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Background Pneumonia is one of the complications of COVID-19. Primary care electronic health records (EHR) have shown the utility as a surveillance system. We therefore analyse the trends of pneumonia during two waves of COVID-19 pandemic in order to use it as a clinical surveillance system and an early indicator of severity. Methods Time series analysis of pneumonia cases, from January 2014 to December 2020. We collected pneumonia diagnoses from primary care EHR, a software system covering > 6 million people in Catalonia (Spain). We compared the trend of pneumonia in the season 2019–2020 with that in the previous years. We estimated the expected pneumonia cases with data from 2014 to 2018 using a time series regression adjusted by seasonality and influenza epidemics. Results Between 4 March and 5 May 2020, 11,704 excess pneumonia cases (95% CI: 9909 to 13,498) were identified. Previously, we identified an excess from January to March 2020 in the population older than 15 years of 20%. We observed another excess pneumonia period from 22 october to 15 november of 1377 excess cases (95% CI: 665 to 2089). In contrast, we observed two great periods with reductions of pneumonia cases in children, accounting for 131 days and 3534 less pneumonia cases (95% CI, 1005 to 6064) from March to July; and 54 days and 1960 less pneumonia cases (95% CI 917 to 3002) from October to December. Conclusions Diagnoses of pneumonia from the EHR could be used as an early and low cost surveillance system to monitor the spread of COVID-19.

eConsulta-that is, asynchronous, two-way teleconsultation in primary care-is one of the most important telemedicine developments in the Catalan public health system, a service that has been heavily boosted by the onset of the COVID-19 pandemic. It is vital to know the characteristics of its users in order to be able to meet their needs and understand the coverage of this service in a context where there is reduced accessibility to the health system.BACKGROUNDeConsulta-that is, asynchronous, two-way teleconsultation in primary care-is one of the most important telemedicine developments in the Catalan public health system, a service that has been heavily boosted by the onset of the COVID-19 pandemic. It is vital to know the characteristics of its users in order to be able to meet their needs and understand the coverage of this service in a context where there is reduced accessibility to the health system.This study aims to analyze the profile of the citizens who use the eConsulta tool and the reasons for their use, as well as to gain an understanding of the elements that characterize their decision to use it while distinguishing between those who used it before and those who have used it since the onset of the COVID-19 pandemic.OBJECTIVEThis study aims to analyze the profile of the citizens who use the eConsulta tool and the reasons for their use, as well as to gain an understanding of the elements that characterize their decision to use it while distinguishing between those who used it before and those who have used it since the onset of the COVID-19 pandemic.A descriptive, observational study based on administrative data was performed. This study differentiates between the COVID-19 pandemic era and the period preceding it, considering the day the state of emergency was declared in Spain (ie, March 12, 2020) as the cut-off point. It also differentiates between eConsulta users who send messages and those who only receive them.METHODSA descriptive, observational study based on administrative data was performed. This study differentiates between the COVID-19 pandemic era and the period preceding it, considering the day the state of emergency was declared in Spain (ie, March 12, 2020) as the cut-off point. It also differentiates between eConsulta users who send messages and those who only receive them.During the pandemic, the number of unique users of this teleconsultation service had almost tripled, with up to 33.10 visits per 1000 inhabitants per month reported in the first three months. For the two user profiles analyzed, most users since the start of the COVID-19 outbreak were predominantly female, systematically younger, more actively employed, and with less complex pathologies. Furthermore, eConsulta users received more messages proactively from the health professionals. There was also a relative decrease in the number of conversations initiated by higher-income urban users and an increase in conversations initiated by users in rural areas.RESULTSDuring the pandemic, the number of unique users of this teleconsultation service had almost tripled, with up to 33.10 visits per 1000 inhabitants per month reported in the first three months. For the two user profiles analyzed, most users since the start of the COVID-19 outbreak were predominantly female, systematically younger, more actively employed, and with less complex pathologies. Furthermore, eConsulta users received more messages proactively from the health professionals. There was also a relative decrease in the number of conversations initiated by higher-income urban users and an increase in conversations initiated by users in rural areas.The COVID-19 pandemic has helped to generalize the use of telemedicine as a tool to compensate, to some extent, for the decline in face-to-face visits, especially among younger citizens in Catalonia. Telemedicine has made it possible to maintain contact between citizens and the health care system in the context of maximum complexity.CONCLUSIONSThe COVID-19 pandemic has helped to generalize the use of telemedicine as a tool to compensate, to some extent, for the decline in face-to-face visits, especially among younger citizens in Catalonia. Telemedicine has made it possible to maintain contact between citizens and the health care system in the context of maximum complexity.

Background The aim of our study is to analyse the trends in the diagnosis of sexually transmitted infections (STIs) during the COVID-19 pandemic. Methods We conducted an observational retrospective population-based study using data from primary care electronic health records spanning from January 2016 to December 2022 (involving 5.1 million people older than 14 years). We described the daily number of new STI diagnoses from 2016 to 2022; as well as the monthly accumulation of new STI diagnoses for each year. We compared the monthly averages of new diagnoses in 2019, 2020, 2021 and 2022 using the T-test. Finally, we performed a segmented regression analysis of the daily number of STI diagnoses. Results We analysed 200,676 new STI diagnoses. The number of diagnoses abruptly decreased coinciding with the lockdown. Overall in 2020, we observed a reduction of 15%, with higher reductions for specific STIs such as gonorrhoea (-21%), chlamydia (-24%), and HIV (-31%) compared to 2019. Following this drastic drop, which was temporarily associated with the lockdown, we observed a rapid rebound. In 2021, the number of STI diagnoses was similar to that of 2019. Notably, we found a considerable increase in 2022, particularly for non-specific STI, which lack laboratory confirmation (67% increase). HIV was the only STI with a reduction of up to -38% in diagnoses at the end of 2022 compared to 2019. Conclusions After a significant reduction in 2020, the number of STIs recorded in primary care rapidly rebounded, and the current trend is similar to that of 2019, except for HIV. These findings underscore the dynamic impact of the COVID-19 pandemic on STI diagnoses and highlight the importance of ongoing monitoring and public health interventions in the post-pandemic period.

Nursing homes have accounted for a significant part of SARS-CoV-2 mortality, causing great social alarm. Using data collected from electronic medical records of 1,319,839 institutionalised and non-institutionalised persons ≥ 65 years, the present study investigated the epidemiology and differential characteristics between these two population groups. Our results showed that the form of presentation of the epidemic outbreak, as well as some risk factors, are different among the elderly institutionalised population with respect to those who are not. In addition to a twenty-fold increase in the rate of adjusted mortality among institutionalised individuals, the peak incidence was delayed by approximately three weeks. Having dementia was shown to be a risk factor for death, and, unlike the non-institutionalised group, neither obesity nor age were shown to be significantly associated with the risk of death among the institutionalised. These differential characteristics should be able to guide the actions to be taken by the health administration in the event of a similar infectious situation among institutionalised elderly people.

Background To analyse the impact of the COVID-19 epidemic and the lockdown measures on the follow-up and control of chronic diseases in primary care. Methods Retrospective study in 288 primary care practices (PCP) of the Catalan Institute of Health. We analysed the results of 34 indicators of the Healthcare quality standard (EQA), comprising different types: treatment (4), follow-up (5), control (10), screening (7), vaccinations (4) and quaternary prevention (4). For each PCP, we calculated each indicator’s percentage of change in February, March and April 2020 respective to the results of the previous month; and used the T-Student test for paired data to compare them with the percentage of change in the same month of the previous year. We defined indicators with a negative effect those with a greater negative change or a lesser positive change in 2020 in comparison to 2019; and indicators with a positive effect those with a greater positive change or a lesser negative change. Results We observed a negative effect on 85% of the EQA indicators in March and 68% in April. 90% of the control indicators had a negative effect, highlighting the control of LDL cholesterol with a reduction of − 2.69% (95%CI − 3.17% to − 2.23%) in March and − 3.41% (95%CI − 3.82% to − 3.01%) in April; and the control of blood pressure with a reduction of − 2.13% (95%CI − 2.34% to − 1.9%) and − 2.59% (95%CI − 2.8% to − 2.37%). The indicators with the greatest negative effect were those of screening, such as the indicator of diabetic foot screening with a negative effect of − 2.86% (95%CI − 3.33% to − 2.39%) and − 4.13% (95%CI − 4.55% to − 3.71%) in March and April, respectively. Only one vaccination indicator, adult Measles-Mumps-Rubella vaccine, had a negative effect in both months. Finally, among the indicators of quaternary prevention, we observed negative effects in March and April although in that case a lower inadequacy that means better clinical outcome. Conclusions The COVID-19 epidemic and the lockdown measures have significantly reduced the results of the follow-up, control, screening and vaccination indicators for patients in primary care. On the other hand, the indicators for quaternary prevention have been strengthened and their results have improved.

Background The incidence of chronic diseases during the COVID-19 pandemic has drastically been reduced worldwide due to disruptions in healthcare systems. The aim of our study is to analyse the trends in the incidence of 7 commonly managed primary care chronic diseases during the last 2 years of the COVID-19 pandemic in Catalonia. Methods We performed an observational retrospective population-based study using data from primary care electronic health records from January 2018 to August 2022 (5.1 million people older than 14 years). We divided the study period into two: a pre-pandemic period (before 14 March 2020) and a pandemic period. We performed a segmented regression analysis of daily incidence rates per 100,000 inhabitants of 7 chronic diseases: type 2 diabetes mellitus (T2DM), asthma, chronic obstructive pulmonary disease (COPD), ischemic heart disease (IHD), heart failure (HF), hypertension and hypercholesterolemia. In addition, we compared annual incidence between pandemic years (2020, 2021 and 2022) and 2019. Associated incidence rate ratios (IRR) were also calculated. Finally, we estimated the number of expected diagnoses during the pandemic period using data from 2019 and we compared it with the observed data. Results We analysed 740,820 new chronic diseases’ diagnoses. Daily incidence rates of all 7 chronic diseases were drastically interrupted on 14 March 2020, and a general upward trend was observed during the following months. Reductions in 2020 were around 30% for all conditions except COPD which had greater reductions (IRR: 0.58 [95% CI: 0.57 to 0.6]) and HF with lesser drops (IRR: 0.86 [95% CI: 0.84 to 0.88]). Some of the chronic conditions have returned to pre-pandemic diagnosis levels, except asthma, COPD and IHD. The return to pre-pandemic diagnosis levels compensated for the drops in 2020 for T2DM and HF, but not for hypertension which presented an incomplete recovery. We also observed an excess of hypercholesterolemia diagnoses of 8.5% (95%CI: 1.81% to 16.15%). Conclusions Although primary care has recovered the pre-pandemic diagnosis levels for some chronic diseases, there are still missing diagnoses of asthma, COPD and IHD that should be addressed.

Spain is a highly decentralized country where water governance is a multi-level institutional endeavor requiring effective intergovernmental coordination—in terms of objectives and actions. The paper revisits the evolution of vertical and horizontal intergovernmental interactions in Spain, with a special focus on four interregional river basins. We build on a historical analysis of the evolution of water governance institutions, a mapping of existing interactions over water, careful document analysis, and interviews with selected public officials that are at the interface between the political and the technical spheres. Intergovernmental interaction occurs through different mechanisms that are slowly evolving to adapt to new challenges posed by changing power dynamics and water policy goals. Since the start of political decentralization in 1978, key institutional reforms within and outside of the water sector have opened windows of opportunity for regions to seek new spheres of influence and power. Disputes over water allocation, environmental flows, inter-basin transfers, and even basin boundaries delineation emerge as an expression of a struggle over power distribution between the regions and the central government. The physical and institutional geography of water and diverging visions and priorities (over water and beyond) are among the factors that contribute to shape conflict and cooperation in intergovernmental relations over water.

Grassroots initiatives that aim to defend, protect, or restore rivers and riverine environments have proliferated around the world in the last three decades. Some of the most emblematic initiatives are anti-dam and anti-mining movements that have been framed, by and large, as civil society versus the state movements. In this article, we aim to bring nuance to such framings by analyzing broader and diverse river-commoning initiatives and the state–citizens relations that underlie them. To study these relations we build on notions of communality, grassroots scalar politics, rooted water collectives, and water justice movements, which we use to analyze several collective practices, initiatives, and movements that aim to protect rivers in Thailand, Spain, Ecuador, and Mozambique. The analysis of these cases shows the myriad ways in which river collectives engage with different manifestations of the state at multiple scales. As we show, while some collectives strategically remain unnoticed, others actively seek and create diverse spaces of engagement with like-minded citizen initiatives, supportive non-governmental organizations, and state actors. Through these relations, alliances are made and political space is sought to advance river commoning initiatives. This leads to a variety of context-specific multi-scalar state–citizens relations and river commoning processes in water governance arenas.

The process of drafting, approving and implementing the Water Framework Directive (WFD) has played a pivotal role in the water-related political agenda of the Iberian Peninsula. The WFD has provided an institutional impetus for a shift from the dominant hydraulic paradigm towards a new water governance approach. The new approach, known as the New Water Culture (NWC), predated the WFD. It was initiated in Spain and Portugal in the 1990s and has been promoted by a coalition of academics, social activists, and water managers. Given the long tradition and relevance of water debates in Spain and Portugal, the sociopolitical and territorial conflicts surrounding the implementation of the new regulatory framework are of particular significance. Legal debates about the (in)correct transposition of the WFD into Spanish and Portuguese legislation are still unresolved. Legal debates about the (in)correct transposition of the WFD into Spanish and Portuguese legislation are still unresolved. Controversies focus on issues such as the use of economic instruments, for instance cost recovery and the use of public subsidies (a key component of the hydraulic paradigm), as well as the role of public participation in decision making processes. Significant resistance has been mounted by the traditional water policy community, which continues to dominate power structures surrounding water. Throughout the long WFD implementation process, conflicting views and interests have consistently emerged with regard to the diagnosis and identification of existing pressures and the definition, evaluation and implementation of the proposed measures. Controversies have also emerged around the extensive use of exceptions which has allowed the hydraulic paradigm to persist over time. Progress towards the promised governance model, however, is taking place, with significant improvements in transparency, more accurate knowledge regarding the aquatic ecosystems services and the inclusion in water management agencies of more diverse experts including social scientists, biologists and geologists. This paper looks at the role the WFD implementation process is playing in the struggle for the transformation of water policy in Spain and Portugal. It examines this through the lens of the NWC movement.

Climate change adaptation is primarily a local endeavor in response to impacts that are specific to regions, communities and ecosystems. Assessments of adaptation action must take into consideration the specific socioeconomic and environmental contexts where it takes place. This study aims to understand how context-specific attributes influence the adaptive capacity of implemented measures. Building on the work of other authors, we developed a mixed methods approach to characterize drought and climate risk management measures and adaptation strategies that take into consideration farmer input and local context. We applied this methodology to the response of extensive dryland livestock farmers in a dehesa agroforestry system in southcentral Spain during a prolonged drought. Qualitative data was collected through interviews, focus groups and workshops, and coded and analyzed through deductive content analysis and complementary statistical correlation and multicriteria analysis. Measures were classified to place them along a coping-adaptation spectrum. They were further characterized in terms of their basic features, effectiveness, enabling conditions and feasibility requirements. The analysis helped identify potential barriers and opportunities to enhance strategies that reduce vulnerability to future climate-driven impacts. In the face of climate crisis, farmers will often tend to choose coping measures that have immediate effectiveness and are useful to swiftly address an unexpected critical situation, while more adaptive measures often need years or decades to achieve full effectiveness. Our work showed that the adaptive capacity of specific measures are context- and timing- dependent so that, for instance, some coping measures such as seasonal rental of dehesa for pasture or acorns or purchase of water tanks can help address short-term impacts to allow for devising more long-term adaptive strategies. Results highlighted the important role that cooperatives played in helping farmers face climate-related impacts. Inadequate information or limited understanding of local conditions constrains the ability of farmers to design effective adaptation strategies. These must build on an understanding of local priorities, values, socioeconomic and institutional contexts and local conditions to ensure their success. Applicability of adaptation strategies across case studies requires a careful adjustment of adaptation “success stories” documented in other regions to the multifaceted local reality.