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Background In many countries, the prevalence of non-communicable diseases risk factors is commonly assessed through self-reported information from health interview surveys. It has been shown, however, that self-reported instead of objective data lead to an underestimation of the prevalence of obesity, hypertension and hypercholesterolemia. This study aimed to assess the agreement between self-reported and measured height, weight, hypertension and hypercholesterolemia and to identify an adequate approach for valid measurement error correction. Methods Nine thousand four hundred thirty-nine participants of the 2018 Belgian health interview survey (BHIS) older than 18 years, of which 1184 participated in the 2018 Belgian health examination survey (BELHES), were included in the analysis. Regression calibration was compared with multiple imputation by chained equations based on parametric and non-parametric techniques. Results This study confirmed the underestimation of risk factor prevalence based on self-reported data. With both regression calibration and multiple imputation, adjusted estimation of these variables in the BHIS allowed to generate national prevalence estimates that were closer to their BELHES clinical counterparts. For overweight, obesity and hypertension, all methods provided smaller standard errors than those obtained with clinical data. However, for hypercholesterolemia, for which the regression model’s accuracy was poor, multiple imputation was the only approach which provided smaller standard errors than those based on clinical data. Conclusions The random-forest multiple imputation proves to be the method of choice to correct the bias related to self-reported data in the BHIS. This method is particularly useful to enable improved secondary analysis of self-reported data by using information included in the BELHES. Whenever feasible, combined information from HIS and objective measurements should be used in risk factor monitoring.

Funding Information: INSEF was developed as part of the predefined project of the Public Health Initiatives Program “Improvement of epidemiological health information to support public health decision and management in Portugal: Towards reduced inequalities, improved health, and bilateral cooperation”, which benefited from a EUR 1,500,000 grant from Iceland, Liechtenstein, and Norway through the European Economic Area Grants and from the Government of Portugal. Publisher Copyright: © 2021 The Author(s). Published by S. Karger AG, Basel on behalf of NOVA National School of Public Health. Introduction: The incidence of colorectal cancer is increasing worldwide. However, the screening uptake is generally low. We analyzed the association between sociodemographic, economic, and access-to-healthcare factors and the use of exams that are the basis for colorectal cancer screening in Portugal. Methods: We conducted a cross-sectional study based on data from the 1st National Health Examination Survey. We used Poisson regression to estimate prevalence ratios and study factors associated with the use of fecal immunochemical tests (FIT) and colonoscopy in a Portuguese population aged 50-74 years (n = 2,489). Results: 45.7% of the individuals reported using FIT in the previous 2 years; 37.3% reported using colonoscopy in the previous 5 years. The use of FIT was associated with age group, health region, and having a family doctor. It was higher in older individuals (47.6% in the age group 70-74 years vs. 38.1% in the age group 50-54 years; adjusted prevalence ratio [aPR] = 1.32; 95% CI 1.05-1.65), and in individuals assigned to a family doctor (47.6 vs. 30.3%; aPR = 1.50; 95% CI 1.14-1.98). Colonoscopy was associated with age group, health region, higher education, economic capacity, and having a family doctor. It was higher in older individuals (45.3% in the age group 70-74 years vs. 25.6% in the age group 50-54 years; aPR = 1.85; 95% CI 1.42-2.40), individuals with a higher economic capacity (40.5 vs. 32.4%; aPR = 1.19; 95% CI 1.01-1.40), and individuals assigned to a family doctor (38.7 vs. 25.6%; aPR = 1.43; 95% CI 1.08-1.91). Discussion/Conclusion: In our analysis, the use of FIT and colonoscopy was influenced by sociodemographic, economic, and access-to-healthcare factors. This is relevant to guide interventions in this area. It is essential to ensure an equitable and uniform implementation of the screening program, with family doctors as an important part of the process. publishersversion published

In Italy, the last 30 years witnessed the implementation of cross-sectional surveys providing baseline data on numerous risk factors collected from random samples of the adult general population. In order to support those groups who would like to implement an health examination survey (HES), according to the experience of the CUORE Project surveys, the objective of this paper is to describe some information related to the organization of a survey (examination sites and sampling, selection of analytic laboratory, coordination and personnel involved, sample selection, recruitment and appointment scheduling, informative notice and informed consent, participation rate, non-participation bias, quality assurance, survey data, long term storage of the samples, internal quality control, external quality assessment, feedback to participants, error checking, correction and documentation of the data, transfer and storage of the data, statistical analyses and interpretation of results, dissemination of results), usually shortly described in scientific papers but relevant when an HES is planned.

AD HOC SURVEYS: HOW TO MEASURE AND REPORT QUALITY METHODS Surveys need a clear report on adopted quality methods to support surveillance, research and to implement evidence-based health policies. Aim of this report is to provide a simple and practical tool to those interested in survey, like HIS or HES , suggesting the different aspects of the quality to be controlled. These are crucial to generate useful and reliable results that can help the monitoring of health policy in Europe. Starting from the wide literature available in the field, the various quality dimensions that should be documented in a quality report and support the published results are briefly presented. In this paper, the six dimensions of the quality are analysed, as well as the different steps necessary to implement a survey, with particular attention to the quality and taking account of the remarkable expertise in the field. Before starting the survey, as known, the planning of specific steps is required. Moreover, to improve quality, training and testing of personnel involved in the different sets (organization, data collection, data processing, and statistical analysis) are fundamental. The methods used and the results obtained need to be published.

Background In 2018 the first Belgian Health Examination Survey (BELHES) took place. The target group included all Belgian residents aged 18 years and older. The BELHES was organized as a second stage of the sixth Belgian Health Interview Survey (BHIS). This paper describes the study design, recruitment method and the methodological choices that were made in the BELHES. Methods After a pilot period during the first quarter of the BHIS fieldwork, eligible BHIS participants were invited to participate in the BELHES until a predefined number (n = 1100) was reached. To obtain the required sample size, 4918 eligible BHIS participants had to be contacted. Data were collected at the participant’s home by trained nurses. The data collection included: 1) a short set of questions through a face-to-face interview, 2) a clinical examination consisting of the measurement of height, weight, waist circumference, blood pressure and for people aged 50 years and older handgrip strength and 3) a collection of blood and urine samples. The BELHES followed as much as possible the guidelines provided in the framework of the European Health Examination Survey (EHES) initiative. Finally 1184 individuals participated in the BELHES, resulting in a participation rate of 24.1%. Results for all the core BELHES measurements were obtained for more than 90% of the participants. Conclusion It is feasible to organize a health examination survey as a second stage of the BHIS. The first successfully organized BELHES provides useful information to support Belgian health decision-makers and health professionals. As the BELHES followed EHES recommendations to a large extent, the results can be compared with those from similar surveys in other EU (European Union) member states.

Background: Participation rates in health surveys, recognized as an important quality dimension, have been declining over the years, which may affect representativeness and confidence in results. The Portuguese national health examination survey INSEF (2015) achieved a participation rate of 43.9%, which is in line with participation rates from other similar health examination surveys. The objective of this article is to describe how local teams of survey personnel conducted the survey, describing strategies used to solve practical survey problems and to try to increase the participation rate. Methods: After a literature search, informal interviews were conducted with 14 public health officials from local health examination teams, regional and central authorities. Forty-one of the local staff members (survey personnel) also filled in a short questionnaire anonymously. The interviews and self-administered questionnaires were analysed using mixed methods, informed by thematic analysis. Results: The local teams believed that the detailed manual, described as a “cookbook for making a health examination survey”, made it possible to maintain high scientific standards while allowing for improvising solutions to problems in the local context. The quality of the manual, supported by a series of training workshops with the central research and support team, gave the teams the confidence and knowledge to implement local solutions. Motivation and cohesion within the local teams were among the goals of the training process. Local teams felt empowered by being given large responsibilities and worked hard to incite people to attend the examination through a close and persuasive approach. Local teams praised their INSA contacts for being available for assistance throughout the survey, and said they were inspired to try harder to reach participants to please their contacts for interpersonal reasons. Conclusions: The theory of organizational improvisation or bricolage, which means using limited resources to solve problems, was useful to discuss and understand what took place during INSEF. A detailed manual covering standard procedures, continuous monitoring of the data collection and face-to-face workshops, including role-play, were vital to assure high scientific standards and high participation rates in this health examination survey. Close contacts between the central team and local focal points in all regions and all survey sites were key to accommodating unexpected challenges and innovative solutions. The Portuguese National Health Examination Survey 2015 (INSEF) was developed as part of the Pre-defined project of the Public Health Initiatives Program (reference 000039_ PDP), ‘‘Improvement of epidemiological health information to support public health decision and management in Portugal. Towards reduced inequalities, improved health, and bilateral cooperation”, that benefits from a 1.500.000€ Grant from Iceland, Liechtenstein and Norway through the European Economic Area Financial Mechanism (EEA Grants), 85%, and from the Portuguese Government, 15%. The INSEF data collection was co-funded by EEA Grants and the Portuguese Government. The analyses and writing of the present study were funded by the Norwegian Institute of Public Health and the workplaces of the co-authors. info:eu-repo/semantics/publishedVersion

Introduction: The metabolic syndrome consists of a set of factors that, when associated, are associated with a higher risk of developing cardiovascular diseases and type 2 diabetes, and is thus an important public health problem. The objective of this study was to estimate the prevalence of this syndrome in the Portuguese population, and to evaluate possible associations with demographic and socioeconomic determinants. Material and Methods: Based on the 1st National Health Survey with Physical Examination of 2015, a cross-sectional epidemiological study was conducted on a representative sample of the Portuguese population (n = 4797) aged between 25 and 74 years old. The prevalence was estimated for the total population and each gender, stratified by age group, health region, type of urban area, marital status, education, professional status, and risk of poverty. The magnitude of the associations was measured with adjusted prevalence ratios. Results: In the Portuguese population the estimated prevalence was 33.4% [95% CI, 31.7 – 35.1] [35.6% in men (95% CI, 31.9 – 39.2) and 31.3% in women (95% CI, 28.5 – 34.2)]. In both genders, the highest prevalence was significantly associated with increasing age, widowed/married/de facto partners and those with lower levels of education. There was no association with gender, health region, type of urban area, professional status or risk of poverty. Discussion: This syndrome was present in a third of the Portuguese population. The knowledge of its epidemiology enables the identification of population groups with higher cardiovascular and metabolic risk. Conclusion: Metabolic syndrome was independently associated with specific groups. This knowledge reinforces the importance of a holistic assessment of the health determinants associated with the metabolic syndrome. Introdução: A síndrome metabólica consiste num conjunto de fatores que, quando associados, conferem maior risco de desenvol-ver doenças cardiovasculares e diabetes tipo 2, constituindo um importante problema de saúde pública. O objetivo deste estudo foi estimar a prevalência desta síndrome na população portuguesa, e avaliar possíveis associações com determinantes demográficos e socioeconómicos.Material e Métodos: Com base no primeiro Inquérito Nacional de Saúde com Exame Físico de 2015, realizou-se um estudo epidemio-lógico transversal numa amostra representativa da população portuguesa (n = 4797) entre os 25 e 74 anos. A prevalência foi estimada na população total e em cada sexo, estratificada por grupo etário, região de saúde, tipologia de área urbana, estado civil, escolaridade, situação profissional e risco de pobreza. A magnitude das associações foi medida pelas razões de prevalências ajustadas.Resultados: A prevalência estimada foi de 33,4% (IC 95%, 31,7 – 35,1) na população portuguesa [35,6% nos homens (IC 95%, 31,9 – 39,2) e 31,3% nas mulheres (IC 95%, 28,5 – 34,2)]. Em ambos os sexos, a maior prevalência estava significativamente associada ao aumento da idade, a indivíduos viúvos/casados/unidos de facto e com menor escolaridade. Não se verificou associação com sexo, região de saúde, tipologia de área urbana, situação profissional ou risco de pobreza.Conclusão: A síndrome metabólica estava independentemente associada a grupos específicos. Este conhecimento reforça a impor-tância de uma avaliação holística dos determinantes de saúde associados à síndrome metabólica. 1º Inquérito Nacional de Saúde com Exame Físico (INSEF 2015), parte integrante do projeto pré-definido do Programa Iniciativas em Saúde Pública “Improvement of epidemiological health information to support public health decision and management in Portugal. Towards reduced inequalities, improved health, and bilateral cooperation”, beneficia de um apoio financeiro de cerca de 1 500 000€ concedido pelo Mecanismo Financeiro do Espaço Económico Europeu 2009-2014 através das EEA Grants e pelo Governo de Portugal. info:eu-repo/semantics/publishedVersion

Background Metabolic syndrome (MetS) is a public health problem in Europe, affecting all age groups. Several MetS definitions are available. The aim of this study was to compare four different MetS definitions in the Finnish adult population, to assess their agreement and to evaluate the impact of the choice of the definition on the prevalence of MetS. Methods Data from FinHealth 2017, a cross-sectional national population health survey, focusing on adults aged 25 years or older were used in the analysis (n=5687). Measured data on anthropometrics, blood pressure and biomarkers together with questionnaire data were used to classify the participants into the MetS categories according to the four definitions. The definitions chosen for the comparison were those by the World Health Organization (WHO) (1998), National Cholesterol Education Program Adult Treatment Panel III (NCEP-ATP III) (2004), International Diabetes Federation (IDF) (2005), and Joint Interim Statement (JIS) (2009). Results The four MetS definitions resulted in substantially different MetS prevalence: 17.7% by WHO, 33.3% by NCEP-ATP III, 41.5% by IDF, and 43.0% by JIS. Regardless of the definition used, the prevalence of MetS increased with age. The prevalence of the different components varied between the definitions, depending on the different cut-off points adopted. Out of all participants, only 13.6% were identified to have MetS according to all four definitions. Agreement between participants recognised by different MetS definitions, estimated through kappa coefficients, was almost perfect for IDF vs. JIS (0.97), strong for JIS vs. NCEP-ATP III (0.80), moderate for IDF vs. NCEP-ATP III (0.76) and weak for WHO vs. NCEP-ATP III (0.42), WHO vs. IDF (0.41) and WHO vs. JIS (0.40). Conclusions Differences between observed prevalence of MetS in Finnish men and women using different MetS definitions were large. For cross-country comparisons, as well as for trend analyses within a country, it is essential to use the same MetS definition to avoid discrepancies in classification due to differences in used definitions.

UIDB/04647/2020 UIDP/04647/2020 Background Participation rates in health surveys, recognized as an important quality dimension, have been declining over the years, which may affect representativeness and confidence in results. The Portuguese national health examination survey INSEF (2015) achieved a participation rate of 43.9%, which is in line with participation rates from other similar health examination surveys. The objective of this article is to describe strategies used by the local teams to increase participation rates and to solve practical survey problems. Methods After a literature search, informal interviews were conducted with 14 public health officials from local health examination teams, regional and central authorities. 41 of the local staff members also filled in a short questionnaire anonymously. The interviews and self-administered questionnaires were analysed using mixed methods, informed by thematic analysis. Results The local teams believed that the detailed manual, described as a "cookbook for making a health examination survey", made it possible to maintain high scientific standards while allowing for improvising solutions to problems in the local context. The quality of the manual, supported by a series of training workshops with the central research and support team, gave the teams the confidence and knowledge to implement local solutions. Motivation and cohesion within the local teams were among the goals of the training process. Local teams felt empowered by being given large responsibilities and worked hard to incite people to attend the examination through a close and persuasive approach. Local teams praised their INSA contacts for being available for assistance throughout the survey, and said they were inspired to try harder to reach participants to please their contacts for interpersonal reasons. Conclusions The theory of organizational improvisation or bricolage, which means using limited resources to solve problems, was useful to discuss and understand what took place during INSEF. A detailed manual covering standard procedures and face-to-face workshops, including role-play, were vital to assure high scientific standards and high participation rates in this health examination survey. Close contacts between the central team and local focal points in all regions and all survey sites were key to accommodating unexpected challenges and innovative solutions. publishersversion published

Variations in blood count parameters are potential mechanisms involved in the occurrence of cardiovascular events caused by particulate matter (PM) exposure. This study aims to estimate the effect of PM10 exposure on blood count parameters with potential to mediate a cardiovascular event. We used data from 2211 participants of the 1st Portuguese Health Examination Survey (INSEF, 2015) with available information on blood count parameters and living within a 30-km radius of at least one air quality monitoring station with available PM10 measurements. Generalised linear models were used to assess both short (3 days) and long-term effects (1 year) of PM10 exposure on blood count parameters. Both short and long-term PM10 effects on blood count parameters were found, with males and females affected in a different way. In the short-term scenario, we found a 2.76% (95% CI: 0.65–4.87) increase in white blood cells among females per each 10μg/m3 PM10 increment. Additionally, there was a 2.96% (95% CI: 0.80–5.12) increase in red cell distribution width (RDW), per each 10μg/m3 PM10 increment, among males, when considering the long-term scenario. In conclusion, we detected some sex-differential associations regarding the short and long-term effect of PM10 exposure on blood count parameters with potential to mediate a cardiovascular event, namely on the RDW parameter, that were never been described. It is uncertain whether changes in blood count parameters due to PM10 exposure constitute an adverse health outcome or it reflects only a normal immunity response. However, due to its potential to trigger cardiovascular events, it is essential to reduce PM10 levels exposure to protect the population’s cardiovascular health. INSEF was developed as part of the Pre-defined project financed under the Public Health Initiatives Program. “Improvement of epidemiological health information to support public health decision and management in Portugal. Towards reduced inequalities, improved health and bilateral cooperation” with a 1.500.000€ Grant from Iceland, Liechtenstein and Norway from EEA Grants and the Portuguese Government. The present study was also funded by the Portuguese Foundation for Science and Technology (FCT) (PhD Scholarship Reference: SFRH/BD/129426/2017). J. Ferreira is funded by national funds (OE), through FCT – Fundação para a Ciência e a Tecnologia, I.P., in the scope of the framework contract foreseen in the numbers 4, 5 and 6 of the article 23, of the Decree-Law 57/2016, of August 29, changed by Law 57/2017, of July 19. Thanks are also due to FCT/MCTES for the financial support to CESAM (UIDP/50017/2020+UIDB/50017/2020), through national funds. info:eu-repo/semantics/publishedVersion

Background Nationwide data on cardiovascular risk factors prevalence is lacking in Greece. This work presents the findings of the national health examination survey EMENO (2013–2016) regarding the prevalence of hypertension, hypercholesterolemia, diabetes, obesity and smoking. Methods A random sample of adults (≥18 years) was drawn by multistage stratified random sampling based on 2011 Census. All EMENO participants with ≥1 measurement of interest [blood pressure (BP), fasting glucose, HbA1c, total cholesterol (TC), Body Mass Index (BMI)] were included. Hypertension was defined as BP ≥ 140/90 mmHg and/or antihypertensive treatment; diabetes as fasting glucose≥126 mg/dL and/or HbA1c ≥ 6.5% or self-reported diabetes; hypercholesterolemia as TC ≥ 190 mg/dL. Sampling weights were applied to adjust for study design and post-stratification weights to match sample age and sex distribution to population one. Non-response was adjusted by inverse probability weighting. Results Of 6006 EMENO participants, 4822 were included (51.5% females, median age:47.9 years). The prevalence of hypertension was 39.2%, higher in men (42.4%) than in women (36.1%); of hypercholesterolemia 60.2%, similar in men (59.5%) and women (60.9%); of diabetes 11.6%, similar men (12.4%) and women (10.9%); of obesity 32.1%, higher in women (33.5% vs 30.2%), although in subjects aged 18–40 year it was higher in men; of current smoking 38.2%, higher in men (44.0%) than in women (32.7%). The prevalence of all risk factors increased substantially with age, except smoking, which followed an inverse U shape. Conclusions The burden of cardiovascular risk factors among Greek adults is alarming. There is considerable preventive potential and actions at health care and societal level are urgently needed.

Improving healthy life years requires an effective understanding and management of the process of healthy ageing. Assessing the perceived health status and its determinants is a relevant step in this process. This study explored the potentialities of the Minimum European Health Module (MEHM) to cope with this critical issue. Investigation was conducted on 4798 Italian residents (49.7% women, aged 35&ndash, 79 years), participating in the CUORE Project Health Examination Survey 2008&ndash, 2012. The three MEHM questions&mdash, perceived health status, chronic morbidity and activity limitations&mdash, were examined also in association with living context, seasonality, marital status and level of education. A higher prevalence of health status negative perception was associated with older age (9% and 24% respectively in men and women aged 35&ndash, 44 years, 46% and 61% respectively in men and women aged 75&ndash, 79 years). In women, this negative perception was higher than in men in any age group, and reached 50% in the 65&ndash, 69 age group, 10 years earlier than in men. For both sexes, the level of education had a strong impact on this negative perception (odds ratio 2.32 and 2.72 in men and women respectively), while &ldquo, living alone&rdquo, played a greater impact in women than in men. MEHM activity limitations subscale was as much as 30% higher for questionnaires answered during the hottest months. This study identified potential predictors of perceived health status in adults aged 35&ndash, 79 years, which can be used to target interventions aimed at improving self-perceived health status.

Background The disability-adjusted life years (DALYs) summarize the burden of years of life lost (YLL) due to premature mortality and years lost due to disability (YLD). Our aim was to estimate the burden of ischemic heart disease (IHD) and chronic obstructive pulmonary disease (COPD) in Finland in 2012, and to examine, how much the YLD are affected by the use of different data sources. Methods The YLL were calculated using mortality data for the Finnish 25–74-year-old population in 2012. The YLD were calculated using data from the FINRISK 2012 survey (3041 males, 3383 females aged 25–74 years) and then directly adjusted to the corresponding population. Different administrative registers on 1) hospital inpatient episodes and specialist outpatient visits, 2) entitlement to specially reimbursed medicines, and 3) purchases of prescribed medicines were used for estimation of the YLD in addition to self-reported data. The DALYs were calculated without age-weighting. Results The YLL for IHD were 37.5 for males and 9.1 for females per 1000 population among 25–74-year-old people in Finland in 2012. The YLD for IHD varied markedly depending on which data sources were used. All data sources combined, the YLD per 1000 were 5.3 for males and 2.5 for females resulting in estimated 42.8 and 11.6 DALYs per 1000 due to IHD among males and females, respectively. For COPD, the YLL were 4.7 for males and 2.0 for females per 1000. Also for COPD, the YLD varied markedly depending on data sources used. The YLD per 1000 based on all data sources combined were 2.0 for males and 1.6 for females. As a result, estimated 6.7 and 3.6 DALYs per 1000 were due to COPD among males and females, respectively. Conclusions Especially for COPD, all mild disease cases could probably not be identified from the included registers. Thereby, including survey data improved the coverage of the data. The YLD of IHD and COPD varied markedly between the data sources used in the calculations. However, as YLL constituted a major part of DALYs for these diseases, the variation in YLD did not lead to substantial variation in DALYs.

UIDB/04647/2020 UIDP/04647/2020 Health surveys constitute a relevant information source to access the population's health status. Given that survey errors can significantly influence estimates and invalidate study findings, it is crucial that the fieldwork progress is closely monitored to ensure data quality. The objective of this study was to describe the fieldwork monitoring conducted during the first Portuguese National Health Examination Survey (INSEF) regarding protocol deviations and key performance indicators (KPI). Methods: Data derived from interviewer observation and from the statistical quality control of selected KPI were used to monitor the four components of the INSEF survey (recruitment, physical examination, blood collection and health questionnaire). Survey KPI included response rate, average time distribution for procedures, distribution of the last digit in a specific measure, proportion of haemolysed blood samples and missing values. Results: Interviewer observation identified deviations from the established protocols, which were promptly corrected. During fieldwork monitoring through KPI, upon implementation of corrective measures, the participation rate increased 2.5-fold, and a 4.4-fold decrease in non-adherence to standardized survey procedures was observed in the average time distribution for blood pressure measurement. The proportion of measurements with the terminal digit of 0 or 5 decreased to 19.6 and 16.5%, respectively, after the pilot study. The proportion of haemolysed samples was at baseline level, below 2.5%. Missing data issues were minimized by promptly communicating them to the interviewer, who could recontact the participant and fill in the missing information. Discussion/Conclusion: Although the majority of the deviations from the established protocol occurred during the first weeks of the fieldwork, our results emphasize the importance of continuous monitoring of survey KPI to ensure data quality throughout the survey. publishersversion published

Background The existence of multiple chronic conditions in the same patient is a public health problem, recognized as relevant to health systems. Individuals with multimorbidity have additional health needs, which in the context of continuous increase of life expectancy, imply a heavy burden to healthcare services. Methods We analysed the association between healthcare use (primary care, medical specialist consultations and hospitalizations) and multimorbidity in the Portuguese population aged 25-74 years old, using the Health Examination Survey (n = 4911) data. Logistic regression models adjusted for predisposing (age, education) and enabling (income, region of residence) factors were fitted separately for male and female. Odds ratios and CI95% were estimated. Results Prevalence of multimorbidity was 38.3% (95%CI: 35.4%; 41.3%). In males, after adjustment for confounding and when compared to patients without chronic conditions, multimorbidity was associated with greater use of primary care (OR = 3.7; CI95%: 2.3-5.8), medical specialist consultations (OR = 1.9; CI95%: 1.1-3.4) and hospitalizations (OR = 1.8; CI95%: 1.2-2.7). In female, statistically significant association between multimorbidity and healthcare use was observed for primary care (OR = 2.6; CI95%: 1.6-4.3) and medical specialist consultations (OR = 2.8; CI95%: 2.0-3.9), but not for hospitalizations. Both male and female with multimorbidity reported greater use of primary care, compared to individuals with only one chronic condition (OR = 2.4; CI95%: 1.3-4.4 and OR = 1.7; CI95%: 1.1-2.8, respectively). Conclusions Our results show a greater healthcare use in patients with multimorbidity, both in primary and hospital care. The availability of scientific evidence regarding the healthcare use, by patients with multimorbidity, may substantiate the discussion about the possible need for the Portuguese health system to adapt to these patients, with changes in policies that will allow better and more efficient treatment. Key messages This study may support the discussion about the adaptation of Portuguese health system to patitents with multimorbidity. Further discussion on policy change is needed, targeting an efficient management of these patients.

IntroductionWith the rapid ageing of the population in Europe, reliable estimates of the future development of the disease and disability burden as well as healthy life years in the older sections of the population are crucial. Meanwhile, the future prospects of the health and functional ability of the working-aged population are critical. The aims ofthe Projections of the burden of disease and disability in Finland – health policy prospectsresearch project are to provide information about the long-term consequences of health-related behaviours of the population and to project the potential improvement of the burden of disease and disability based on realistic scenarios about the development of risk behaviours in the total population and its subgroups.Methods and analysisThe analyses will be based on data from representative cross-sectional and longitudinal health examination surveys (HESs) conducted between 1972 to 2017 in Finland, and register data from several national administrative registers. Included HESs (FINRISK Surveys from 1972 to 2012, Mini-Finland Survey from 1978 to 1980, the Health 2000/2011 Surveys and the FinHealth 2017 Study) provide abundant information about biological and behavioural risk factors and the health and morbidity of the population. The modifiable risk factors used as predictors include hypertension, hyperlipidaemia, obesity, diabetes, physical inactivity, smoking, alcohol use and unfavourable diet. The main outcomes are ischaemic heart disease, cerebrovascular diseases, lung cancer, chronic obstructive pulmonary disease, Alzheimer’s disease and diabetes. Within the project, novel projection techniques of data-driven Bayesian hierarchical models to provide robust and comparable estimates will be developed.Ethics and disseminationThe prevailing legislation and regulations have been followed for all surveys. Surveys since 1997 have been approved by the respective Ethics Committees covering the scope of this project. A written informed consent was obtained from participants since 1997. The outputs of the project will include 8 to 10 scientific papers in peer-reviewed journals.

Objectives: This study aimed to compare the magnitude of educational inequalities in self-reported and examination-based hypertension and hypercholesterolemia and to assess the impact of self-reported measurement error on health inequality indicators. Methods: We used the Portuguese National Health Examination Survey data (n = 4911). The slope index of inequality (SII) and the relative index of inequality (RII) were used to determine the magnitude of absolute and relative education-related inequalities. Results: Among the 25-49-year-old (yo) men, absolute and relative inequalities were smaller for self-reported than for examination-based hypertension (SIIeb = 0.18 vs. SIIsr = - 0.001, p < 0.001; RIIeb = 1.99 vs. RIIsr = 0.86, p = 0.031). For women, the relative inequalities were similar despite differences in self-reported and examination-based hypertension prevalence. For hypercholesterolemia, self-reported relative inequalities were larger than examination-based inequalities among the 50-74-yo men (RIIsr = 2.28 vs. RIIeb = 1.21, p = 0.004) and women (RIIsr = 1.22 vs. RIIeb= 0.87, p = 0.045), while no differences were observed among 25-49-yo. Conclusions: Self-reported data underestimated educational inequalities among 25-49-yo men and overestimated them in older individuals. Inequality indicators derived from self-report should be interpreted with caution, and examination-based values should be preferred, when available. The Portuguese National Health Examination Survey (INSEF) was developed as part of the Pre-defined project of the Public Health Initiatives Program, “Improvement of epidemiological health information to support public health decision and management in Portugal. Towards reduced inequalities, improved health, and bilateral cooperation”, that benefits from a 1.500.000€ Grant from Iceland, Liechtenstein and Norway through the EEA Grants and by Portuguese Government. info:eu-repo/semantics/publishedVersion

INTRODUCTION: Oral health is a determinant for quality of life and preventive behaviours such as regular tooth brushing can reduce the risk of a wide spectrum of oral diseases. Adopting preventive behaviours increases the likelihood of being healthy and can be conditioned by demographic and socio-economic factors. OBJECTIVE: This study aims to describe preventive oral hygiene behaviours in the Portuguese population and assess their association with sociodemographic and socioeconomic factors. MATERIAL AND METHODS: A cross-sectional epidemiologic study was developed using data from the first Portuguese National Health Examination Survey. The target population comprised Portuguese community-dwelling residents aged between 25 and 74 years old. The percentage of individuals who brushed their teeth at least twice a day, provided that once was before sleeping, was considered the indicator showing a preventive behaviour, as this is recommended by the General Directorate of Health in Portugal. Poisson regression was used to identify factors independently associated with this behaviour. RESULTS: Sixty-five per cent of the participants reported tooth brushing as recommended. The prevalence of adoption of this preventive behaviour was higher among those living in urban areas and those who have higher educational level. Results show an association between being male and having low educational level with lesser adoption of preventive oral health behaviours. CONCLUSION: These findings suggest a need for integrated approaches, from measures tackling social inequalities to actions focused on improving health literacy. It is also important to expand dental healthcare services and improve effective coverage to increase access for rural population. INSEF was developed as part of the Pre-defined project of the Public Health Initiatives Program, entitled ‘Improvement of epidemiological health information to support public health decision and management in Portugal. Towards reduced inequalities, improved health and bilateral cooperation’, that benefited from a 1,500,000€ grant from Iceland, Liechtenstein and Norway through the EEA Grants. info:eu-repo/semantics/publishedVersion

Background: This study aimed to compare self-reported and examination-based prevalence of hypertension and hypercholesterolemia in Portugal in 2015 and to identify factors associated with the measurement error in self-reports. Methods: We used data from the Portuguese National Health Examination Survey (n = 4911), that combines personal interview, blood collection and, physical examination. Sensitivity and specificity of self-reported hypertension and hypercholesterolemia were calculated. Poisson regression was used to estimate prevalence ratios (PRs) of underreport of hypertension and hypercholesterolemia according to sex, age, socioeconomic status (education and income) and general practitioner (GP) consultation in the past year. Results: Sensitivity of self-reports was 69.8% for hypertension and 38.2% for hypercholesterolemia. Underreport of hypertension was associated with male gender (PR = 1.54), lack of GP consultation (PR = 1.70) and being 25–44 years old (PR = 2.45) or 45–54 years old (PR = 2.37). Underreport of hypercholesterolemia was associated with lack of GP consultation (PR = 1.15), younger age (PR = 1.83 for 25–44 age group and PR = 1.52 for 45–54 age group), secondary (PR = 1.30) and higher (PR = 1.27) education. Conclusion: Self-reported data underestimate prevalence of hypertension and hypercholesterolemia. Magnitude of measurement error in self-reports varies by health conditions and population characteristics. Adding objective measurements to self-reported questionnaires improve data accuracy allowing better understanding of socioeconomic inequalities in health. O primeiro Inquérito Nacional de Saúde com Exame Físico foi desenvolvido como parte integrante do projeto “Improvement of epidemiological health information to support public health decision and management in Portugal. Towards reduced inequalities, improved health, and bilateral cooperation”, que beneficiou de um apoio financeiro de 1.500.000€ concedido pela Islândia, Liechtenstein e Noruega, através do Programa Iniciativas em Saúde Pública (PT06) financiado pelas EEA Grants 2009-2014. info:eu-repo/semantics/publishedVersion

Introduction Reduction of unfair differences in health between socioeconomic groups and countries constitutes an important public health challenge in the 21st century. To monitor progress on this goal, health inequalities are most frequently estimated based on self-reported data from population surveys. However, it has been shown that self-reported data on cardiovascular disease risk factors is prompt to reporting error. If errors occur more often in specific socioeconomic groups (due to under-diagnosis or lower literacy) they are likely to seriously bias health inequality estimates. This study aims at comparing measurement errors between socioeconomic categories in self-reported hypertension, and their consequences on health inequality estimates. Methods We used data from the Portuguese National Health Examination Survey (INSEF), a cross-sectional nationwide study conducted in 2015 on a probabilistic sample (n = 4911) of community-dwelling individuals aged between 25 and 74-years-old. INSEF combines measured biochemical parameters and blood pressure with self-reported data. Self-reported hypertension was defined based on the question: “Do you have any of the following diseases or conditions: hypertension? (Yes/No)”. Examination-based hypertension was defined as having systolic blood pressure of at least 140 mmHg, or diastolic blood pressure of at least 90 mmHg, or using prescribed antihypertensive medication. Participants’ socioeconomic status was measured through the education level (no education/1st cycle of basic education, 2nd cycle of basic education, 3rd cycle of basic education, secondary education and higher education). Inequalities in hypertension between the highest and lowest socioeconomic status groups were measured using relative indexes of inequality (RII) and respective confidence intervals (95% CI), estimated by Poisson regression. Estimates of inequalities were stratified by age and sex, using four population groups (male 25–49-years-old, female 25–49-years-old, male 50–75-years-old, female 50–75-years-old). Results Hypertension was reported by 25.7% [95% CI: 24.0 to 27.4] of participants, while 35.9% [95% CI: 34.2 to 37.5] were considered to have hypertension according to examination-based data. The difference between examination-based and self-reported prevalence was 12.7pp for those with no education/1st cycle of basic education and 4.6pp for those with higher education. Similar educational gradients were observed for both self-reported (RII = 1.87; 95% CI: 1.45 to 2.42) and examination-base (RII = 1.91; 95% CI: 1.60 to 2.28) hypertension, with lowest prevalence of disease among the highly educated. Age- and sex-specific results showed considerable discrepancies in inequality indicators between self-reported and examination-based data. Namely, differences in estimated gradients were more pronounced among 25–49-years-old males, with RII = 0.67 (95% CI: 0.29 to 1.54) for self-reported and RII = 1.90 (95% CI: 1.22 to 2.96) for examination-based hypertension. In 25–49-years-old females inequalities in self-reported hypertension were not statistically significant (RII = 3.18; 95% CI: 0.94 to 10.73), while females with the lowest education were 4.35 (95% CI: 2.60 to 7.27) times more likely to have examination-based hypertension then compared to the most educated. In 50–75 age group educational inequalities in self-reported hypertension were larger than in examination-based for both, male (RII = 1.82; 95% CI: 1.25 to 2.69 vs. RII = 1.40; 95% CI: 1.04 to 1.89) and female (RII = 1.77; 95% CI 1.30 to 2.41 vs. RII = 1.58; 95% CI: 1.22 to 2.04). Conclusions Our results illustrated the significant effect of measurement error in self-reported hypertension on estimates of socioeconomic inequalities. Use of self-reported data led to underestimation of educational inequalities among young and middle-aged individuals and overestimation in older age groups. Inequality indicators derived from self-report should be interpreted with caution.

Background: In Health Examination Surveys interview information is complemented with objective information, providing more accurate indicators than self-reported data. We report the study design, planning and implementation of the first Portuguese Health Examination Survey (INSEF). Methods: INSEF was a cross-sectional population-based study representative at regional and national level. Individuals aged between 25 and 74 years old, residing in Portugal were selected from the national health users’ registry through multi-stage stratified probabilistic sampling. Sample size was set at 4200 individuals. Data was collected in primary care units and included blood pressure, height, weight, hip and waist measurements, blood collection for lipid profile, HbA1c and blood count and a general health questionnaire. European HES procedures were followed. Results: A total of 4911 individuals agreed to participate (43.9% participation rate). Participation rate varied by region, sex and age group, being lower in Lisbon and Tagus Valley (32.8%), for men (41.8%) and for those aged 25–34 years old (36%). Conclusions: INSEF has set up an experienced national and regional structure for HES implementation. Nationally representative quality epidemiological data is now available for public health monitoring, planning and research. The Portuguese National Health Examination Survey 2015 (INSEF) was developed as part of the Pre-defined project of the Public Health Initiatives Program (reference 000039_ PDP), ‘‘Improvement of epidemiological health information to support public health decision and management in Portugal. Towards reduced inequalities, improved health, and bilateral cooperation”, that benefits from a 1.500.000€ Grant from Iceland, Liechtenstein and Norway through the European Economic Area Financial Mechanism (EEA Grants), 85%, and from the Portuguese Government, 15%. info:eu-repo/semantics/publishedVersion

Aims: Health examination surveys (HES) provide important information about population health and health-related factors, but declining participation rates threaten the representativeness of collected data. It is hard to conduct national HESs at examination clinics near to every sampled individual. Thus, it is interesting to look into the possible association between the distance from home to the examination clinic and non-participation, and whether there is a certain distance after which the participation activity decreases considerably. Methods: Data from two national HESs conducted in Finland in 2011 and 2012 were used and a logistic regression model was fitted to investigate how distance was related to non-participation. Results: We found out that non-participation modestly increased with distance to the examination clinic. An additional analysis indicated that the option of having an examination at home may decrease the effect of distance to participation. Conclusions: Long distances from home to the examination clinic are one reason for low participation activity. Possible bias caused by these differences in participation could be decreased by providing the option of a home examination.

To inform policymakers well, there is a need to promote different types of health examination surveys as additional sources of valuable information which, otherwise, would not be available through routine/administrative statistics. This is especially important for former communist countries of South Eastern Europe including Albania, where the existing health information system (HIS) is weak. Among many efforts to strengthen the HIS in Albania, there is currently a commitment to undertake a second round of a nationwide Demographic and Health Survey (DHS). This survey will involve a nationwide representative sample of about 17,000 private households, where all women aged 15-59 years and their respective partners will be interviewed and examined. Externally, the upcoming Albanian DHS will contribute to the European Union accession requirements regarding provision of standardized and valid health information. Furthermore, the DHS will considerably enhance the core functions of the Albanian health system in line with the WHO recommendations. Internally, the DHS will promote societal participation and responsibility in transitional Albania. Importantly, the forthcoming survey will promote good governance including transparency, accountability and health system responsiveness. Also, the DHS will allow for collection of internationally valid and standardized baseline socio-demographic and health information for: assessment of future national trends; monitoring and evaluation of health programs and interventions; evidencing health disparities and inequities; and cross-national comparisons between Albania and different countries of the European Region. Ultimately, findings of the DHS will enable rational decision-making and evidence-based policy formulation in Albania including appropriate planning, prioritization and sound resource allocation. However, transfer of the information collected and implementation in public health policies and interventional programs is rather challenging for most of the countries, particularly for transitional post-communist countries of South Eastern Europe including Albania., South Eastern European Journal of Public Health (SEEJPH), Volume VIII, 2017

This study compares self-reported and examination-based prevalence of hypertension and hypercholesterolemia using data from the Portuguese National Health Examination Survey (n=4911), that combines personal interview and clinical measurements. Sensitivity and specificity of self-reported hypertension and hypercholesterolemia were calculated, logistic regression was used to identify factors associated to incorrect self-reports. Self-reports of hypertension and hypercholesterolemia showed high specificity but low sensitivity. Age, education and use of healthcare services were associated to incorrect self-reports of both conditions. Adding objective measurements to self-reported data allow better understanding of socioeconomic inequalities in health. O primeiro Inquérito Nacional de Saúde com Exame Físico foi desenvolvido como parte integrante do projeto “Improvement of epidemiological health information to support public health decision and management in Portugal. Towards reduced inequalities, improved health, and bilateral cooperation”, que beneficiou de um apoio financeiro de 1.500.000€ concedido pela Islândia, Liechtenstein e Noruega, através do Programa Iniciativas em Saúde Pública (PT06) financiado pelas EEA Grants 2009-2014. N/A

Objectives: To examine cross-sectional and longitudinal associations between physical exercise and cognitive function across different age groups in a nationwide population-based sample of adults aged 18–79 years in Germany. Design: Cross-sectional/prospective. Methods: Cognitive function was assessed in the mental health module of the German Health Interview and Examination Survey for Adults (DEGS1-MH, 2009–2012, n = 3535), using a comprehensive neuropsychological test battery. Cognitive domain scores for executive function and memory were derived from confirmatory factor analysis. Regular physical exercise in the last three months was assessed by self-report and defined as no exercise, Results: Compared to no exercise, more weekly physical exercise was associated with better executive function in cross-sectional (Conclusions: Higher levels of physical exercise were associated with better executive function and memory in cross-sectional and longitudinal analyses with no evidence for differential effects by age.

publicado em: Eur J Public Health. 2015; 25(Suppl 3): 417. doi:10.1093/eurpub/ckv176.118. Disponível em: http://eurpub.oxfordjournals.org/content/eurpub/25/suppl_3/ckv176.118.full.pdf The participation of fieldwork teams is key to successful surveys implementation. Thus, the Portuguese National Health Examination Survey (INSEF) is involving fieldwork teams in survey quality control processes. The aim of this presentation is to report a midterm evaluation's results of the internal quality control concerning participants' recruitment strategies and how these influence participation rate. A focus group discussion was carried out with fieldwork teams (nurses, laboratory technicians and administrative staff) and regional coordinators in the North, Center and Algarve regions. Each focus group had between 8 to 14 participants with an average age of 47 years and a long professional experience with an average of 22 years. A slideshow presentation fostered the discussion of the survey process: strengths and weaknesses of training, recruitment, informed consent, physical exam, blood collection, interview and logistical issues. It also explored the teams' perceptions of local cultural attitudes and the strategies used within the fieldwork. A thematic content analysis was performed. According to fieldwork teams, higher participation rates depend on: invitation letter signed by personal General Practitioner; free clinical analysis; pride in being selected in a scientific study; study conducted by experienced health professionals; data collection in local health center, schedule flexibility, invitation and confirmatory telephone calls. Also important: population's size, cultural factors and fieldwork teams' years of experience. In two focus groups, opinions on invitation letters' legibility differed between socio-professional categories: nurses and administrative staff. Participation rate depends on fieldwork teams' credibility and local community. The use of qualitative methods such as focus group is important to improve survey processes and these can also give valuable input on fieldwork teams' engagement and motivation. The Portuguese National Health Examination Survey is developed as a part of the project “Improvement of epidemiological health information to support public health decision and management in Portugal. Towards reduced inequalities, improved health, and bilateral cooperation”, that benefits from a 1.500.000€ Grant from Iceland, Liechtenstein and Norway through the European Economic Area Grants (EEA Grants).

publicado em: Eur J Public Health. 2015; 25(Suppl 3): 386. doi:10.1093/eurpub/ckv176.035. Disponível em: http://eurpub.oxfordjournals.org/content/eurpub/25/suppl_3/ckv176.035.full.pdf Recruitment of participants in health surveys is recognised as the most challenging step of fieldwork. This work presents preliminary results of recruitment in the first Portuguese National Health Examination Survey (INSEF) comparing participants and non participants. INSEF is a cross-sectional prevalence study targeting 4200 individuals aged 25–74 years, living in Portugal for more than 12 months, non-institutionalized and able to follow an interview in Portuguese. Fieldwork started in February 2015 and to date 9/49 examination sites are completed. Selected individuals received an invitation letter and later were contacted by phone to schedule the appointment. Individuals were then classified in participants, refusals and of unknown eligibility. Participation rates were calculated according to European Health Examination Survey guidelines. Reasons for refusals were recorded and non participant’s characteristics analysed. Chi square and Fisher exact tests were used to compare participants and non participants regarding age, sex, education level, marital status, smoking, use of medication and of healthcare services. 1467 of the 2161 selected individuals were successfully contacted. Overall participation rate was 42%(n = 882), ranging between 27–54% by examination site. 49% of the 512 refusals accepted to respond to a short questionnaire for non participants. The main reasons for non participation were lack of time (27.6%) and professional reasons (22.4%). No significant differences were found for the majority of the analysed variables. Participants were found to be more frequently users of medication (p < 0.001) and to have between 45–54 years old (p = 0.023). To date the planed participation rate of 40% was successfully achieved at national level. Results obtained showed the need to implement strategies to engage in participation specific target groups. To mitigate selection bias adjustment of sampling weights for non response should be done. The Portuguese National Health Examination Survey is developed as a part of the project “Improvement of epidemiological health information to support public health decision and management in Portugal. Towards reduced inequalities, improved health, and bilateral cooperation”, that benefits from a 1.500.000€ Grant from Iceland, Liechtenstein and Norway through the European Economic Area Grants (EEA Grants).

Data missing not at random (MNAR) is a major challenge in survey sampling. We propose an approach based on registry data to deal with non-ignorable missingness in health examination surveys. The approach relies on follow-up data available from administrative registers several years after the survey. For illustration we use data on smoking prevalence in Finnish National FINRISK study conducted in 1972-1997. The data consist of measured survey information including missingness indicators, register-based background information and register-based time-to-disease survival data. The parameters of missingness mechanism are estimable with these data although the original survey data are MNAR. The underlying data generation process is modelled by a Bayesian model. The results indicate that the estimated smoking prevalence rates in Finland may be significantly affected by missing data., Comment: in Stat, 2015

Background Information is needed at all stages of the policy making process. The Health Survey for England (HSE) is an annual cross-sectional health examination survey of the non-institutionalised general population in England. It was originally set up to inform national policy making and monitoring by the Department of Health. This paper examines how the nurse collected physical and biological measurement data from the HSE have been essential or useful for identification of a health issue amenable to policy intervention; initiation, development or implementation of a strategy; choice and monitoring of targets; or assessment and evaluation of policies. Methods Specific examples of use of HSE data were identified through interviews with senior members of staff at the Department of Health and the Health and Social Care Information Centre. Policy documents mentioned by interviewees were retrieved for review, and reference lists of associated policy documents checked. Systematic searches of Chief Medical Officer Reports, Government ‘Command Papers’, and clinical guidance documents were also undertaken. Results HSE examination data have been used at all stages of the policy making process. Data have been used to identify an issue amenable to policy-intervention (e.g. quantifying prevalence of undiagnosed chronic kidney disease), in strategy development (in models to inform chronic respiratory disease policy), for target setting and monitoring (the 1992 blood pressure target) and in evaluation of health policy (the effect of the smoking ban on second hand smoke exposure). Conclusions A health examination survey is a useful part of a national health information system.

Objective. Information regarding health condition, related behavior and utilization of health care services is essential for planning and organization of care delivery. Until recently, only limited information regarding oral health related issues was available in Belgium. This paper illustrates the development and implementation of an Oral Health Data Registration & Evaluation System (OHDRES) in Belgium, including discussion of challenges encountered. Methods. After development of a conceptual plan and pilot phase, the OHDRES was implemented nationwide in 2009-2010. The combined Health Interview (self-administered questionnaire) and Health Examination (standardized oral examination by trained dentist-interviewer at the participant's home)data were supplemented with data on utilization of (oral) health care services. Sampling of Belgian residents (> 5 years)took place using a multi-stage, stratified cluster sampling procedure. Ethical approval was obtained and informed consent was sought from all participants. Results. A total of 2536 households were reached, yielding 3057 respondents (52%). Questionnaire and clinical data were obtained from 90% and 84% of participants. Dentist-interviewers reported difficulties with scoring of periodontal condition and enamel defects. Contacting selected households was the most difficult and time-consuming task for the dentist-interviewers, impacting on retention rate. Conclusion. The first round of the Belgian OHDRES was successfully implemented, after long and complex preparation. The impossibility of integration with the National Health Interview Survey 2009 was a considerable draw-back complicating data collection and limiting opportunities to further data linking and creation of added value. ispartof: Journal of Dental, Oral and Craniofacial Epidemiology vol:1 issue:3 pages:45-54 status: published

publicado em: Eur J Public Health. 2015; 25(Suppl 3): 398. doi:10.1093/eurpub/ckv176.069. Disponível em: http://eurpub.oxfordjournals.org/content/eurpub/25/suppl_3/ckv176.069.full.pdf This work addresses practices related to quality assurance in the first Portuguese National Health Examination Survey (INSEF). INSEF is a cross-sectional population-based study that combines face-to-face interview, physical examination and blood collection and aims to obtain data on 4200 participants from all 7 regions of Portugal. To ensure accurate and high quality data, a monitoring system was implemented as part of internal quality assessment. It includes participant recruitment, physical examination, blood collection and interview and consists of: daily check of recruitment and participation; monitoring of blood pressure and anthropometric measurements by interviewer and collection site; monitoring blood draw, sample haemolyses and laboratory processing; evaluation of average time spent on each survey component by interviewer; daily validation of collected interview data to verify completeness and identify duplicates; regular contact with fieldwork teams to clarify issues raised in questionnaire administration. For each region we carried out survey quality assessment at the end of the second week of fieldwork (N=230 participants). Regional meetings took place to discuss assessment results and propose recommendations for improvement. Monitoring allowed identifying items in higher risk of missing data and challenging issues such as employing exclusion criteria. Proper registry of measurements and time spent were difficult for 3 out of 6 interviewers. We observed junior laboratory technicians to have higher rates of haemolysed samples, 11% compared to 2% from the most experienced. Monitoring of each fieldwork procedure allowed to provide on time feedback so fieldwork teams are able to implement correction actions aimed at reducing total survey error and improving survey quality. The Portuguese National Health Examination Survey is developed as a part of the project “Improvement of epidemiological health information to support public health decision and management in Portugal. Towards reduced inequalities, improved health, and bilateral cooperation”, that benefits from a 1.500.000€ Grant from Iceland, Liechtenstein and Norway through the European Economic Area Grants (EEA Grants).