Portugal has faced three waves of covid-19 (March-April 2020, October-November 2020, January-February 2021), the third being the deadliest one. In the first wave, as all over the world, the Portuguese government realised that the National Health Service (NHS) was unprepared to deal with the new emerging infectious disease. It focused on preventing cases through home isolation and quarantine, with serious economic consequences. At the same time, it reduced access to healthcare for non-covid-19 patients. During the second wave, more localised measures were adopted, such as confinement of particular counties or cities, according to the number of cases and risk of infection. In the third wave, the number of deaths and new cases rose, and Portugal was recognise as having the worst outbreak in Europe. In response, at the end of January, a second state of emergency was declared, and strict measures were imposed, such as mandatory home confinement and the closure of schools, restaurants, all non-essential shops, and borders. While effective, these measures had a significant impact on healthcare and the economy.

This article provides data about how the Portuguese population has experienced the pandemic, from the perspectives of health and healthcare, health-related quality of life (HRQoL) and mental health, social networks, work and economic situation, and satisfaction with life and well-being. It aims to (i) characterise these outcomes during the covid-19 pandemic; (ii) compare them to the state of the Portuguese population before the pandemic; and (iii) identify the social factors that may be linked to these outcomes during the covid-19 pandemic. Data was collected through the telephone survey “H&well-being COVID” from a representative random sample of 1,255 respondents from the general adult Portuguese population, stratified by gender, age group and region. Data was collected between 24th March and 20th April 2021, i.e., during the end of the second national lockdown, that lasted from January to April 2021. To estimate the impact of covid-19 on health and well-being of citizens, survey results were compared with data from previous studies in which the authors measured the HRQoL of the Portuguese population before the pandemic, and during the first lockdown.

In the March-April 2021 survey, respondents were asked to describe their health before the pandemic and to state whether their health had worsened, stayed the same, or improved during the pandemic. One-fourth of the Portuguese citizens rated their health as “very good” before the pandemic, and almost half rated their health as “good” (graph 1). Only 4% of respondents perceived their health as “bad” or “very bad” before the pandemic.  78% of respondents reported their health to be the same as before the pandemic, while a large share—18%—reported that it was worse than before the pandemic. There is significant evidence that perceived health during the pandemic depends on perceived health before the pandemic (c²=46.2; p-value<0.001). Among people reporting only “reasonable” health before the pandemic, 22% reported worse health during the pandemic. In contrast, for people reporting “very good” or “good” health, only 15% and 18%, respectively, reported worse health during the pandemic. 

Access to healthcare has decreased during the pandemic all over the world. In Portugal, hospitals have reduced elective surgery to protect patients from in-hospital viral transmission, released critical care beds for surgeries, and repurposed recovery areas. There has also been a substantial cumulative reduction in medical appointments across all specialties. This study shows that, whilst 4% of citizens had their surgeries postponed or cancelled, more than a quarter had medical appointments or complementary exams postponed or cancelled (graph 2).

Analysing these figures by age group, we conclude that access to healthcare by citizens and patients is significantly dependent on the age group (medical appointments or complementary exams: c²=11.8; p-value=0.008; surgeries: (c²=10.2; p-value=0.017). A greater proportion of citizens in the oldest group experienced postponements/cancellations: 7% of respondents over 65 years old had surgeries postponed or cancelled and 32% had medical appointments or complementary exams postponed or cancelled.

When compared to data from the general population before the pandemic, the respondents’ HRQoL was lower during the first lockdown but not the second, a statistically significant finding (H=80.3; p-value<0.001) (graph 4). During the first lockdown, respondents’ HRQoL decreased 2.9%, and during the second it increased, attaining a level higher than before the pandemic (+1.2%). These results may be explained by an increasing ability of the population to cope with this extreme situation, but also by the availability of the vaccine and the NHS’ growing ability to meet Portuguese citizens’ health needs despite the pandemic. There is significant evidence that HRQoL is different by gender (U=152479; p-value<0.001) and age group (H=103.5; p-value<0.001). Men reported better HRQoL than women, while younger groups reported better HRQoL than older groups.

Half of the Portuguese citizens reported feeling nervous, anxious, or on edge and for 85% of citizens, these feelings were more so than before the covid-19 pandemic (graph 5). Almost 45% of citizens felt sad or depressed and, of these, 85% felt more so than before the pandemic. Almost 39% of respondents reported sleep problems, and, of these, 70% had these problems more than before the pandemic. Finally, loneliness was reported by 29% of citizens (26% some of the time and 6% often), and these feelings have increased with the covid-19 pandemic.

A large share of citizens reported that they went shopping less frequently than before or had stopped shopping (62%) and that they went for a walk less frequently or had stopped going for walks (54%). Almost 60% of citizens reported that they no longer met with more than five people not belonging to their household since the pandemic and 35% reported that they met less frequently with more than five people not belonging to their household. Visits to other family members were also less frequent for the majority of citizens and more than a third had stopped visiting family since the outbreak.

When surveyed in March-April 2021, most respondents (86%) perceived that they had strong economic stability before the pandemic. Using a scale ranging from 0 (strongly disagree) to 10 (strongly agree), we estimate that respondents’ level of agreement with their economic stability before the pandemic is 8.4. To determine if respondents’ perceived economic stability has changed during the pandemic, we analysed to what extent respondents reported that their economic stability had been maintained during the last year. Respondents were more likely to have maintained their economic stability if they had higher economic stability before the pandemic. (H=122.6; p-value<0.001). In addition, there is a significant and positive correlation between economic stability of the household before and during the pandemic (r=0.506; p-value<0.001). Respondents with a strong economic stability before the pandemic rated the maintenance of economic stability during the pandemic at 7.7 out of 10, while the small group of citizens with weak economic stability before the pandemic, rated their maintenance of economic stability at 4.9 out of 10.

Job loss or permanent business closure (c²=293.1; p-value<0.001), a reduction in salary or business turnover (c²=295.3; p-value<0.001), and a postponement of regular payments (c²=66.2; p-value<0.001) were significantly dependent on age. Whilst less than 15% of active age respondents of working age lost their jobs or had to close their companies (graph 8), this percentage rises to a quarter in the case of respondents aged 18-34. Figure 8 shows that almost half of respondents aged 18-34 experienced a reduction in income, which is significantly higher than in older age groups. It also illustrates that about 13% of respondents aged 18-49 postponed regular payments, such as rent or loans, due to the pandemic, which is also significantly higher than in older age groups (50-64 and 65+).

Respondents were slightly satisfied with life, with an average score of 5.1 points out of 7 for overall life satisfaction and a global satisfaction score of 25.4 out of 35 (graph 9).

Respondents reported moderate subjective well-being, with an average score of 74 (within the normative range of 70 to 80 for Western countries). For the items making up the score, respondents reported values that range from 66 to 78, although the majority are above 70. The highest score was for how safe they feel (78), while the lowest was for their future security (66). Notably, the respondents’ estimated average score for satisfaction with life as a whole was 71, which shows their capacity to cope with the impacts of pandemic. 

A regression model showed that the following factors had a significant inverse relationship to respondents’ subjective well-being: having an appointment or complementary exam postponed or cancelled because of covid-19; having had to postpone regular payments, such as rent or loans, because of covid-19; feeling nervous, anxious, or on edge; feeling sad or depressed; having trouble sleeping; and living in the same home with someone belonging to a covid-19 high-risk group. Another regression model showed that the following factors had a significant inverse relationship to respondents’ life satisfaction: having experienced a loss of job or permanent business closure because of covid-19; having had to postpone regular payments, such as rent or loans, because of covid-19; feeling nervous, anxious, or on edge; feeling sad or depressed; and having trouble sleeping. A third regression model revealed that the following factors had a significant inverse relationship to respondents’ HRQoL: having an appointment or complementary exam postponed or cancelled because of covid-19; feeling nervous, anxious, or on edge; feeling sad or depressed; having trouble sleeping; feeling lonely often; and living in the same home with someone belonging to a covid-19 high-risk group. This last regression model also showed that feeling lonely only some of the time, going shopping frequently, and going out for a walk frequently were linked to a higher HRQoL.

Because the study used a representative sample of the Portuguese population, the findings can be extrapolated to provide information on health and healthcare, HRQoL and well-being, social networks, and the work and economic situation of Portuguese citizens more broadly, before and during the pandemic. Overall, it suggests that Portuguese citizens—especially older ones—experienced reduced access to healthcare during the pandemic. Portuguese citizens also experienced worse mental health and interruptions in their social networks. In terms of economic situation, people with the greatest stability before the pandemic were more likely to report that their situation had been maintained during the pandemic. Young adults were hardest hit by the impacts of the pandemic on work and personal finances. Despite the challenges of the pandemic, the study suggests that Portuguese citizens had reasonably good life satisfaction and well-being during the second lockdown.

Additionally, the study identifies the factors that affected Portuguese citizens’ subjective well-being, life satisfaction and HRQoL. These findings can help health authorities and policymakers to prepare the health system to be able to cope with citizens’ healthcare needs during emergencies and to develop psychological interventions to ensure citizens’ mental health and thus good HRQoL and well-being. Moreover, this study sheds light on actions that need to be taken to help Portuguese citizens recover their social networks and improve their economic situation.

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