Summary Background The COVID‐19 pandemic lead scientists and governmental authorities to issue clinical and public health recommendations based on progressively emerging evidence and expert opinions and many of these fast‐tracked to peer‐reviewed publications. Concerns were raised on scientific quality and generalizability of this emerging evidence. Main argument However, this way acting is not entirely new and often public health decisions are based on flawed and ambiguous evidence. Thus, to better guide decisions in these circumstances, in this article we argue that there is a need to follow fundamental principles in order to guide best public health practices. We purpose the usefulness of the framework of principalism in public which has been proved useful in real life conditions as a guide in the absence of reliable evidence. Conclusions It is recommended the implementation of these principles in an integrated manner adopting an holistic system approach to health policies adapted to specificities of local contexts.

Do crisis evolve linearly through sequential one‐directional stages that end with their resolution? Or are crisis, a set of nonlinear events with somewhat a chaotic nature, better represented as multilayer relapse cycles, that is, a series of dynamic processes and templates that evolve at different levels of analysis and can either go forward—achievement—or go back—relapses? Moreover, should crisis always move forward to reach their resolution or should we strive to achieve social systems resilience, grounded on learning and adaptation processes, that is, moving forward and backwards, until achieving it? To argument in favor of achieving crisis resilience, we propose a theoretical model—the crisis layers and thresholds (CLT) model grounded on the following assumptions: (a) individuals' evaluations and responses should be the basis/core of crisis management and crisis communication activities; (b) different concurrent psychosocial and organizational processes occur at different levels of analysis of a crisis, from a microindividual level to a macro organization level; and (c) rather than striving for crisis resolution, we should strive for crisis resilience, preparing the social system for current and future emerging risks and crisis. To implement effective evidence‐based crisis management and crisis communication in line with such assumptions, we also propose the CLT‐ResiliScence approach, an Information and Communication Technology‐mediated crisis sensing approach. This is based on monitoring “social sensors” data, particularly from social media, as an important source of information. Examples of this will be provided based on research on the current COVID‐19 pandemic.

Background During events that involve health risks, people may feel the need personal and social resources to cope with the demands posed by event. Depending on their individual characteristics, people may perceive their resources as sufficient or as insufficient to face the situation. Risk perception analysis was conducted in Portugal during the COVID-19 outbreak, to develop communication strategies, customized to the changing needs, helping people make informed decisions. Methods Citizens messages on social networks of 3 official information sources, and 8 media sources were analyzed between 26th January and 5th March 2020. A sample of comments to publications related to COVID-19 were analyzed in 4-days periods and categorized. A qualitative theory-driven thematic analysis was carried out based on two global categories: Demands and Resources. From this analysis, the threat level ratio (Demands/Resources) was calculated. Results A total of 8,251 comments were analysed in 10 periods of 4 days of data collection, from 26th January to 5th March. The threat level ratio increased during the first 15 days of analysis, having its maximum (6.80) in the period between the 7th and 14th of February, mostly associated with the perceived danger associated with the lack of airports arrivals control from China. After the announcement of the first confirmed case of COVID-19 in a Portuguese citizen outside Portugal, on 23rd February, the risk perception increased 1,4% compared to the previous period of analysis. On the contrary, after announcing the first confirmed case in Portugal, on the 1st March, the risk perception decreased 1,6%, which is inferred to be associated with a shift in the media discourse and to the use of humour. Conclusions Awareness of risks is a necessary condition for people to adhere to the necessary recommendations to mitigate the crisis. During an epidemic, an effective communication strategy can become an opportunity to promote health literacy. Key messages Risk perception is essential to define effective communication strategies to promote health literacy and best practices among targeted populations. effective communication strategies customized to people’s needs and priorities help people making informed decisions during a public health emergency.

Monitoring how different people -as 'social sensors' -evaluate and respond to crisis such as pandemics, allows tailoring crisis communication to the social perceptions of the situation, at different moments. To gather such evidence, we proposed a index of social perceptions of systemic risk (SPSR), as an indicator of a situational threat compromising risks to physical health, psychological health, the economy, social relations, health system, and others. This indicator was the core of a social sensing approach applied to crisis situations, implemented during the COVID-19 pandemic through a content analysis of more than 130.000 public comments from Facebook™ users, in COVID-19 related publications. This content coding allowed creating a SPSR index monitored during a one-year descriptive longitudinal analysis. This index correlated with co-occurring events within the social system, namely epidemiological indicators across measurement cycles (e.g. new deaths; cumulative number of infection cases; Intensive Care Unit hospitalizations) and tended to reflect the epidemiological situation severity (e.g. with the highest level registered during the worst pandemic wave). However, discrepancies also occurred, with high SPSR registered in a low severity situation, i.e. low number of hospitalizations and deaths (e.g. school year beginning), or low SPSR in a high severity situation (e.g. 2nd pandemic wave during Christmas), showing other factors beyond the epidemiological situation contributing to the social perceptions. After each 'crisis period' with SPSR peaking, there was a 'restoration period' , consistently decreasing towards average levels of the previous measurement cycle. This can either indicate social resilience (recovery and resources potentiation) or risk attenuation after a high-severity period. This study serves as preliminary proof of concept of a crises social sensing approach, enabling monitoring of social system dynamics for various crisis types, such as health crisis or the climate crisis.

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Background Articulation between Civil Protection and Public Health authorities is of paramount importance to control, reduce and prevent threats to the health of the population in situations of crisis or catastrophes. National Civil Protection Authority produces Emergency Plans which describe the role of every stakeholder in emergency situations. Role and importance of Public Health and Public Health Authorities is not always present or well described and known amongst stakeholders. Methods Data was collected from all Districtal Emergency Plans (n = 18). Each document was analysed considering time frame, refences to Public Health and Health Authorities, definition of roles, communication channels, coordination and inclusion of intersectoral communication flow. Quantitative analysis included absolute and relative frequencies and qualitative analysis to all parts related to the terms “Public Health” and “Health Authority”. Each document was reviewed by 2 independent researchers. Results From 18 Districtal Emergency Plans (DEP) analysed, 94,4% (n = 17) had references to Public Health, but none referred the role of Public Health Officers. Only 16,7% referred to Health Authorities, although 94,4% mentioned the law 135/2013, defining the role and attributes of Health Authority. In 72,2%, coordination of Public Health Measures was attributed to the National Medical Emergency Institute. Epidemiological surveillance and Public Health Emergencies were referred in 55,6%, and attributed to the Regional Administration of Health. Conclusions Public Health Authorities and Public Health Medical Officers role in articulation with National Civil Protection Authority in emergency situations lacks severely, with this role being replaced by other entities. This is of great concern regarding management and control of diseases, particularly communicable diseases. Key messages Public Health Authorities lack the necessary involvement in Emergency Plans and emergency situations. Public health measures are coordinated by other entities rather than Public Health Authorities.

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The COVID-19 pandemic disrupted health systems worldwide, mobilizing most of its resources to COVID-19 care. In Portugal, since mid-March 2020, the scheduled assistance activity of the primary health care services has been altered or interrupted, to respond to the needs of users with suspected or diagnosed SARS-CoV-2 infection. This study intends aims to assess the impact of the COVID-19 pandemic in terms of access to primary health care during 2020 in Portugal. Primary Health Care accessibility data were extracted from the national data transparency portal. Data were aggregated by the 5 health regions and compared to homologous periods for years 2019 and 2020. In Portugal, in 2020 the number of primary health care consultations decreased in the regions of Alentejo (-5%), Algarve (-1%) and Centre (-1%) but increased in both North (+6%) and Lisbon and the Tagus Valley regions (+7%). The number of scheduled appointments decreased in the 5 regions (-16%), increasing the unscheduled appointments (+24%). Those differences were higher during the first lockdown (-42% schedule appointments vs + 13% unscheduled appointments). Presential consultations decreased by 38%, non-presential increased by 101%, and domiciliary consultations were reduced by 37%. Changes to regular activity of primary health care units compromised the access to presential health care by the non-COVID-19 population. After the first pandemic wave, the resumption of scheduled activity changed from face-to-face to non-presential consultation. The adoption of new technologies and telemedicine increased the total of registered consultations, compared to previous year. However, not all non-presential consultation is in fact patient-facing teleconsultation, with some of them being just for prescription renewal or to prescribe complementary exams. Predominantly urban regions were less affected by the suspension of presential activity, maintaining their assistance by non-presential provision of care and telework. Key messages Amidst the COVID-19 pandemic, the Portuguese primary health care services ensured the assistance to their population by non-presential provision of care. Predominantly rural regions were most affected by the suspension of presential consultation.