim of this study is to identify new potential pricing models...

Background While it is known that educational inequalities in smoking start during early and middle adolescence, it is unknown how they further develop until adulthood. The aim of this article is to map, in the Portuguese context, how educational inequalities in smoking emerge from pre-adolescence until young adulthood. Methods This study used lon...

Background: Smoking is inversely related to people's Physical Activity Level (PAL). As the behavior of friends may affect the choices and behavior of adolescents, having friends with a high PAL may potentially protect against adolescent smoking. This study aims to assess whether adolescents' smoking is associated with the PAL of their friends. Me...

Background While it is known that educational inequalities in smoking start during early and middle adolescence, it is unknown how they further develop until adulthood. The aim of this article is to map, in the Portuguese context, how educational inequalities in smoking emerge from pre-adolescence until young adulthood. Methods This study used lon...

Social network research has evidenced the role of peer effects in the adoption of behaviours. Little is known, however, about whether policies affect how behaviours are shared in a network. To contribute to this literature, we apply the concept of diffusion centrality to school tobacco policies and adolescent smoking. Diffusion centrality is a meas...

Background There is limited evidence on within-country discrepancies in biosimilar uptake. This study analyzes differences in timing and diffusion of biosimilar uptake across Portuguese NHS hospitals and explores possible determinants. Research design and methods We analyzed publicly accessible consumption data of originator biologic and biosimila...

Economic evaluation of public health interventions have mostly been performed for interventions whose cost and effectiveness can be well identified, such as protective interventions (vaccination or screening), clinical interventions (prevention drugs) or counselling and education programs. Yet, following the Thomas Frieden's health impact pyramid,...

Background School staff members’ consistent enforcement of school tobacco policies (STPs) is needed to decrease adolescent smoking and exposure to tobacco smoke. Staff’s confidence, indicating their perceived ability to cope with students’ negative responses, explains variations in staff’s STPs enforcement, yet understanding of the determinants for...

Background: The decreasing adherence in Mediterranean Diet (M.D.) during the last decades has been attributed to social, cultural and economic factors. However, recent efforts to improve dietary habits and the economic improvement might be reversing this trend. We analyze the changes in M.D. adherence between 2013 and 2019 among a sample of Europe...

Background Previous literature has showed that the likelihood of smoking is higher among offspring with smoking parents. The aim of this cohort study is to investigate during which smoking initiation stages and at what ages adolescents are more likely to be influenced by parental smoking. Methods This study used the EPITeen Cohort, which recruited...

Introduction: International evidence has unveiled the existence of social inequalities in the risk of death associated with SARS-CoV-2 (COVID-19). In Portugal, the impossibility to identify the socioeconomic condition of deceased people hinders this evaluation. This study analyzes the social inequalities in the risk factors of COVID-19 mortality i...

This study assesses factors associated with perception of need and affordability concerns regarding mental health services (MHS), among 978 persons with meaningful depressive symptoms (Patient Health Questionnaire≥10). We used data from the 6th Portuguese National Health Interview Survey and used logistic regressions with gender, age, severity of s...

Objectives: Recent literature points out that elderly people are psychologically resilient to COVID-19, but the studies were performed in specific contexts. We measured the link between the worsening of mental health symptoms, the epidemiologic situation, and control measures among European people aged 50 or older. Methods: We used data from the 20...

Introduction: Delayed hospital discharge is a phenomenon identified since the 50s of the last century, with studied effects on patients’ health status deterioration and health system’s func-tioning implications, resulting in high social and economic costs. This study aims to study its extension and determinants for the Portuguese National Health Se...

Introduction Training school children may help to increase the rate of citizen-initiated resuscitation. However, training in school settings exclusively by healthcare professionals would lead to high costs for the Portuguese National Health Service. The aim of this study was to assess the costs and effectiveness of training by school teachers, in c...

Food subsidies for healthier foods and higher taxes for less healthy alternatives have been increasingly used to promote a healthy diet. Yet, some have argued that the fiscal burden on unhealthy products would fall disproportionately on the worse-off, raising equity concerns. This study estimates the association between income and the consumption o...

Background: Deprescribing can reduce the use of inappropriate or unnecessary medication; however, the economic value of such interventions is uncertain. Objective: This study seeks to identify and synthesise the economic evidence of deprescribing interventions among community-dwelling older adults. Methods: Full economic evaluation studies of depre...

Introduction The COVID-19 pandemic has transformed working at home (WAH) into the exclusive mode of working for many European workers. Although WAH will likely remain after COVID-19, its consequences on workers' health are unclear. This study examines the association of WAH and the change of four mental health (MH) domains. Methods We used data fr...

Background Accurate data on hypertension is essential to inform decision-making. Hypertension prevalence may be underestimated by population-based surveys due to misclassification of health status by participants. Therefore, adjustment for misclassification bias is required when relying on self-reports. This study aims to quantify misclassification...

Objectives There is no clear evidence about the association between socioeconomic status (SES) and mental health services (MHS) use. Those with lower SES may be less prone to recognize they need MHS, but they may access free health services. This study aims to assess the link between SES, needs perception and affordability of MHS, among depressed p...

Background Women are more likely than men to use mental health services use (MHS) when depressed. Gendered presentations of depression may contribute to explain this gender gap. This study aims to identify depression symptom profiles among men and women and to understand their relationship with perception of MHS need. Methods We used data from the...

Background Multimorbidity among the elderly represents a serious challenge for health systems. Older adults are often exposed to polypharmacy and inappropriate medication, which are associated with adverse events and increased healthcare use. This study aims to identify and synthetize the economic evidence of deprescribing interventions among commu...

Research has shown that health service utilisation for depression (HSUD) is less common among men than women. However, most evidence is cross-sectional, and there is limited information about gendered outcomes of depression. This cross-country study assesses gender differences in HSUD and in the persistence of depression by using cross-sectional an...

Background Adherence to the Mediterranean diet has been decreasing in southern Europe, which could be linked to several cultural or educational factors. Our aim is to evaluate the extent to which economic aspects may also play a role, exploring the relationship between food prices in Portugal and adherence to the Mediterranean diet. Methods We eva...

Background The relationship between socioeconomic position (SEP) and adolescent physical activity is uncertain, as most evidence is limited to specific settings and a restricted number of SEP indicators. This study aimed to assess the magnitude of socioeconomic differences in adolescent vigorous physical activity (VPA) across various European count...

Background: Food is a major determinant of chronic noncommunicable diseases. Because of this, social inequalities in food consumption will likely produce social inequalities in disease and life expectancy. Objectives: This study analyses the social inequalities in food consumption in Portugal and whether they differ between men and women and betwe...

Background Paid employment has been shown to benefit childless women’s health, while employed mothers experience poorer health, and more pronounced fatigue. This study measures the association between job characteristics and the health and well-being of employed mothers and the differential susceptibility to job characteristics between coupled and...

Background Despite an overall reduction in suicide, educational disparities in suicide have not decreased over the last decade. The mechanisms behind educational disparities in suicide, however, remain unclear: low educational status may increase the risk of suicide (“causation”) or low educational status and suicide may share confounders. This pap...

Objectives The aim of this study was to evaluate the federal government expenditures with oncological care, for the most incident cancer types among the Brazilian population, using registries of all patients treated by the Brazilian National Health Service (SUS) between 2001 and 2015. We adopted the formal healthcare sector perspective in this stud...

Significant gender-based health inequalities have been observed across Europe, with women reporting worse health than men. Still, there has been little examination of how the gender–health gap has changed over time, and how it has been shaped by societal gender equality. We used data from the Statistics on Income and Living Conditions Eurostat data...

Background Across Europe, women tend to report worse health than men, probably due to women's lower position in society. Although societal gender inequalities have decreased, differences persist regarding employment, income and use of time. This study aims to assess the evolution of gender-based inequalities in 27 European countries between 2004 a...

Background Depression is largely unrecognized and untreated, particularly among men. Help-seeking behaviors are known to differ between genders, yet, these discrepancies are expected to vary along the socioeconomic distribution. This study assesses the gender-related treatment gap for depression and analyzes how it varies with the socioeconomic sta...

Background Women combining paid job and motherhood may experience a poorer health status than those childless. This risk is expectedly higher among lone mothers due to their greater emotional, social, and economic vulnerability. This study aims to assess the impact of employment characteristics on the health of working mothers and to understand dif...

In March 2018, a Mission Structure (EMSPOS) was created in Portugal, under supervision of both Ministries of Health and Finance, to analyze the economic situation of the National Health Service (NHS), and propose recommendations to ensure its financial sustainability. The main concern was the recurrent cycles of overdue debt of NHS hospitals, which...

Between 2005 and 2007, important reinforcements of the tobacco legislation have been implemented in Portugal, which may have affected smoking patterns. The aim of this study was to measure the change in prevalence of first- and second-hand smoking (SHS) among adults, and its socio-demographic patterning in Portugal from 2005 to 2014. Data from the...

Peer networks at school and students’ position in these networks can influence their academic well-being. We study here individual students’ network position (isolation, popularity, social activity) and peer network structures at the school level (centralization, density, clustering, school connectedness) and their relations to students’ academic w...

In 2006 a major primary care reform was initiated in Portugal. The most significant aspect of this reform was the creation of a new organizational model of primary care provision: Family Health Units (FHUs), consisting of small voluntarily constituted multidisciplinary teams that have functional autonomy and are partly financed through capitation a...

There is evidence of a relationship between in utero exposure to catastrophic events and adverse birth outcomes, usually attributed to heightened maternal stress. The objective of our work was to evaluate if the breakage of a dam containing wastefrom a mining cite in Brazil, in 2015, an environmental disaster popularly known as the Mariana Tragedy,...

Background Advocacy, resources and intersubjective reasonable arguments are known as factors that contribute to smoke-free (SF) adoption and implementation in Chinese and Anglo-Saxon places. Less is known about how the implementation of smoking bans differs across European places. The aim of this qualitative comparative study is to identify and cl...

Objectives To describe the association between multimorbidity and intention of retirement in Europe and to understand whether this relationship is modified by the working environment and disability integration policies. Methods Participants were 11,790 employees aged 50–65 years old who responded to the sixth wave of SHARE project (2015). We model...

Background: Many European schools implement smoke-free school policies (SFSPs). SFSPs may decrease adolescent smoking by causing adolescents to perceive stronger anti-smoking norms, yet there exists no quantitative evidence that indicates for which norms and for whom such effects may occur. This study therefore assessed to what extent adolescents'...

Background Secondhand smoke exposure is responsible for over half a million premature deaths. With regulation now reducing smoking in most public enclosed spaces, one major source of indoor exposure remains the home environment. Home smoking bans (HSBs) are household rules that restrict smoking from certain (partial HSB) or all areas (complete HSB)...

Background That women generally have worse health than men has long been shown. Yet, the situation in Europe might have changed recently. Gender inequalities have decreased in access to education, employment, and political representation. However, women have increasingly adopted traditionally masculine unhealthy behaviors, such as smoking. Also, th...

Background: Tobacco-control policies have been suggested to reduce smoking among adolescents. However, there is limited evidence on the real-world costs of implementation in different settings. In this study, we aimed at estimating the costs of school smoking bans, school prevention programmes and non-school bans (smoking bans in non-educational p...

Introduction: Bans on smoking in public places and on sales to minors have been widely implemented across the globe. However, many countries have either adopted non-comprehensive (i.e., partial) bans and/or weakly enforce those bans. Little is known, from the adolescents' perspective, how this affects their smoking-related perceptions and behavior...

Objective Food insecurity (FI) is defined as uncertain access to healthy food in quantity and quality. We hypothesize that FI may be associated with greater health-care use and absenteeism because it may amplify the effect of diseases; also, FI may be associated with reduced health-care access because it reflects economic vulnerability. The present...

Background Smoke-free school policies (SFSPs) may influence adolescents’ smoking through the development of anti-smoking beliefs. We assessed which types of anti-smoking beliefs (health, social and societal) are associated with SFSPs and whether these associations were different for adolescents in smoking permissive versus prohibitive families. M...

Introduction Economic evaluations of tobacco control policies targeting adolescents are scarce. Few take into account real-world, large-scale implementation costs; few compare cost-effectiveness of different policies across different countries. We assessed the cost-effectiveness of five tobacco control policies (non-school bans, including bans on s...

Background Although there is evidence for socioeconomic inequalities in health and health behaviour in adolescents, different indicators of socioeconomic status (SES) have rarely been compared within one data sample. We examined associations of five SES indicators with self-rated health (SRH) and smoking (ie, a leading cause of health inequalities)...

Background: Schools have a crucial role to play in preventing youth smoking. However, the well-known long-term health consequences of youth smoking may be insufficient to convince education stakeholders to devote efforts to implement school-based programmes. However, if youth smoking were to have short-term consequences, this evidence could prompt...

In a context of increasing ageing of the population, it is crucial to better understand multimorbidity and its consequences. This study measured the prevalence of multimorbidity in a Southern Europe population and projected its evolution based on expected demographic changes. It also analysed its associated consequences on self-reported health stat...

Objective We aimed at analysing changes in consumption of selected food groups in the Portuguese population before and after the Great Recession, which hit the country between 2008 and 2013. Design We used pooled cross-sectional data from the Portuguese National Health Interview Surveys of 2005/2006 and 2014. We modelled the probability of consump...

In Portugal, a mental health reform process is in place aiming to redefine the model of service provision. In 2008, a National Mental Health Plan (NMHP) was approved to provide policy guidance over the transition period. The NMHP intended, among others, to develop community‐based services, with a specific focus on rehabilitation and deinstitutional...

Background and Aims The impact of tobacco control on European older adults has not been studied, despite evidence that smoking cessation at old age can bring significant life expectancy gains. Our aim was to evaluate the impact of tobacco control policies on smoking among older adults in Europe from 2004 to 2013. Design We used longitudinal data fr...

Although winter mortality and morbidity are phenomena common to most European countries, their magnitude varies significantly from country to country. The geographical disparities among regions with similar climates are the result of several social, economic, demographic, and biological conditions that influence an individual’s vulnerability to win...