Improved childhood asthma control after exposure reduction interventions for desert dust and anthropogenic air pollution: the MEDEA randomised controlled trial

INTRODUCTION

Elevated particulate matter (PM) concentrations of anthropogenic and/or desert dust origin are associated with increased morbidity among children with asthma.

OBJECTIVE

The Mitigating the Health Effects of Desert Dust Storms Using Exposure-Reduction Approaches randomised controlled trial assessed the impact of exposure reduction recommendations, including indoor air filtration, on childhood asthma control during high desert dust storms (DDS) season in Cyprus and Greece.

DESIGN, PARTICIPANTS, INTERVENTIONS AND SETTING

Primary school children with asthma were randomised into three parallel groups: (a) no intervention (controls); (b) outdoor intervention (early alerts notifications, recommendations to stay indoors and limit outdoor physical activity during DDS) and (c) combined intervention (same as (b) combined with indoor air purification with high efficiency particulate air filters in children's homes and school classrooms. Asthma symptom control was assessed using the childhood Asthma Control Test (c-ACT), spirometry (forced expiratory volume in 1 s (FEV1), forced vital capacity (FVC)) and fractional exhaled nitric oxide (FeNO).

RESULTS

In total, 182 children with asthma (age; mean=9.5, SD=1.63) were evaluated during 2019 and 2021. After three follow-up months, the combined intervention group demonstrated a significant improvement in c-ACT in comparison to controls (β=2.63, 95% CI 0.72 to 4.54, p=0.007), which was more profound among atopic children (β=3.56, 95% CI 0.04 to 7.07, p=0.047). Similarly, FEV1% predicted (β=4.26, 95% CI 0.54 to 7.99, p=0.025), the need for any asthma medication and unscheduled clinician visits, but not FVC% and FeNO, were significantly improved in the combined intervention compared with controls.

CONCLUSION

Recommendations to reduce exposure and use of indoor air filtration in areas with high PM pollution may improve symptom control and lung function in children with asthma.

TRIAL REGISTRATION NUMBER

NCT03503812.

Knowledge on Stroke Recognition and Management among Emergency Department Healthcare Professionals in the Republic of Cyprus

Stroke is a global leading cause of death and disability. Knowledge of related guidelines is crucial for emergency department (ED) staff, influencing early diagnosis and timely treatment. We investigated Greek Cypriot ED healthcare professionals' (nurses and physicians) knowledge in recognizing and managing stroke. A descriptive cross-sectional study spanned November 2019 to April 2020, encompassing four private and seven public EDs in the Republic of Cyprus. The data were collected through a self-reported questionnaire developed by the research team, consisting of 37 questions. Eight questions focused on sociodemographic and employment characteristics, twenty-eight assessed knowledge in stroke recognition and management (each item was equally weighted without deliberate prioritization), and one question addressed self-assessment of knowledge in stroke care. A total of 255 nurses (response rate (RR): 74.1%) and 26 physicians (RR: 47.3%) completed the questionnaire. The average correct response rate was 12.9 out of 28 statements (SD: 4.2), with nurses and physicians scoring 12.6 (SD: 4.1) and 15.7 (SD: 4), respectively. Work experience significantly influenced stroke knowledge, with all groups demonstrating superiority over those with less than one year of experience. Participants with previous training scored an average of 1.45 additional correct answers while educational attainment did not significantly influence stroke knowledge. Investigating stroke knowledge among emergency department nurses and physicians in the Republic of Cyprus revealed significant deficits. This study stresses targeted interventions, including education, yearly examinations, workshops with hands-on training, and repeated training, to address these gaps and enhance the overall stroke care capabilities of the healthcare professionals.

Informational support and information-seeking during transition to parenthood: Baby Buddy Forward's focus groups with pregnant women and new mothers in Cyprus

INTRODUCTION

Relevant and accurate information during the transition to parenthood is vital for active participation in decision-making. The aim of the study was to gain an in-depth understanding of informational support and information-seeking practices among women in Cyprus during the transition to parenthood with a focus on the use of the internet and informed decision making.

METHODS

Qualitative descriptive exploratory design of 12 focus groups with 64 participants representing different language-cultural groups served by the Baby Buddy Cyprus app. A topic guide covering expectations, experiences and practices guided the discussions. Data were analyzed using inductive content analysis.

RESULTS

Seven themes and several subthemes emerged. In an 'unsupportive system', 'void' of informational support, pregnant women strive to have a 'confident voice'. They find themselves 'self-navigating in parallel worlds' of formal and informal information, where the internet holds a prominent place. 'Supplementing and filtering', instinctively and selectively, results in a state of 'doubt and faith' towards the trustworthiness of the information but also healthcare providers. Effective communication with providers is needed to break the cycle, but seems dependent on the self-efficacy of the women themselves ('art of communication'). Women 'deconstruct and reimagine' their experiences, often assigning responsibility on themselves for not having been better prepared.

CONCLUSIONS

Women want control over decisions affecting their pregnancy. While the internet is a prevalent source of information, they value communication with healthcare providers and want direction. A shift is needed from current practices of unguided information-searching. Maternity healthcare professionals need to recognize this phenomenon, offer appropriate guidance, and support active participation in informed decision-making.

Assessing perceived and functional health literacy among parents in Cyprus: A cross-sectional study

BACKGROUND

Parents often must take decisions regarding their children's health, which requires certain skills and competences. Parental health literacy (HL) is important in establishing positive health-promoting behaviours and better health outcomes to their children. Limited parental HL has been associated with various negative children's health outcomes. The aim of the study was to explore perceived and functional HL among parents in Cyprus.

METHOD

A cross-sectional study was conducted with a convenience sample of 416 parents of children, aged 6 months to 15 years old, presenting in pediatric outpatient departments across three Cypriot cities. Participants completed the HLS-EU-Q47, a self-reported measure of HL, and the NVS (Newest Vital Sign), a performance-based measure of HL. Associations with socio-demographic characteristics and health behaviors were explored.

RESULTS

Based on suggested ranges, among 416 parents, mostly mothers (83.2%), almost half of parents (42.6%) were classified as having inadequate or problematic perceived HL. Consistently, 62.8% showed high likelihood or significant possibility of limited functional HL, based on the NVS with a mean score of 2.73 out of 6 (SD = 2.02). Nevertheless, no correlation was observed between the two measures of HL. Limited parental perceived HL was statistically significantly associated with lower educational attainment, lower number of children in the family, increased self-assessed health status, and limited exercise habits. Limited parental functional HL was statistically significantly associated with female gender, younger age, lower educational attainment, receiving financial aid, lower family income, and lower alcohol consumption.

CONCLUSION

Even though there was lack of agreement in the classification according to the HLS-EU-Q47 and the NVS, moderate-to-low levels of perceived HL appear consistent with a performance-based measure of HL. As a high number of parents may face challenges in assessing and applying health information to improve outcomes for their children, with evidence of social gradient, healthcare services should be oriented towards identifying problematic HL while Public Health interventions are needed to enhance parental HL.

A qualitative study exploring the social contagion of attitudes and uptake of COVID-19 vaccinations

Vaccination attitudes and uptake can spread within social networks. This study aims to understand the perceived social contagion mechanisms of vaccination uptake in the context of COVID-19 pandemic. Eleven semi-structured interviews were conducted following a purposive sampling of three hesitant, three anti- COVID-19 vaccine and five pro- COVID-19 vaccine (27% females). Thematic Analysis suggested two general themes reflecting the type of contagion: 1) information contagion and 2) behavior contagion. Transcending these themes was the notion of ownership of choice/decision. Almost all participants used the media and experts as the main source of information regarding vaccination. They influenced - and they were being influenced by - friends and family members with whom they share similar traits and attitudes and have a close relationship of trust and intimacy. Also, being exposed to positive attitudes and beliefs toward vaccination and COVID-19 vaccines, enhanced vaccination behaviors. However, the vaccination decision-making process was not perceived as a passive process - there was ownership over the decisions made. This study highlights the perceived mechanisms of social contagion. It also suggests that the meaning individuals pose on their social world is crucial on their decision-making. Policymakers are advised to consider including social networks of individuals and trusted sources (i.e. healthcare providers) when delivering interventions or educational campaigns on vaccinations.

Cognitive impairment in adults under compulsory psychiatric care: association with psychotic symptoms and high-dose antipsychotics

BACKGROUND

There is limited evidence on the association between cognitive function, psychotic symptoms and doses of antipsychotics in adults under compulsory psychiatric care.

AIMS

We assessed (a) the degree of cognitive impairment in adults involuntarily hospitalised for compulsory psychiatric care and (b) correlation of Montreal Cognitive Assessment (MoCA) score with psychotic symptoms, polypharmacy and prescription of high-dose antipsychotics.

METHOD

This was a nationwide, cross-sectional study, conducted at the only referral state hospital for compulsory psychiatric care in Cyprus (December 2016-February 2018). Τhe MoCA was applied for the assessment of cognitive functioning. The Positive and Negative Syndrome Scale (PANSS) was applied for the assessment of psychotic symptoms.

RESULTS

The sample comprised 187 men and 116 women. The mean MoCA score was 22.09 (reported scale range (RSR): 3-30); the mean PANSS general symptoms subscale score was 49.60 (RSR = 41-162). The participants who reported positive psychiatric history (mean 21.71, s.d. 5.37), non-adherence to pharmacotherapy (mean 21.32, s.d. 5.56) and prescription of high-dose antipsychotics (with medication prescribed as needed: mean 21.31, s.d. 5.70; without medication prescribed as needed: mean 20.71, s.d. 5.78) had lower mean MoCA scores compared with those who reported negative psychiatric history (mean 23.42, s.d. 4.51; P = 0.017), adherence to pharmacotherapy (mean 23.10, s.d. 6.61; P = 0.003) and no prescription of high-dose antipsychotics (with medication prescribed as needed: mean 22.56, s.d. 4.90; without medication prescribed as needed: mean 22.60 s.d. 4.94; P = 0.045-0.005), respectively. Mean MoCA score was mildly and inversely associated with total PANSS score (r = -0.15, P = 0.03), PANSS general (r = -0.18, P = 0.002) and PANSS negative (r = -0.16, P = 0.005) symptoms subscales, respectively.

CONCLUSIONS

Our findings support the evaluation of cognitive functioning in adults under compulsory psychiatric care via the MoCA tool, with focus on those prescribed high-dose antipsychotics, with positive mental health history and non-adherence to pharmacotherapy.

MEDEA randomised intervention study protocol in Cyprus, Greece and Israel for mitigation of desert dust health effects in adults with atrial fibrillation

INTRODUCTION

Mediterranean countries experience frequent desert dust storm (DDS) events originating from neighbouring Sahara and Arabian deserts, which are associated with significant increase in mortality and hospital admissions, mostly from cardiovascular and respiratory diseases. Short-term exposure to ambient air pollution is considered as a trigger for symptomatic exacerbations of pre-existing paroxysmal atrial fibrillation (AF) and other types of heart arrhythmia. The Mitigating the Health Effects of Desert Dust Storms Using Exposure-Reduction Approaches clinical randomised intervention study in adults with AF is funded by EU LIFE+programme to evaluate the efficacy of recommendations aiming to reduce exposure to desert dust and related heart arrhythmia effects.

METHODS AND ANALYSIS

The study is performed in three heavily exposed to desert dust regions of the Eastern Mediterranean: Cyprus, Israel and Crete-Greece. Adults with paroxysmal AF and implanted pacemaker are recruited and randomised to three parallel groups: (a) no intervention, (b) interventions to reduce outdoor exposure to desert dust, (c) interventions to reduce both outdoor and indoor exposure to particulate matter during desert dust episodes. Eligible participants are enrolled on a web-based platform which communicates, alerts and makes exposure reduction recommendations during DDS events. Exposure changes are assessed by novel tools (smartwatches with Global Positioning System and physical activity sensors, air pollution samplers assessing air quality inside and outside participant's homes, etc). Clinical outcomes include the AF burden expressed as the percentage of time with paroxysmal AF over the total study period, the incidence of ventricular arrhythmia episodes as recorded by the participants' pacemakers or cardioverters/defibrillators and the disease-specific Atrial Fibrillation Effect on QualiTy-of-Life questionnaire.

ETHICS AND DISSEMINATION

Local bioethics' authorities approved the study at all sites, according to national legislations (Cyprus: National Bioethics Committee, Data Protection Commissioner and Ministry of Health; Greece, Scientific Committee and Governing Board of the University General Hospital of Heraklion; Israel: Institutional Review Board ('Helsinki committee') of the Soroka University Medical Center). The findings will be publicised in peer-reviewed scientific journals, in international conferences and in professional websites and newsletters. A summary of the results and participants' interviews will be included in a documentary in English, Greek and Hebrew.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov Identifier; NCT03503812.

Exploring the impact of particulate matter on mortality in coastal Mediterranean environments

Air pollution is one of the most important problems the world is facing nowadays, adversely affecting public health and causing millions of deaths every year. Particulate matter is a criteria pollutant that has been linked to increased morbidity, as well as all-cause and cause-specific mortality. However, this association remains under-investigated in smaller-size cities in the Eastern Mediterranean, which are also frequently affected by heat waves and dust storms. This study explores the impact of particulate matter with an aerodynamic diameter ≤ 10 μm (PM₁₀) and ≤ 2.5 μm (PM_2.5) on mortality (all-cause, cardiovascular, respiratory) in two coastal cities in the Eastern Mediterranean; Thessaloniki, Greece and Limassol, Cyprus. Generalized additive Poisson models were used to explore overall and gender-specific associations, controlling for long- and short-term patterns, day of week and the effect of weather variables. Moreover, the effect of different lags, season, co-pollutants and dust storms on primary associations was investigated. A 10 μg/m³ increase in PM_2.5 resulted in 1.10 % (95 % CI: -0.13, 2.34) increase in cardiovascular mortality in Thessaloniki, and in 3.07 % (95 % CI: -0.90, 7.20) increase in all-cause mortality in Limassol on the same day. Additionally, significant positive associations were observed between PM_2.5 as well as PM₁₀ and mortality at different lags up to seven days. Interestingly, an association with dust storms was observed only in Thessaloniki, having a protective effect, while the gender-specific analysis revealed significant associations only for the males in both cities. The outcome of this study highlights the need of city- or county-specific public health interventions to address the impact of climate, population lifestyle behaviour and other socioeconomic factors that affect the exposure to air pollution and other synergistic effects that alter the effect of PM on population health.

Improved indoor air quality during desert dust storms: The impact of the MEDEA exposure-reduction strategies

Desert dust storms (DDS) are natural events that impact not only populations close to the emission sources but also populations many kilometers away. Countries located across the main dust sources, including countries in the Eastern Mediterranean, are highly affected by DDS. In addition, climate change is expanding arid areas exacerbating DDS events. Currently, there are no intervention measures with proven, quantified exposure reduction to desert dust particles. As part of the wider "MEDEA" project, co-funded by LIFE 2016 Programme, we examined the effectiveness of an indoor exposure-reduction intervention (i.e., decrease home ventilation during DDS events and continuous use of air purifier during DDS and non-DDS days) across homes and/or classrooms of schoolchildren with asthma and adults with atrial fibrillation in Cyprus and Crete-Greece. Participants were randomized to a control or intervention groups, including an indoor intervention group with exposure reduction measures and the use of air purifiers. Particle sampling, PM₁₀ and PM_2.5, was conducted in participants' homes and/or classrooms, between 2019 and 2022, during DDS-free weeks and during DDS days for as long as the event lasted. In indoor and outdoor PM₁₀ and PM_2.5 samples, mass and content in main and trace elements was determined. Indoor PM_2.5 and PM₁₀ mass concentrations, adjusting for premise type and dust conditions, were significantly lower in the indoor intervention group compared to the control group (PM_{2.5-intervention}/PM_2.5-control = 0.57, 95% CI: 0.47, 0.70; PM_{10-intervention}/PM_10-control = 0.59, 95% CI: 0.49, 0.71). In addition, the PM_2.5 and PM₁₀ particles of outdoor origin were significantly lower in the intervention vs. the control group (PM_2.5 infiltration intervention-to-control ratio: 0.49, 95% CI: 0.42, 0.58; PM₁₀ infiltration intervention-to-control ratio: 0.68, 95% CI: 0.52, 0.89). Our findings suggest that the use of air purifiers alongside decreased ventilation measures is an effective protective measure that reduces significantly indoor exposure to particles during DDS and non-DDS in high-risk population groups.

Impact of the MEDEA exposure-reduction strategies on indoor air quality during desert dust storms

Background

Desert dust storms (DDS) impact the Mediterranean basin heavily, particularly in the context of climate change, reduced precipitation and increasing desertification. There is a pressing need to develop policies protecting EU citizens’ health from DDS. While Public Health authorities in affected regions commonly issue warnings, the effectiveness of recommendations to reduce exposure has not been documented.

Methods

This work is part of the wider “MEDEA” intervention studies, co-funded by LIFE 2016 Programme. Among other outcomes, the studies examined the effectiveness of an indoor exposure-reduction intervention (i.e., decrease home ventilation and use of air cleaners) across homes of asthmatic schoolchildren and individuals with atrial fibrillation in Cyprus. Participants were randomized to either a control or indoor intervention group. The assessment took place in a sample of participants’ homes, during 2019 and 2021, with the collection of indoor and outdoor PM10 and PM2.5 samples, which were analyzed for mass and elemental concentrations.

Results

Indoor PM2.5 and PM10 mass and elements concentrations were significantly lower in the indoor intervention group compared to the control group, both during days with no dust (e.g., 55% and 48% reduction for PM2.5 and PM10, respectively) and days with desert dust (PM2.5: 47% and PM10: 40% reduction). In addition, the infiltration of PM2.5 and PM10 particles from the outdoor to the indoor air was significantly lower in the intervention vs. the control group (PM2.5: -55%, 95% CI: -42%, -65%; PM10: -41%, 95% CI: -61%, -12%).

Conclusions

The study assessed a realistic exposure-reduction strategy and provided first-time evidence that closing doors and windows along with air cleaners can reduce indoor exposure to DDS particles. This evidence can further inform decision-making and strategic planning for population-level mitigation of DDS health effects in Mediterranean Europe.

Key messages

Assessing perceived and functional health literacy among Cypriot parents

Background

Health literacy (HL) refers to people’s competencies in accessing, understanding, assessing and applying health information to meet demands in healthcare, preventing illness and promoting health. In the case of children, parental HL is important in establishing health-promoting behaviours and better health outcomes.

Methods

A cross-sectional study was conducted among parents of children, aged 6 months to 15 years, in Cyprus with the aim of assessing perceived and functional HL. A convenience sample of parents presenting in pediatric outpatient departments in three Cypriot cities rated their HL using the HLS-EU-Q47 and the NVS (Newest Vital Sign), a performance-based measure of HL. Participants were classified according to the overall and domain-specific scores and associations with socio-demographics were explored.

Results

HLS-EU-Q47 mean score among 416 parents (83.2% female, 83.8% tertiary education) was 35.30 (SD = 7.45). Based on suggested ranges, almost half (42.6%) were classified as having inadequate or problematic HL. Consistently, 62.8% showed high likelihood or significant possibility of limited functional HL, based on the NVS with a mean score of 2.73 (SD = 2.02). Competency of understanding health information was rated higher (37.71, SD = 7.39), whereas assessing health information was rated lower (33.55, SD = 9.05). Among the three domains of the HLS-EU-Q47, the highest mean score was for healthcare (36.16, SD = 7.04) and the lowest score for health promotion (34.60, SD = 8.88). Parental HL was statistically significantly associated with education and financial difficulties.

Conclusions

Moderate-to-low levels of perceived HL appear consistent with a performance-based measure of HL. As a high number of parents may face challenges in assessing and applying health information to improve outcomes for their children, healthcare services should be oriented towards identifying problematic HL, while Public Health interventions are needed to enhance parental HL.

Key messages

• According to both a perceived and a performance-based measure of health literacy, the study suggests that a high proportion of parents in Cyprus may have inadequate or problematic health literacy.

• Health education interventions within clinical settings as well as at Public Health level are needed to enhance parental health literacy, currently not standard practice.

Information-seeking on the internet during the transition to motherhood: descriptive survey, Cyprus

Background

Internet use in pregnancy is very prevalent. However, there are issues with information quality as well as acceptance by healthcare providers which can add to the frustration.

Methods

An online anonymous survey, shared via Baby Buddy Cyprus, addressed women who are pregnant or recently gave birth in Cyprus. Adapting previously used questionnaires, the survey covered reasons and patterns of internet use, perceptions of trustworthiness, appraisal means and usefulness in decision-making.

Results

Among 357 responses so far in this ongoing survey (38% pregnant, 62% new mums, 66% primiparas, 42% C/S, 78% private sector), searching online seems very frequent, even though 70% report coming across wrong or misleading information often. Checking for consistency across sites and/or with information by healthcare provider (HP) is the most common technique for assessing trustworthiness. While the majority discuss information with HP, only half characterize their reception as positive and welcoming. As many as 89% believe that HP should recommend sites, but only 6.5% report their HP made recommendations. The role of the internet in assisting decision-making is rated as moderate (M = 3.0, SD = 1.0 on 5-point scale averaged across 11 items); yet more than half search online to be prepared and have control over decisions. Among reasons cited for using the internet is insufficient time with HP and/or is unclear or unsatisfactory information. While only 11.6% prepare material for the next appointment, 54.5 % use the internet to verify information given by HP or for a second opinion.

Conclusions

While a prevalent source of information, the flow is problematic as it appears that women are more likely to search online to verify information rather than discuss this information with their providers. Insights about characteristics and attributes of internet use in pregnancy suggest that health services need to engage with, rather than ignore, this reality and offer appropriate guidance.

Key messages

• Pregnant women in Cyprus search for information online, due to insufficient time or information by healthcare providers, even though they recognize there are issues with quality and expect guidance.

• In a landscape of unguided information-seeking, searching for consistency and verification, a shift in current practices is needed whereby healthcare providers and services engage with this reality.

Timing and social patterning of weaning practices in Cyprus: BrEaST start in life longitudinal study

Background

Introduction of solids in the infant diet, according to WHO recommendations, should initiate onwards of sixth months. Evidence, however, suggests that solids introduction occurs earlier even if breastfeeding continues. With low breastfeeding rates, Cyprus is ranking last in Europe and little is known about the timing and socio-demographic pattern of solid introduction.

Methods

Using the retrospective event calendar method at the 4th and 6th month after birth, the timing of initiation of solids was estimated among a consecutive sample of 350 mother-baby dyads from all public (N = 5) and 29 (of 35) private maternity clinics. The likelihood of early introduction according to socio-demographic characteristics and breastfeeding self-efficacy (measured at birth and 1st month) was estimated in logistic regression models.

Results

Three out of ten women (30.8%) had initiated solids before the 4th month and only 20% hadn't by the 6th month. Almost half of non-Cypriot mothers (47.1%) initiated solids earlier than the 5th month, twice more likely compared to 25.1% of Cypriot mothers (OR: 2.45 95% CI: 1.30-4.57). There was a stepwise association with educational attainment with mothers with tertiary education more likely to initiate solids later (OR: 2.76 95% CI: 1.33-5.71) compared to those with at most secondary education. A similar social gradient was observed with income but was not statistically significant in multivariable models, while no association was observed with mode of birth (55.9% by C/S). Even though low breastfeeding self-efficacy at first month was predictive of earlier initiation, surprisingly, primiparous or multiparous mothers without previous breastfeeding experience were more likely to initiate solids later.

Conclusions

Early introduction of solids with a clear social gradient suggests the need for strengthening the currently weak community-based interventions to improve weaning practices, including screening for breastfeeding self-efficacy.

Key messages

• Four in five mums in Cyprus introduce solids before the 6th month with one in three introducing solids in the infant’s diet before the 4th month, with a clear social gradient in the patterning.

• Community-based intervention programmes are needed to improve weaning practices, including screening for low breastfeeding self-efficacy in a country with low breastfeeding rates.

Associations between breastfeeding and the “10 Steps for Successful Breastfeeding”

Background

The Baby-Friendly Hospital Initiative’s (BFHI) ‘‘Ten Steps for Successful Breastfeeding'’ has been the cornerstone of national and international strategies for decades; however, adherence is suboptimal. Despite successive National Strategies, breastfeeding rates remain low in Cyprus.

Methods

The overall experience of a consecutive sample of 568 mother-baby dyads (response: 70.8%) across all public (N = 5) and 29 (of 35) private maternity clinics was operationalized as the sum score of full, partial or no implementation of each WHO/UNICEF BFHI self-assessment questionnaire item, with the exclusion of Step 6 (exclusivity). Associations with initiation and continuation of any (BF) and exclusive breastfeeding (EBF) up to the 6th month were explored in logistic regression after adjusting for potential confounders, including breastfeeding self-efficacy.

Results

At mean score 5.6 (SD = 2.4), the overall 10 steps experience was low (theoretical range 0-14), even among those who breastfed exclusively (M = 6.9, SD = 2.1; p < 0.001). EBF and BF initiation and continuation showed a stepwise association with self-reported experience of the 10 steps. Across quartiles of increasing scores, the prevalence of EBF was 7.1%, 15.1%, 17.0% and 35.6%. The quartile of mothers who assessed their experience more favourably were 8- (adjOR: 8.4, 95% CI 1.5-48.0; p = 0.017) and 4-times (adjOR: 4.1; 95% CI 1.7-9.8, p = 0.002) more likely to initiate BF and EBF, even though only 6.5% continued EBF by the 6th month. Step 7 (rooming-in) and step 9 (no pacifiers) were least practiced but more strongly associated with EBF initiation.

Conclusions

While breastfeed intention may determine the actual experience of the 10 steps, implementation across maternity clinics appeared fragmented, despite clear association with successful initiation and continuation of BF, at the same time that the Cyprus National Committee for Breastfeeding is embarking on the first BFHI accreditation of maternity clinics.

Key messages

• Despite successive National Strategies identifying breastfeeding as Public Health priority, adherence to the WHO/UNICEF’s 10 Steps appears fragmented across Cypriot maternity clinics.

• Despite low overall adherence, mothers reporting experiencing more of the 10 steps were more likely to initiate and continue breastfeeding.

Mitigating effects of desert dust storms in asthmatic children: health visitors’ perceptions, Cyprus

Background

Countries of the Mediterranean basin such as Cyprus are experiencing frequent desert dust storm (DDS) events that adversely impact children with asthma. As school health visitors (SHVs) have important role in asthma management, we examined SHVs practices and perceptions on asthma management and their level of engagement in school-based interventions to mitigate DDS- health effects.

Methods

A descriptive cross-sectional survey was conducted among SHVs across state schools in Cyprus via an anonymous questionnaire, which rated the importance of asthma management measures (10-point scale), current implementation of these practices (1=never - 5=always), and regulatory authorities’ preparedness to respond to DDS events (1-5 Likert scale).

Results

Responses from 78 of the 93 SHVs (84%), with an average work experience of 13.5 years (SD 7.3), revealed discordance between high perception of the importance of asthma management measures and their actual implementation, with poor scoring especially in assessment of asthma control (M = 2.4, SD = 1.5), tracking school absenteeism (M = 2.1, SD = 1.0) and monitoring of asthma triggers (M = 1.9, SD = 1.4). Any DDS-related measures (e.g. air quality real-time monitoring, warnings, recommendations, awareness campaigns, etc) were implemented very infrequently. Ratings of authorities’ preparedness were moderate (&lt;3.5), and only slightly higher in the health versus the educational or other government services. SHVs who recognized the severity of DDS and potential impact on asthmatic children were more likely to support school-based interventions for DDS events (OR = 7.3, 95% CI: 2.1-25.3).

Conclusions

Asthma management practices in school settings in Cyprus are suboptimal and responses during DDS are fragmented. While SHV’s awareness and support for interventions is high, this is not reflected in current practices. A concerted effort is needed for adoption of policies and implementation of action plans for DDS within school settings.

Key messages

• Suboptimal asthma management policies and practices were found to be implemented in schools in Cyprus, a country highly exposed to dust events.

• School health visitors recognize the health impact of desert dust on asthmatic children and support the plan for dust-mitigation programmes in schools, despite authorities’ low preparedness.

Identifying barriers to the educational role of midwives in Cyprus and defining determinants in behaviour terms using the Behaviour Change Wheel: a mixed-method formative study

Background

Τhe Baby Buddy Cyprus webapp was co-created with parents and health professionals within a Participatory Action Research framework. While using Baby Buddy in routine consultations can support the educational role of mother–child healthcare providers (HP), antenatal education (AE) may be currently perceived as a formal activity within the physical space of the antenatal class. We aimed to gain an understanding of influences on midwives engaging in an educational role during routine appointments and identify potential interventions using the Behaviour Change Wheel (BCW) framework.

Methods

This is a formative mixed-methods research study, with a convergent parallel design, guided by the COM-B model and related Theoretical Domains Framework (TDF). Complimentary methods were used to collect information from in-training and registered midwives: focus group (N = 11), questionnaire survey (N = 24) and Nominal Group Technique during workshops (N = 40). Deductive content analysis of qualitative data and quantitative survey analysis shaped the behaviour diagnosis along the 6 COM-B and 14 TDF domains, and informed the selection of relevant intervention functions and related Behaviour Change Techniques from the BCW taxonomy.

Results

AE is viewed as a core function of the professional role, yet neither supported nor prioritized by current practices. Problematic areas relate to organizational context, such as weak interprofessional collaboration and lack of policy, protocols and resources. In addition, medicalization of birth and related socio-cultural norms, pertaining to users and providers, are sustaining alienation of the midwife and conditions of power dynamics. AE was perceived as a means to enhance the autonomy of the profession but there might be issues with procedural knowledge and the need for skill development was identified. Several intervention functions were identified as promising, however cognitive re-framing through strategic communication and modelling may also be needed both in terms of providing “credible models” for the role itself as well as re-framing AE through the concept of “making every contact count”.

Conclusions

AE is currently perceived to be a ‘bad fit’ with routine practice. The study identified several barriers to the educational role of midwives, influencing Capacity, Opportunity and Motivation. While digital tools, such as Baby Buddy, can facilitate aspects of the process, a much wider behaviour and system change intervention is needed to enhance midwives’ educational role and professional identity. In addition to proposing a theory-driven research-informed intervention, the process functioned as a participatory learning experience through collective reflection.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-08599-7.

Involuntary psychiatric admission in Cyprus: A descriptive correlational study

INTRODUCTION

Studies on the clinical and socio-demographic characteristics of those involuntarily admitted to psychiatric settings could help professionals and researchers to develop effective, targeted interventions, alternative to compulsory psychiatric care.

AIM

The association between socio-demographic and clinical characteristics in adults under involuntary hospitalization for psychiatric treatment in the Republic of Cyprus was assessed.

METHOD

This was a descriptive, cross-sectional and correlational study. Data collection was achieved (December 2016 to February 2018) via a census sampling method. Socio-demographic and clinical data of individuals involuntarily admitted to the reference psychiatric hospital of Cyprus with psychotic symptomatology were recorded.

RESULTS

The sample encompassed 144 females and 262 males. The most frequent diagnosis was schizophrenia or a relevant psychotic disorder (72.9%). The most frequent cause of admission was "Disorganized behaviour" along with non-adherence to pharmacotherapy (53.7%). Approximately 42.8% of the participants confirmed positive substance use history, which was more frequently reported in males than in females (88.5% vs. 11.5%, respectively, p < 0.001). Additionally, males were more frequently admitted due to Disorganized behaviour with substance use compared to females (31.3% vs. 4.9%, respectively, p < 0.001), while females were more frequently admitted due to d"Disorganized behaviour with non-adherence to pharmacotherapy (70.1% vs. 44.7%, respectively, p < 0.001). Also, males were more frequently involuntarily hospitalized due to suicidal/self-harming behaviour compared to females (12.2% vs. 5.6%, respectively, p = 0.031).

CONCLUSION

Gender differences were noted in relation to clinical characteristics of the participants, highlighting the need for gender-specific interventions to decrease compulsory psychiatric care, including enhancement of adherence to therapy.

A qualitative study of assessing learning needs and digital health literacy in pregnancy: Baby Buddy Forward Greek findings

INTRODUCTION

The purpose of this study was to explore the learning needs and the digital health literacy of pregnant women in Greece regarding perinatal health and care issues.

METHODS

This was a qualitative study involving thirteen Greek pregnant women, in two focus groups of primiparous and multiparous. The interview topic guide was developed by consensus during a training workshop of the European Baby Buddy Forward research program. The interviews were recorded, transcribed and inductively content analyzed.

RESULTS

Pregnant women described a range of learning needs and identify antenatal classes, health professionals, Internet, books, friends and relatives, as their main sources of information. Women expressed satisfaction in terms of their communication with midwives, but they expressed ambiguity regarding communication with doctors. With regard to the Internet, women highlighted their concern about the validity of information and point out the difficulties they face in order to access reliable scientific resources. Moreover, the process of seeking information online occurs in parallel and independently from healthcare providers, who discourage it, thus, many women were reluctant to discuss any information they retrieved from the Internet with health professionals.

CONCLUSIONS

The content of antenatal classes should be tailored to address pregnant women learning needs more holistically. However, taking into consideration that a major source of information for pregnant women is the Internet, it is vital for health professionals to acknowledge this reality and provide pregnant women with trusted websites. It is also particularly important for health professionals to practice their communication skills and update their digital knowledge.

The Greek version of the Professional Quality of Life (ProQoL) scale version 5

Funding Acknowledgements

Type of funding sources: None.

Background

The Professional Quality of Life (ProQοL) scale is one of the most widely measures of compassion satisfaction and fatigue used, despite there is not much of published evidence to support its validity. The ProQoL scale assesses multiple domains of work experiences; compassion satisfaction, burnout and secondary traumatic stress. Our aim was to examine the psychometric properties of the Greek version of the ProQoL scale version 5 (Gr-ProQoL-5).

Method

A methodological study was contacted in order to assess the construct validity and reliability of the Gr-ProQoL-5. For that reason, 264 questionnaires were administrated by Greek-Cypriot healthcare professionals (HPs). Confirmatory factor analysis (CFA) and Exploratory factor analysis (EFA) were conducted to examine the relationship between the three Gr-ProQoL-5 dimensions (compassion satisfaction, burnout and secondary traumatic stress). Cronbach’s a was calculated as well.

Results

CFA for Gr-ProQOL-5, did not confirm the initial scale’s dimensions. In EFA five models were emerged. The models were then tested with CFA and after a panel discussion, the research team decided to keep one final model for the Gr-ProQoL-5. Items 1, 2, 4, 10, 15, 17 and 29 were eliminated from the analysis due to low communalities and multiple components loading. Three components were found representing compassion satisfaction, burnout and secondary traumatic stress.

Conclusions

The Gr-ProQoL-5 is an adequate instrument to assess ProQoL in Greek-Cypriot HPs and may be valuable for designing effective interventions to reduce burnout and compassion fatigue, and promote compassion satisfaction of HPs. More than ever and in the era of the pandemic the ProQοL seems to be a necessary quality indicator for health care systems.

The Diagnostic Accuracy of 18F-FGD-PET/CT for Cancer of the Gallbladder: A Retrospective Study

Background  Gallbladder cancer has a poor prognosis and imaging can have variable diagnostic accuracy. We assessed the ability of preoperative ¹⁸ F-fluorodeoxyglucose positron emission tomography computed tomography ( ¹⁸ F-FDG-PET/CT) imaging to predict a postoperative histological diagnosis of gallbladder cancer.

Method  A retrospective analysis was undertaken in a cohort of patients, who had suspected gallbladder cancer on cross-sectional imaging and that underwent preoperative FDG-PET/CT scan. The discriminatory power of FDG-PET/CT was determined in receiver operator characteristic (ROC) analysis and diagnostic accuracy parameters were estimated at different thresholds of maximum standard unit value (SUV _max ) _.

Results  Twenty-two patients were included in the study; 7 had malignant and 15 benign diagnoses. There was no statistically significant difference between the measured SUV _max between the two groups ( p  = 0.71). With an area under the curve of 0.486, the ROC curve did not indicate any discriminatory power of FDG-PET/CT at any potential threshold of SUV _max.

Conclusion  This study indicates that the diagnosis of primary gallbladder cancer cannot be accurately confirmed with FDG PET/CT scanning.

Health literacy and eHealth literacy and their association with other caring concepts among carers of people with dementia: A descriptive correlational study

Health literacy (HL) and eHealth literacy (eHL) can facilitate carers of people with dementia (PwD) to search, find, assess and apply information related to dementia-specific issues from different resources. There is a lack of research with regard to HL and eHL among carers of PwD. The aim of this study is to identify the levels of HL and eHL among carers of PwD in Greece and Cyprus and to search for the associations with other caring concepts. This study followed a descriptive correlational design. In total, 174 primary informal carers of PwD, mostly women, over 45 years old and with more than 12 years of education and 67 secondary carers (family, friends or neighbours) participated in the study. Primary informal carers completed a face-to-face survey on the level of HL and eHL, internet use, dementia-specific internet use, care-giving self-efficacy, coping strategies, care-giving perceptions and social support. Primary informal carers reported a high level of eHL and HL. Carers with higher HL were more likely to report higher score of eHL, care-giving self-efficacy and lower score of problematic/dysfunctional coping. Higher score of eHeals-Carer "information seeking" was related with higher use of emotion-focused strategies. From this study, a positive message was received with regard to the role of HL and eHL in the everyday caring life. Non-for-profit organisations and healthcare professionals could integrate in their practice assessment tools and develop tailored training courses for carers enhancing low level of HL and eHL.

Profiling the variability and inequity in the residential environment in Cyprus according to citizens' ratings: a cross-sectional internet-based "Place Standard" survey

Background

The “Place Standard Tool” (PST) offers a practical framework for structuring conversations about physical and social dimensions of Place which impact on health and well-being. The aim of this study was to survey citizens’ perceptions of Place across diverse settings in Cyprus. While the PST has been extensively used in the context of community engagement, its properties as a measurement tool haven’t been explored.

Methods

An open call was addressed to citizens to rate their neighbourhood environment across the 14 PST items (1: large to 7: little room for improvement). Exploratory factor, cluster and regression analyses were used to explore the dimensionality of the scale, depict neighbourhood profiles and explore differences in ratings according to socio-demographic characteristics, area-level census indicators and residents’ assessment of neighbourhood social position (10-step ladder).

Results

With the exception of safety (M = 4.4, SD = 1.7), 492 participants (mean age 42, 50% residents for > 10 years) from 254 postcodes (21.7% islandwide) did not rate other features favourably, with lowest scores for “influence and sense of control” and “public transport”. A stepwise pattern of dissatisfaction was observed along the social position continuum both for features rated less as well as more favourably (e.g. social contact). For instance, among participants who placed their neighbourhood at the three top steps of the ladder, 48.8% gave a low rating for “influence and sense of control”, while the equivalent figure was 81.0% at the bottom three steps (OR = 4.5, 95% CI 2.3, 8.6). A clear dimensionality of Built (6 items, Cronbach’s α = 0.798), Physical (3 items, α = 0.765), Social (2 items, α = 0.749) and Service (3 items, α = 0.58) environment was identified. A social gradient was evident according to census measures of socio-economic disadvantage (e.g. pre-1980 housing, single-parent households) with larger differences in terms of the built than the social environment.

Conclusions

The study profiled the variability and documented the inequity in the health-related neighbourhood environment across Cypriot communities. The readily interpretable dimensionality of the scale supports its construct validity, allowing calculation of composite scores. The PST can be used as measurement tool in research as well as public health practice to advocate for neighbourhood initiatives which support and enhance citizens’ participation.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-12706-y.

Pediatric asthma symptom control during lockdown for the COVID-19 pandemic in Spring 2020: A prospective community-based study in Cyprus and Greece

OBJECTIVES

To prospectively quantify at the community level changes in asthma symptom control and other morbidity indices, among asthmatic schoolchildren in response to coronavirus disease 2019 (COVID-19) lockdown measures.

METHODS

In Spring 2019 and Spring 2020, we prospectively assessed monthly changes in pediatric asthma control test (c-ACT), asthma medication usage, infections and unscheduled visits for asthma among schoolchildren with active asthma in Cyprus and Greece. We compared asthma symptom control and other morbidity indices before and during lockdown measures, while participants' time spent at home was objectively assessed by wearable sensors.

RESULTS

A total of 119 asthmatic children participated in the study during Spring 2020. Compared to a mean baseline (pre-COVID-19 lockdown) c-ACT score of 22.70, adjusted mean increases of 2.58 (95% confidence interval [CI]: 1.91, 3.26, p < 0.001) and 3.57 (95% CI: 2.88, 4.27, p < 0.001) in the 2nd and 3rd monthly assessments were observed after implementation of lockdown measures. A mean increase in c-ACT score of 0.32 (95% CI: 0.17, 0.47, p < 0.001) was noted per 10% increase in the time spent at home. Improvement was more profound in children with severe asthma, while significant reductions in infections, asthma medication usage and unscheduled visits for asthma were also observed. During Spring 2019, 39 children participated in the study in the absence of lockdown measures and no changes in c-ACT or other indices of disease severity were observed.

CONCLUSIONS

Clinically meaningful improvements in asthma symptom control, among asthmatic schoolchildren were observed during the COVID-19 lockdown measures in Spring 2020. Improvements were independently associated with time spent at home and were more profound in the children with severe asthma.

Gaps in Knowledge About SARS-CoV-2 & COVID-19 Among University Students Are Associated With Negative Attitudes Toward People With COVID-19: A Cross-Sectional Study in Cyprus

University students represent a highly active group in terms of their social activity in the community and in the propagation of information on social media. We aimed to map the knowledge, attitudes, and perceptions of University students in Cyprus about severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) and Coronavirus disease 2019 (COVID-19) to guide targeted future measures and information campaigns. We used a cross-sectional online survey targeting all students in conventional, not distance-learning, programs in five major universities in the Republic of Cyprus. Students were invited to participate through the respective Studies and Student Welfare Office of each institution. The survey was made available in English and Greek on REDCap. Participation was voluntary and anonymous. The questionnaire was developed based on a consensus to cover the main factual information directed by official channels toward the general public in Cyprus at the time of the survey. In addition to sociodemographic information (N = 8), the self-administered questionnaire consisted of 19 questions, assessing the knowledge regarding the characteristics of SARS-CoV-2 and COVID-19, infection prevention and control measures (N = 10), perceptions related to COVID-19, for instance, whether strict travel measures are necessary (N = 4), and attitudes toward a hypothetical person infected (N = 2). Furthermore, participants were asked to provide their own assessment of their knowledge about COVID-19 and specifically with regard to the main symptoms and ways of transmission (N = 3). The number of students who completed the survey was 3,641 (41% studying Health/Life Sciences). Amongst them, 68.8% responded correctly to at least 60% of knowledge-related questions. Misconceptions were identified in 30%. Only 29.1% expressed a positive attitude toward a hypothetical person with COVID-19 without projecting judgment (9.2%) or blame (38%). Odds of expressing a positive attitude increased by 18% (95% CI 13–24%; p < 0.001) per unit increase in knowledge. Postgraduate level education was predictive of better knowledge (odds ratio (OR) 1.81; 95% CI 1.34–2.46; p < 0.001 among doctoral students] and positive attitude [OR 1.35; 95% CI 1.01–1.80; p = 0.04). In this study, we show that specific knowledge gaps and misconceptions exist among University students about SARS-CoV-2 and COVID-19 and their prevalence is associated with negative attitudes toward people with COVID-19. Our findings highlight the integrated nature of knowledge and attitude and suggest that improvements to the former could contribute to improvements in the latter.

Health effects of desert dust storm events in the south-eastern Mediterranean: perceptions and practices of local stakeholders

Background

The south-eastern Mediterranean experiences frequent desert dust storm events (DDS) that have been shown to be associated with adverse health effects.

Aims

This study assessed the perceptions and practices towards DDS of local authorities and stakeholders from 3 countries in the region, Cyprus, Greece and Israel.

Methods

Between October 2017 and April 2018, we administered a semi-structured questionnaire to regulatory authorities involved in public protection from DDS as well as social stakeholders in the 3 countries. The questionnaire addressed their knowledge regarding DDS, perceptions on the relationship between DDS and health effects and relevant actions taken towards public protection.

Results

Out of 58 stakeholders contacted, 49 participated in the study (84.5% response rate). Fourteen (28.6%) were regulatory authorities and 35 (71.4%) were social stakeholders. All responders were familiar with DDS but several underestimated the frequency of events while the majority (73%) instinctively reported that elders, children and respiratory patients are susceptible subpopulations. Nevertheless, 71% were unaware of a national policy on DDS, or considered that this was lacking in their country. Although several stakeholders reportedly receive questions from the public regarding DDS effects, only few reply according to a pre-determined action plan.

Conclusions

Regulatory authorities and social stakeholders in Cyprus, Greece and Israel are characterized by good knowledge of DDS and associated health effects, although implementation of pre-determined action plans for public protection is limited. Future efforts should concentrate on increasing awareness among stakeholders and the public and developing national policies, including effective measures to minimize DDS exposure.

Behavioural change intervention for re-framing antenatal education to make “every contact count”

Issue

A trusted source of information, the Baby Buddy webapp was co-created with parents and professionals to support the educational role of maternal healthcare providers. However, providers in Cyprus and elsewhere may not actively engage in antenatal education (AE) to make “every contact count”.

Description of Problem

The impact of Public Health digital interventions can be maximized when adopted in care pathways. To define barriers and enablers in behavioural terms complimentary methods were used guided by the COM-B model and related Theoretical Domains Framework: questionnaire survey (N = 49), focus group (N = 11) and round-table workshops (N = 40) among in-training and registered midwives.

Results

Beliefs about the benefits of AE are strong and viewed as a core function of the professional role, yet not supported nor prioritized by current practice. Many problematic areas relate to organizational context, such as weak interprofessional collaboration and lack of policy, protocols and resources. Medicalization of birth and socio-cultural norms are sustaining alienation of the midwife and conditions of power dynamics. AE was perceived as a means to enhance the autonomy of the profession but the phenomenon is complex and also pertains to perceptions and behaviours of service users. There are also issues with procedural knowledge and the need for skill development was identified.

Lessons

As a digital tool, Baby Buddy can enrich the user-provider exchange. However, AE beyond the formal setting of the antenatal class is perceived to be a ‘bad fit' with current practice. Training (e.g. skills strengthening), persuasion (e.g. reflection on professional identity), enablement (e.g. protocols) were identified as promising intervention functions. Modelling was identified as the most promising both in terms of “credible models” for the role itself as well as re-framing the concept of AE not as preparation for childbirth but in the context of shared decision-making.

Key messages

Barriers to being an effective antenatal educator are several, originating from an unsupportive system and wider socio-cultural norms of users and providers. In addition to designing a theory-driven research-informed intervention, the process functioned as a participatory learning experience through collective reflection.

Knowledge, perceptions and attitudes of university students regarding COVID-19, Cyprus

Background

University students represent an active group with important implications in the novel coronavirus transmission. Elucidating their knowledge, attitudes and perceptions was important for customizing communication material and other information activities.

Methods

The cross-sectional online INTERACT survey targeted students in conventional programs in the five main Universities in the Cyprus Republic between 17-31 March 2020, a week either side of the first national lockdown (24 March).

Results

A total of 3641 students completed the survey (19% response rate): 65.5% female, 80.9% Bachelor, 41% Health/Life sciences. Amongst participants, 68.8% and 20.6% responded correctly to at least six and eight of 10 knowledge-related questions. Objective knowledge did not vary substantially according to self-evaluation of knowledge. Misconceptions were identified in 25-30%. Only 29.1% expressed positive attitude towards a hypothetical person with COVID-19 without also projecting judgement or blame. Odds of expressing positive attitude increased by 18% (95%CI 13-24%) per unit increase in knowledge. Studying at postgraduate level was predictive of better knowledge (OR of ≥score8 1.81; 95%CI 1.34-2.46) and positive attitude (OR 1.35; 95%CI 1.01-1.80). With average knowledge score 6.4 (SD 1.6) vs 6.1 (SD 1.6), Health/Life Sciences students performed marginally better, but were not any more likely to express positive attitude.

Conclusions

Although Cypriot University students appeared relatively knowledgeable, there were specific gaps and misconceptions, some of which may be attributed to changes in information provided to the public. Attitudes should also be interpreted in the local context where reporting, though seemingly neutral, was not characterised by empathy towards people affected. Findings highlight the importance of continuous and good communication, especially as guidance changes, both in terms of content as well as effect.

Key messages

Misconceptions and negative attitudes related to COVID19 were identified among Cypriot University students, including those in Health Sciences.

Good quality communication is important both in terms of content as well as its effect on shaping attitudes.

Depicting socioeconomic disadvantage and social gradient in quality of life in Limassol, Cyprus

Background

The lack of validated and accepted area-level indices of socioeconomic disadvantage at national or regional level in Cyprus poses a barrier to “spatial thinking” among Public Health policy-makers and researchers.

Methods

A composite index of socioeconomic disadvantage was constructed by exploring the factor structure of 28 commonly used census indicators at city quarter (N = 38, median population 3894, IQR 2570-6169) and postcode level (N = 124, median 1320, IQR 798-2014). Predictive validity was explored in mixed random-effect regression models in term of associations with SF-36 health-related quality of life among a stratified random sample aged 45-64 (N = 450, 45 neighbourhoods).

Results

There was wide variability across communities in all indicators, for instance, 0.4%-25.9% unemployment, 41.1%-90.7% at most secondary level education, 3.6%-95.9% residences built prior to 1980. Two factors were identified: “socioeconomic disadvantage” (SED), with the same set of 11-12 indicators at the two levels of geographical aggregation, and “built environment”, reflecting proximity to the city centre, with nevertheless no meaningful associations with the outcome of interest. The SED index captured a stepwise decrease in physical (-1.39 95%CI -2.06, -0.72) and mental health (-1.26 95% -1.98, -0.54) scores across quartiles of postcodes with increasing disadvantage, of similar clinically significant effect size by gender. Associations attenuated slightly but remained significant after adjusting for person-based indicators of social position, with some weak evidence of cross-level interactions for physical, but not mental, health.

Conclusions

The composite index, tapping on educational, economic, material, occupational and social disadvantage, allowed the exploration of socioeconomic disadvantage patterning at a small-area level in the city of Limassol and documented the social gradient in health-related quality of life among a late working-life sample of residents.

Key messages

First-time depiction of the geographical patterning of socioeconomic disadvantage across the small geographical level of postcodes in the city of Limassol, Cyprus. Social gradient in physical and mental health in men and women across the continuum of socioeconomic disadvantage over and above person-based indicators of social position.

Objective and subjective assessment of the neighborhood health environment, Limassol, Cyprus

Background

While neighborhood audit tools are commonly assessed for inter- and intra-rater reliability, validity and relevance are not always demonstrated.

Methods

A stratified random sample of 45 neighbourhoods in Limassol were audited with the 150-item Cyprus Neighborhood Observational Tool for urban environments (CyNOTes). Ratings were correlated with census indicators of socioeconomic disadvantage. The extent to which residents' neighborhood assessment (Place Standard, N = 444) and self-rated quality of life (SF-36 in second sample N = 450) differed across neighborhoods classified according to domain were explored in mixed random effect models.

Results

CyNOTes items are organized in 9 domains (internal consistency=0.5-0.9) with a 3-factor higher structure. In seven, a stepwise pattern of lower mean ratings was observed across increasing socioeconomic disadvantage, for domains rated generally high across neighborhoods (e.g. lack of physical disorder) and low (e.g. outdoor spaces). Though not always statistically significant, a systematic pattern of higher self-rated health was observed in better-off neighborhoods across most domains. “Pedestrian environment” captured the largest difference for both physical (1.34 95%CI 0.42,2.26), p = 0.005 per tertile increase) and mental health (1.46 95% 0.54,2.40; p = 0.003). “Social contact” and “Safety: lack of security-related features” were more likely to be rated favorably in disadvantaged neighborhoods, however no associations with quality of life were observed. While the residents' assessment was often in the expected direction, more for built environment features, this was not always the case.

Conclusions

The study demonstrated the content, construct, criterion and predictive validity of an audit tool for supplementary profiling the built, physical and social health-related neighbourhood environment. Concurrent validity against residents' perceptions was not always supported, raising questions about differential expectations.

Key messages

Neighbourhood audits can provide useful supplementary information not captured by other community assessment methods and independent of residents’ perceptions. Depicting the social gradient in the neighborhood microenvironment can trigger and contextualize the conversation about place effects on health among Public Health research and policy community.

Identifying the carers’ profiles of health literacy, eHealth literacy and caregiving concepts

Background

Carers of people with dementia (PwD) undertake the role of supporting their relatives in everyday life and caring tasks, sometimes without adequate knowledge of the progression of the disease, practical advice and support mechanisms or services. This study aims to describe the Health Literacy (HL) and eHealth Literacy (eHL) profiles of carers of PwD in Greece and Cyprus and to explore associations with dimensions influenced by the delivery of care.

Methods

This descriptive correlational design study measured HL (HLS-EU-Q16 tool), eHL (eHeals-Carer) and dimensions of care (Brief-COPE, caregiving self-efficacy, COPE index and Multidimensional Perceived Social Support). In total, 174 primary carers of PwD and 67 secondary carers participated in a face-to-face survey. Correlation and regression analysis were performed to explore associations between the concepts of interest and cluster analysis (N = 123) to identify profiles of carers.

Results

Carers, primary and secondary, reported high scores of eHL and HL. HL scores were associated with eHL and both variables with the two dimensions of caregiving self-efficacy: “obtain respite” and “behavior management”. Three carers' profiles were identified: 1) carers with high levels of HL, eHL, Self-Efficacy and low coping strategies, 2) carers with problematic coping, negative caregiving perceptions, and lower HL and eHL, and 3) carers with high HL and eHL, with strong Social Network, high emotional-focused coping strategies and low problematic coping.

Conclusions

Understanding the role of HL and eHL in the caregiving process and identifying carers' profiles could assist healthcare professionals in their educational role with families and planning of care. There is a need to develop more ways to assess these concepts for this population and to develop training courses focusing on enhancing the HL skills of carers and healthcare professionals.

The COST action NET4AGE-friendly supported the conference participation.

Key messages

HL and eHL are related to the caregiving role and may not only influence health-related decisions made by the carers on behalf of their relatives but also their own self-efficacy and coping. HL and eHL should be appropriately assessed and taken into consideration by healthcare professionals in management plans for PwD and their families.

Supportive care reinforces telemonitoring in heart failure patients: pilot results of the “SupportHeart”

Introduction

Disease management programs for HF are characterized by heterogeneity and different levels of complexity, thus the results regarding of their effectiveness are controversial. The trajectory of HF makes supportive care (SC) mandatory. The main feature of this framework is continuing communication addressing patient's support needs.

Aim

To evaluate the effectiveness of an individualized SC management program.

Study design

This was a pilot study of a randomized control trial (RCT) [control group (CG) and intervention group (IG)], the “SupportHeart” to assess a SC management program for HF patients. Patients allocated in the IG received written material for HF self-management and the first brief educational session was conducted by a nurse in the bedside.

The intervention was consisted by monthly meetings including educational sessions about the HF syndrome, pharmacological and non- pharmacological treatment, self-management and physical activity (PA). The evaluation of the intervention included health-related quality of life (HR-QoL), self-care management, adherence to PA, anxiety and depression and perceived support. Furthermore, acute events (readmissions and deaths) were measured. Monthly phone calls were also contacted by the research team and patients could call them whenever they needed to. Statistical comparisons were performed and Kaplan Meir curves and the log-rank test (LRT) were utilised to explore the time until the first acute event.

Results

Thirty-five patients with HF participated in the study and the intervention lasted for six months (mth). A better HR-QoL was found for both groups in the sixth mth period with a difference in the social dimension of the HR-QoL favoring the IG. IG: baseline = 4.8 (4.9)/1st mth = 3.3 (3.5)/6th mth=2.8 (3.1), CG: baseline = 2.3 (1,1)/1st mth = 3.4 (2,7)/6th mth = 2.7 (2.8)]. Also, a difference in the sub-scale of family/significant others was indicated where the IG followed an increased trend [IG baseline = 50.9 (5.4)/6th mth = 52.7 (3.4)] [CG baseline = 50.3 (8.9)/6th mth = 49.9 (4.2)]. No difference was found for self-care management, except of the sub-dimension of PA and recognition of deteriorating symptoms favoring IG. IG: baseline = 11.7 (3.4)/1st mth = 13.1 (2.0)/6th mth = 13.6 (1.7). The survival of the CG was lower than that of the IG in 30 days: (LRT, χ2(1)=5.7, p=0.02), 90 days: (LRT, χ2(1)=12.3, p&lt;0.001) and 180 days: (LRT, χ2(1)=6.8, p=0.009).

Conclusion

This is the first RCT assessing the effectiveness of SC in HF and it seems to be a promising concept for HF management programs. There was a great effect in acute events as it was found a reduced risk by 87% for a patient receiving SC. Continuing communication which seems to be achievable through telehealth and phone follow-up incorporating patients' preferences, values, beliefs, illness understanding and information needs into the decision-making process and is shown to be a promising approach in the care of patients with HF.

Funding Acknowledgement

Type of funding sources: None.

The greek version of the professional quality of life (ProQoL) scale version 5

Background

The Professional Quality of Life (ProQoL) scale is one of the most widely measures of compassion satisfaction and fatigue used, despite there is not much of published evidence to support its validity. The ProQoL scale assesses multiple domains of work experiences; compassion satisfaction, burnout and secondary traumatic stress. Our aim was to examine the psychometric properties of the Greek version of the ProQoL scale version 5 (Gr-ProQoL-5).

Method

A methodological study was contacted in order to assess the construct validity and reliability of the Gr-ProQoL-5. For that reason, 264 questionnaires were administrated by Greek-Cypriot healthcare professionals (HPs). Confirmatory factor analysis (CFA) and Exploratory factor analysis (EFA) were conducted to examine the relationship between the three Gr-ProQoL-5 dimensions (compassion satisfaction, burnout and secondary traumatic stress). Cronbach's a was calculated as well.

Results

CFA for Gr-ProQOL-5, did not confirm the initial scale's dimensions. In EFA five models were emerged. The models were then tested with CFA and after a panel discussion, the research team decided to keep one final model for the Gr-ProQoL-5. Items 1, 2, 4, 10, 15, 17 and 29 were eliminated from the analysis due to low communalities and multiple components loading. Three components were found representing compassion satisfaction, burnout and secondary traumatic stress.

Conclusions

The Gr-ProQoL-5 is an adequate instrument to assess ProQoL in Greek-Cypriot HPs and may be valuable for designing effective interventions to reduce burnout and compassion fatigue, and promote compassion satisfaction of HPs. More than ever and in the era of the pandemic the ProQoL seems to be a necessary quality indicator for health care systems.

Funding Acknowledgement

Type of funding sources: None.

337Systematic social observation tool for auditing the physical, built and social health-related urban neighboourhood environment

Background

Several generic or feature-specific neighborhood audit tools have been developed. While inter/intra-observer reliability if commonly assessed, validity is not always considered.

Methods

A two-phase mixed-methods process was used to develop the Cyprus Neighborhood Observational Tool for urban environments (CyNOTes). Phase I: draft based on literature review, culturally adapted and content validated in focus groups with community professionals and social media ethnographic study of citizens’ experience and feasibility tested across 15 neighbourhoods. Phase II: variability in features across 45 neighbourhoods along the social disadvantage continuum and associations with census area indicators, citizens’ perceptions and health-related quality of life were assessed.

Results

Content validity was supported by residents’ and professionals’ descriptions of neighbourhood problems, giving rise to a 17-domain, 151-item inventory, 126 from the literature and 25 arising via Nominal Group Technique consensus and content analysis of social media posts. With good inter- and intra-observer agreement, neighborhoods with lower educational attainment scored lower in over half domains. Social gradient and clustering of adverse features observed while in neighbourhoods with adverse features residents reported lower physical and mental health-related quality of life. The social gradient was not always reflected in the perception survey. With the exception of social aspects, residents did not rate the built and physical environment favorably. “Influence and sense of control” was rated lowest while “Citizens’ voice” emerged in the inductive content analysis of residents’ lived experience.

Conclusions

A culturally relevant audit tool of the health-related neighborhood microenvironment was developed by assessing its content, concurrent, criterion and predictive validity.

Key messages

There is need for valid audit tools, independent of residents’ perceptions, for supplementary profiling of the health-related neighbourhood microenvironment

Neighborhoods audits can trigger and widen conversation among local research community and policy-makers about health and place.

113Social gradient in health literacy among primary healthcare users in Cyprus

Background

From a notion concentrated on the ability to understand health information, health literacy (HL) has become a broad concept, considered a critical determinant of community health. The HLS-EU-measures perceived HL based on a theoretical model of the concept.

Methods

This study explored the metric properties of the tool in a new European setting among a convenience sample of 300 healthcare users in a state General Hospital, including the construct and known-group validity by social position and health-related behaviours.

Results

While factor analysis did not reveal the 12 theoretical subscales, there was a meaningful 3-factor structure (52.1% variance): “access to information”, “prevention and health promotion” and “user-provider interaction”. The postulated four cognitive skills (access, understand, appraise, apply) were evident within each domain (healthcare, prevention, health promotion), and vice versa. Overall, HL was problematic in 50.7% of participants with a steep gradient by social position. Alcohol consumption and physical activity were associated with HL, but not being overweight (mean BMI 26.8, SD: 5.2) or smoking (45.6% current or past smokers), which were generally prevalent.

Conclusions

HLS-EU-Q47 supports at least partly the theoretical construct of HL. The social gradient supports the criterion validity of the tool and highlights an important aspect of health inequality.

Key messages

HLS-EU-Q47 is a valid measure of perceived health literacy

There was a steep gradient in low health literacy by social position

112Neighbourhood environment and health-related quality of life, Limassol, Cyprus

Background

The extent and magnitude of socio-geographical inequalities in health in Cyprus is not clear as neither “place” nor “health inequalities” feature on the public health agenda.

Methods

In the context of a wider Neighbourhood Environment and Health programme, the magnitude of inequality in health-related quality of life (HRQoL) among Limassol citizens was explored in a door-to-door SF-36 survey of residents aged 45-64 (N = 450, 50:50 gender quota) across 45 randomly selected neighbourhoods stratified by socio-economic disadvantage and profiled using a culturally-adapted Systematic Social Observation neighbourhood audit tool.

Results

The social gradient was steeper for physical than mental component scores of HRQoL irrespective of the indicator of social position. Education and income captured the gradient better in women, and occupational-based social class in men, with large effect (0.7-1 SD) on the SF-36 scale at opposite ends of the continuum. Lower HRQoL and more adverse health behaviours observed in disadvantaged neighborhoods according to census area-level measures and neighbourhood audit profiles, with generally larger differences in women.

Conclusions

This study profiled the variability in the urban neighbourhood environment,and documented the magnitude of social gradient in health and health-related quality of life in a representative sample of late working-life population in Cyprus.

Key messages

Social gradient in health behaviours and quality of life in late working-life Cypriot population.

Gradient apparent in both men and women across individual and neighborhood measures of social position.

111“Place standard” depicts the social gradient in the neighbourhood environment in Cyprus

Background

Census data, GIS, surveys and audits are used to profile “place”, each with shortcomings. There are several “neighbourhood environment” tools, including the “Place Standard” a policy and advocacy tool developed in Scotland. “Place” is not a strong feature in the public health agenda in Cyprus.

Methods

In an internet survey, participants rated 14 features of their neighborhood environment. Exploratory factor, cluster and regression analysis were used to explore the dimensionality of the concept, neighborhood profiles and differences according to individual and area-level characteristics.

Results

With the exception of safety (M = 4.4, SD = 1.7 on a 1: large to 7: little improvement), 492 participants (mean age 42, 50% residents for &gt;10 years) from 266 postcodes (33% islandwide) did not rate other features favourably. A clear dimensionality of Built, Physical, Social and Service environment supports the construct validity of the tool. People who rated their neighbourhood lower on a social position ladder were consistently more likely to rate all contextual neighrbourhood features less favourably. The social gradient was evident according to individual and area measures of socio-economic disadvantage and appeared stronger in terms of the built than the social environment.

Conclusions

The “place standard” shows good metric properties and captures the variability ad inequity in the neighbourhood environment.

Key messages

The “Place Standard” can be used to profile the context of health inequalities.

Evidence of a social gradient across all features with larger differences in terms of the built environment.

117A digital resource for enhancing parental health literacy during the transition to parenthood

Background

While the transition to parenthood is critical for mother-child health, traditional antenatal education has been questioned. Digital resources provide opportunities for reducing social disparities and enhancing health literacy, particularly important in a medicalized and decentralized birth environment with high caesarean and low breastfeed rates.

Methods

Within a Participatory Action Research (PAR) framework, formative qualitative and quantitative methods were employed to assess the cross-national transferability of Baby Buddy (UK), and deliver a locally relevant resource to inform, enhance user-provider communications and support shared decision-making.

Results

Using consensus-building and priority-setting techniques, we engaged with the local health professional community and parents-to-be to assess available resources, identify gaps and priorities in an eDelphi survey (N = 275 mums, 193 professionals) and gain an in-depth understanding on information-seeking behaviours and participation in decision-making in a series of focus groups with antenatal educators (N = 20) and new mums/ mums-to-be (N = 62). New material was co-created with participants and an intervention for embedding the tool in clinical practice was proposed within the COM-B behavioural change framework.

Conclusions

The project is a “proof of concept” for exchange of innovation and a “complimentary” model of maternal healthcare delivery. Beyond a learning experience for the participants, the use of PAR provided ground for building transdisciplinary alliances.

Key messages

Other than enhancing health literacy, digital resources can support the educational role of health professionals

PAR provides a framework to engage with the community, building a sense of common purpose

447Decoding the effect of neighbourhood on arterial health (DEpICT): Preliminary results on neighbourhood self-evaluation

Background

DEpICT is an ongoing exploratory, observational, cross-sectional study in community-dwelling individuals in Limassol, Cyprus aiming to combine individual-level and community-level risk factors to decode their effect on arterial health (stiffness) as measured with pulse wave velocity (PWV).

Methods

Participants are &gt;40 years and living in the same address for ≥5 years. They provide personal information on quality of life and mental health (SF-12 and GHQ-12), physical activity (IPAQ), adherence to Mediterranean diet (MedDiet) and sociodemographic. Arterial stiffness is measured as PWV. Neighborhood is self-assessed using the “Place Standard” Tool, as well as independent neighborhood audit with the newly-developed CyNoTes tool.

Results

Mean age of the first 176 participants (53%male) was 55.2 (±8.6). All participants rated their health between excellent/very good (50.5%) and good/modest (49.5%), however participants with a higher net family income reported significantly better health (p for trend=0.02), with 61.4% reporting very good/excellent health in those earning &gt;2000E Vs 40.2% in those earning ≤ 2000E/m (p = 0.005). Out of 14 constructs in “Place”, “Public transport” and “Participation and sense of control” were rated lowest (3.1 ± 1.9 and 3.1 ± 1.8) and “Identity and sense of belonging” and “Safety” highest (4.1 ± 1.9 and 4.5 ± 1.8). Out of these, family income was associated with “Safety” (p = 0.005) and self-health with “Participation and sense of control”.

Conclusions

Participants rate social and safety aspects of their neighborhood higher than build aspects.

Key messages

Participants express the need for more public engagement in community decision-making; sense of lacking control may affect individual health.

Prescription patterns in psychiatric compulsory care: polypharmacy and high-dose antipsychotics

BACKGROUND

Antipsychotic polypharmacy and prescription of high-dose antipsychotics are often used for the treatment of psychotic symptoms, especially in compulsory psychiatric care although there is lack of evidence to support this practice and related risks for patients.

AIMS

We aimed to investigate prescription patterns in patients with psychosis under compulsory psychiatric treatment in Cyprus and to identify predictors for pharmaceutic treatment patterns.

METHOD

This was a nationwide, descriptive correlational study with cross-sectional comparisons, including 482 patients with compulsory admission to hospital. Sociodemographic and clinical data were collected. Psychotic symptoms were assessed with the Positive and Negative Syndrome Scale (PANSS). Prescribed medication patterns, including use of medication pro re nata (PRN, when required), were recorded.

RESULTS

Antipsychotic polypharmacy with a PRN schema was reported in 33.2% (n = 160) of the participants. Polypharmacy without a PRN schema was reported in 5.6% (n = 27) of the participants. We found that 27.2% (n = 131) of the participants were prescribed high-dose antipsychotics without PRN included; and 39.2% (n = 189) prescribed high-dose antipsychotics with PRN included. In the logistic regression analyses, predictors for prescription of high-dose antipsychotics were male gender, positive psychiatric history, receiving state benefits and a negative history of substance use. Male gender was the only predictor for polypharmacy without a PRN schema whereas male gender, negative family psychiatric history, receiving state benefits and the total score on the positive symptoms PANSS subscale were predictors for polypharmacy with a PRN schema included.

CONCLUSIONS

A high frequency of polypharmacy and use of medication PRN beyond clinical guidelines has been reported for the first time in psychiatric compulsory care in Cyprus; revision in antipsychotic prescription is needed.

Depressive symptoms in involuntary hospitalized patients in Cyprus: Socio-demographic and psychopathological characteristics

Τhe severity and variation of depressive symptoms (DS), among psychotic individuals under involuntary hospitalization is unclear. We investigated the socio-demographic and clinical characteristics of psychotic adults with DS involuntarily hospitalized for compulsory treatment in Cyprus. We also evaluated the psychometric properties (internal consistency, known-group and discriminant validity) of the HDRS-17 and HAM-A for the assessment of depressive and anxiety symptoms, respectively. A descriptive correlational study with cross-sectional comparisons was applied. Data on demographics, cognitive functioning (MoCA scale), depressive (HDRS-17 scale), anxiety (HAM-A scale) and psychotic (PANSS scale) symptoms were collected (December 2016 -February 2018). Following informed consent, the sample included 406 patients. Among them, 21 males and 23 females reported DS (HDRS-17 total score ≥8). The latter were mainly Greek-Cypriots (61.4%), 45-65 years old (38.6%), single (77.3%), unemployed (72.7%), mainly admitted due to aggressiveness towards others (47.7%), most frequently diagnosed with a bipolar disorder (59.1%). The mean score (M) in the HDRS-17 was 30.72 (scale range: 8-50; Standard Deviation [SD]: 10.42). The highest mean score (M) per item was in the variables "Suicide behavior"'(M:3.09; SD:1.09) and "Depressive mood" (M=2.95; SD=1.07). The DS group (HDRS-17 score≥8) reported higher PANSS positive symptoms subscale score (t-test, p=0.003) and HAM-A total score (t-test, p=0.05) compared to the non-DS group (HDRS-17 score<8). In multivariable logistic regression analysis only female sex [OR (95%CI) = 3.28 (1.33.-8.04), p=0.01)] and a mood disorder diagnosis [OR95% CI: 15.22(4.13.-56.14), p<0.0001)] retained a statistically significant association with DS. Cronbach' s alpha was 0.827 for the HDRS, and 0.763 for the HAM-A. The present findings partially support the known-group validity of the HDRS-17 and the ΗΑΜ-Α, and the discriminant validity of the HDRS-17 in psychotic patients under involuntary hospitalization. Additionally, the most frequent diagnosis in the DS group was a bipolar disorder, and the most frequent admission cause was aggressiveness towards others; it is possible that the majority of the DS group participants were patients with a bipolar disorder in episodes with mixed features, presenting simultaneously depressive symptoms and aggressiveness. Further studies on relapse prevention regarding this clinical group are proposed, as well as studies on specificity and sensitivity of the HDRS-17 and HAM-A.

Burden of non-communicable diseases in Cyprus, 1990-2017: findings from the Global Burden of Disease 2017 study

BACKGROUND

Non-communicable diseases (NCDs) accounted for over 90% of all deaths in the Cypriot population, in 2018. However, a detailed and comprehensive overview of the impact of NCDs on population health of Cyprus over the period of 1990 to 2017, expressed in disability-adjusted life years (DALYs), is currently not available. Knowledge about the drivers of changes in NCD DALYs over time is paramount to identify priorities for the prevention of NCDs in Cyprus and guide evidence-based decision making. The objectives of this paper were to: 1) assess the burden of NCDs in terms of years of life lost (YLLs), years lived with disability (YLDs), and DALYs in Cyprus in 2017, and 2) identify changes in the burden of NCDs in Cyprus over the 28-year period and assess the main drivers of these changes.

METHODS

We performed a secondary database descriptive study using the Global Burden of Disease (GBD) 2017 results on NCDs for Cyprus from 1990 to 2017. We calculated the percentage change of age-standardized DALY rates between 1990 and 2017 and decomposed these time trends to assess the causes of death and disability that were the main drivers of change.

RESULTS

In Cyprus in 2017, 83% (15,129 DALYs per 100,000; 12,809 to 17,707 95%UI) of total DALYs were due to NCDs. The major contributors to NCD DALYs were cardiovascular diseases (16.5%), neoplasms (16.3%), and musculoskeletal disorders (15.6%). Between 1990 and 2017, age-standardized NCD DALY rates decreased by 23%. For both males and females, the largest decreases in DALY rates were observed in ischemic heart disease and stroke. For Cypriot males, the largest increases in DALY rates were observed for pancreatic cancer, drug use disorders, and acne vulgaris, whereas for Cypriot females these were for acne vulgaris, psoriasis and eating disorders.

CONCLUSION

Despite a decrease in the burden of NCDs over the period from 1990 to 2017, NCDs are still a major public health challenge. Implementation of interventions and early detection screening programmes of modifiable NCD risk factors are needed to reduce occurrence and exacerbation of leading causes of NCDs in the Cypriot population.

The association of breastfeeding self-efficacy with breastfeeding duration and exclusivity: longitudinal assessment of the predictive validity of the Greek version of the BSES-SF tool

INTRODUCTION

While breastfeeding self-efficacy (BSES) is an important modifiable determinant of breastfeeding, a structured assessment is not standard practice in Cyprus. We assessed the Greek version of the Breastfeeding Self-Efficacy Scale (BSES-SF), including its predictive validity in terms of Breastfeeding (BF) and Exclusive Breastfeeding (EBF) up to the sixth month.

METHODS

A methodological study with longitudinal design among 586 mother-infant dyads, as part of the "BrEaST Start in Life" project. BSES was assessed 24-48 h after birth and at the first month. Breastfeeding status was assessed at the clinic, the 1st, 4th and 6th month. The association between BSES and breastfeeding was estimated in logistic regression models and its diagnostic ability in ROC analysis.

RESULTS

With Mean = 3.55 (SD = 0.85), BSES was moderate, and lower among Cypriot women, primiparas and those who delivered by Cesarean Section (C/S). There was good internal consistency across the 14 items (Cronbach's α = 0.94) while factor analysis revealed a two-factor structure. BSES scores were higher among mothers who initiated exclusive breastfeeding (M = 3.92, SD = 0.80) compared to breastfeeding not exclusively (M = 3.29, SD = 0.84) and not breastfeeding (M = 3.04, SD = 1.09; p-value < 0.001). There was a stepwise association with exclusivity (40.5% in the highest vs 7.9% lowest quartile of self-efficacy). The association between in-hospital BSES and long-term EBF persisted in multivariable models. Women in the upper quartile of BSES at 48 h were more likely to breastfeed exclusively by adjOR = 5.3 (95% CI 1.7-17.1) at the 1st and adjOR = 13.7 (95% CI 2.7-68.6) at the 4th month. Similar associations were observed between self-efficacy at the 1st month and BF at subsequent time-points. High first month BSES (> 3.96 as per ROC) had 58.9% positive and 79.6% negative predictive value for breastfeeding at 6 months which reflects higher sensitivity but lower specificity.

CONCLUSIONS

The Greek version of BSES-SF showed good metric properties (construct, know-group, concurrent and predictive validity). In the absence of community support structures or programmes in Cyprus, prevalence of breastfeeding remains low. This suggests a need for policy, educational and community support interventions, including the systematic use of BSES scale as a screening tool to identify those at higher risk for premature BF discontinuation.

Nurses' attitudes and knowledge regarding patient rights: a systematic review

OBJECTIVE

To synthesize current evidence on nurses' attitudes and/or knowledge on the entire spectrum of patient rights.

METHOD

A systematic search of the literature was performed in Web of Science, PubMed, Scopus and CINAHL. Studies were selected according to pre-defined inclusion/exclusion criteria. The Cochrane and PRISMA guidelines, including templates for systematic reviews, were applied. For rigor assessment, the Critical Appraisal Skills Program Qualitative Research Checklist, and the Center for Evidence-Based Management tool were employed.

RESULTS

Thirteen studies were included, that exhibited important methodological limitations, such as convenience sampling, mediocre response rates and inadequate instrument validity. Findings indicated: a) low level of awareness regarding patient rights among nurses, b) knowledge discrepancies on specific aspects of patient rights, c) low priority ascribed to a patient's right to access information, and d) insufficient evidence on formal educational sources of knowledge on the topic of patient rights.

CONCLUSION

Narrow geographical localization, heterogeneity and methodological limitations render generalizability of the conclusions difficult. Further research based on robust methodology is proposed.

Social gradient in health-related quality of life among urban middle-age residents in Limassol, Cyprus: research article

Background

Social inequalities in health threaten social cohesion and their investigation is an important research field. Monitoring the health of the population is necessary to identify health needs, design programs focused in people’s needs and to evaluate the effectiveness of health policies.

Methods

A cross-sectional survey using primary data was applied. The study investigated the size and the extent of social inequalities in quality of life and health behaviours in Limassol, Cyprus. Data collection was done door-to-door in the form of survey interviews. The sample consisted of 450 residents aged 45–64 across 45 randomly selected neighbourhoods, that met the selection criteria. The tools used were: Demographic questionnaire, SF 36 Questionnaire, IPAQ- International Physical Activity Questionnaire short form.

Results

The social gradient appears in all social indicators. Physical dimension of health has a strong relationship between health-related quality of life with the education index. Specifically, the range is 12 points for males and 14 points for females (p for interaction = 0.16). Profession systematically appears to have a stronger relationship with men than with women, and is present in both physical and mental dimensions. The range is 13 points for men and 10 points for women (p for interaction = 0.31).

Conclusions

It seems that young highly educated males, employed full time, earning high income and engaging in mild physical activity, have significantly higher level of health-related life quality, compared to other middle age adult groups, living in Limassol. This finding is in agreement with other studies that show correlations between gender and the patterns of risk factors.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-020-10027-6.

Socio-Demographic and Clinical Characteristics of Adults With Psychotic Symptomatology Under Involuntary Admission and Readmission for Compulsory Treatment in a Referral Psychiatric Hospital in Cyprus

Socio-demographic and clinical characteristics of adults under compulsory psychiatric treatment, have not been reported adequately in Southern European countries. We investigated the socio-demographic and clinical characteristics of adults with psychotic symptomatology who were involuntarily treated in the acute Mental Health Services in Cyprus. A descriptive cross-sectional study was applied. Data collection (December 2016 to February 2018) achieved via a structured questionnaire including demographic and clinical variables. Census sampling was applied in Cyprus referral center for compulsory psychiatric treatment. The sample included 406 individuals (262 males, 144 females). Approximately 86.2% were single, 77.6% were unemployed, and 24.9% held a bachelor's degree. The most frequent clinical diagnosis was schizophrenia or a relevant psychotic disorder (86.4%). The most frequent admission cause was non-adherence to pharmacotherapy along with disorganized behavior (agitation and/or self-care deficit, and/or aggressive behavior, and/or suicidal behavior) (53.6%). Moreover, 70.7% of the sample reported a positive personal history of mental health problems, while 42.1% reported a positive family history of mental health disorders. Half of the participants (52%) were previously involuntarily admitted for compulsory treatment. Adjusted associations of readmission status were reported with Cypriot ethnicity (OR: 4.40, 95%CI: 2.58-7.50), primary education only (OR: 3.70, 95%CI: 1.64-8.37), readmission due to disorganized behavior along with non-adherence to pharmacotherapy (OR: 10.84, 95%CI: 2.69-43.72), as well as along with substance use (OR: 6.39, 95%CI: 1.52-26.82). Readmission was almost five times more likely to occur due to suicidal behavior (OR: 5.01, 95%CI: 1.09-22.99) compared to disorganized behavior not otherwise specified. Additionally, those with a diagnosis of schizophrenia were more than 12 times more frequently readmitted for compulsory treatment compared to other diagnoses (OR 12.15, 95%CI: 1.04-142). Moreover, the participants with higher secondary education had 54.6% less odds to be involuntarily re-admitted compared to Bachelor degree holders (OR 0.442, 95%CI: 0.24-0.79). A high percentage of involuntary treatment was noted due to non-adherence to pharmacotherapy and substance use. Re-evaluation of the effectiveness of relevant community interventions is suggested, as well as implementation of structured educational programs on therapy adherence during psychiatric hospitalization.

The MEDEA childhood asthma study design for mitigation of desert dust health effects: implementation of novel methods for assessment of air pollution exposure and lessons learned

BACKGROUND

Desert dust events in Mediterranean countries, originating mostly from the Sahara and Arabian deserts, have been linked to climate change and are associated with significant increase in mortality and hospital admissions from respiratory causes. The MEDEA clinical intervention study in children with asthma is funded by EU LIFE+ program to evaluate the efficacy of recommendations aiming to reduce exposure to desert dust and related health effects.

METHODS

This paper describes the design, methods, and challenges of the MEDEA childhood asthma study, which is performed in two highly exposed regions of the Eastern Mediterranean: Cyprus and Greece-Crete. Eligible children are recruited using screening surveys performed at primary schools and are randomized to three parallel intervention groups: a) no intervention for desert dust events, b) interventions for outdoor exposure reduction, and c) interventions for both outdoor and indoor exposure reduction. At baseline visits, participants are enrolled on MEDena® Health-Hub, which communicates, alerts and provides exposure reduction recommendations in anticipation of desert dust events. MEDEA employs novel environmental epidemiology and telemedicine methods including wearable GPS, actigraphy, health parameters sensors as well as indoor and outdoor air pollution samplers to assess study participants' compliance to recommendations, air pollutant exposures in homes and schools, and disease related clinical outcomes.

DISCUSSION

The MEDEA study evaluates, for the first time, interventions aiming to reduce desert dust exposure and implement novel telemedicine methods in assessing clinical outcomes and personal compliance to recommendations. In Cyprus and Crete, during the first study period (February-May 2019), a total of 91 children participated in the trial while for the second study period (February-May 2020), another 120 children completed data collection. Recruitment for the third study period (February-May 2021) is underway. In this paper, we also present the unique challenges faced during the implementation of novel methodologies to reduce air pollution exposure in children. Engagement of families of asthmatic children, schools and local communities, is critical. Successful study completion will provide the knowledge for informed decision-making both at national and international level for mitigating the health effects of desert dust events in South-Eastern Europe.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT03503812 , April 20, 2018.

Device-associated health care-associated infections: The effectiveness of a 3-year prevention and control program in the Republic of Cyprus

BACKGROUND

Device-associated health care-associated infections (DA-HAIs) are a major threat to patient safety, particularly in the Intensive Care Unit (ICU). This study aimed to evaluate the effectiveness of a bundle of infection control measures to reduce DA-HAIs in the ICU of a General Hospital in the Republic of Cyprus, over a 3-year period.

METHODS

We studied 599 ICU patients with a length of stay (LOS) for at least 48 hours. Our prospective cohort study was divided into three surveillance phases. Ventilator-associated pneumonia (VAP), central line-associated blood-stream infections (CLABSI), and catheter-associated blood-stream infections (CAUTI) incidence rates, LOS, and mortality were calculated before, during, and after the infection prevention and control programme.

RESULTS

There was a statistically significant reduction in the number of DA-HAI events during the surveillance periods, associated with DA-HAIs prevention efforts. In 2015 (prior to programme implementation), the baseline DA-HAIs instances were 43: 16 VAP (10.1/1000 Device Days), 21 (15.9/1000DD) CLABSIs, and 6 (2.66/1000DD) CAUTIs, (n = 198). During the second phase (2016), CLABSIs prevention measures were implemented and the number of infections were 24: 14 VAP (12.21/1000DD), 4 (4.2/1000DD) CLABSIs, and 6 (3.22/1000DD) CAUTIs, (n = 184). During the third phase (2017), VAP and CAUTI prevention measures were again implemented and the rates were 6: (3 VAP: 12.21/1000DD), 2 (1.95/1000DD) CLABSIs, and 1 (0.41/1000DD) CAUTIs, (n = 217). There was an overall reduction of 87% in the total number of DA-HAIs instances for the period 1 January 2015 to 31 December 2017.

CONCLUSIONS

The significant overall reduction in DA-HAI rates indicates that a comprehensive infection control programme can affect DA-HAI rates.

Association Between Workplace Bullying Occurrence and Trauma Symptoms Among Healthcare Professionals in Cyprus

Workplace bullying/mobbing is an extreme work-related stressor, but also a severe hazard for physical, mental and psychological health in healthcare employees, including nurses. A range of trauma-related symptoms has been linked with bullying victimization. The aim of the study was the investigation of workplace bullying/mobbing-related trauma symptoms in Greek-Cypriot nurses working in emergency and critical care settings, as well as of potential correlations with demographic and occupational variables. A descriptive, cross-sectional correlational study was performed in a convenience sample of 113 nurses. A modified version of the Part B.CII of The Workplace Violence in the Health Sector-Country Case Studies Research Instrument (WVHS-CCSRI Part C.II-M) and the modified Secondary Traumatic Stress Scale (STSS-M) were used for the assessment of bullying/mobbing frequency and workplace bullying/mobbing-related trauma symptoms, respectively. A total of 46.9% of the sample reported experiences of both bullying/mobbing victimization and witnessing of bullying/mobbing to others (VWB subgroup), 21.2% reported solely bullying/mobbing victimization (SVB subgroup) and 10.6% reported witnessing of bullying/mobbing to others (SWB subgroup). A total of 22.3% did not experience or witness any bullying/mobbing at the workplace. Trauma symptoms intensity (STSS-M total score) was more severe in the participants a) with a high frequency of workplace bullying/mobbing experiences compared to those with a moderate frequency of such experiences (p = 0.018), b) of the VWB subgroup compared to those of the SWB subgroup (p = 0.019), c) employed in Emergency Departments compared to those employed in ICUs (p = 0.03), d) who had considered resigning due to bullying/mobbing experiences compared to those who had never considered resigning (p = 0.008), e) who had been punished for reporting a bullying/mobbing incident compared to those who had not (p = 0.001), and f) who considered the incident unimportant to be reported compared to those who avoided reporting due to other causes (p = 0.048). This data highlights the need to establish effective and safe procedures for bullying/mobbing reporting, aiming to support bulling/mobbing victims and witnesses, and further to protect their legal rights. Both victims and witnesses of workplace bullying/mobbing need to be assessed by mental health professionals for PTSD symptoms in order to have access to effective treatment.

Nursing quality indicators for adult intensive care: A consensus study

BACKGROUND

The selection of quality indicators demonstrating the efficiency and relevance of nursing practice in patient outcomes in the intensive care unit remains a challenge.

AIM

The aim of this study was to develop a set of potential quality indicators to quantify nursing care provided to critically ill patients through a consensus method.

DESIGN

This was a three-phase study including a European survey of intensive care unit (ICU) nurses (phase one) followed by a two-phase face-to-face consensus meeting of experts from Cyprus.

METHOD

Two distinct panels of experts were asked to rate each quality indicator using a 4-point Likert scale in phases one and two. The level of consensus was set at 60%. In phase three, scores of the content validity index for items and scales were considered for the final selection of quality indicators.

RESULTS

The phase one survey included 139 ICU nurses from 13 European countries, and phases two and three included seven ICU experts from Cyprus. "Consensus in" was achieved for 12 items at the end of phase two. Three of the quality indicators were significantly different by country: (a) falls (P = .006), (b) accidental removal of nasogastric tube (P < .001), and (c) accidental removal of intravascular catheters (P < .001). Only falls was significantly correlated with higher academic qualifications of the participants (P = .002).

CONCLUSIONS

Fifteen items have been identified as potential indicators for adult ICU nursing quality. These need to be prospectively studied to determine the extent to which they can accurately capture nursing care quality in this setting.

RELEVANCE TO CLINICAL PRACTICE

The study provides a set of relevant quality indicators. A nursing set for the ICU may serve as the basis for nursing management and facilitate the strategy dedicated to the vision of health care quality assurance.

“Place standard” depicts social gradient in the neighbourhood environment in Cyprus

Background

Census data, GIS, surveys and audits are used to profile “place”, each with shortcomings. There are several “neighbourhood environment” tools, including the “Place Standard” a policy and advocacy tool developed in Scotland. “Place” is not a strong feature in the public health agenda in Cyprus.

Methods

In an internet survey under the auspices of the Cyprus Healthy Cities Office, participants rated 14 features of their neighborhood environment. Exploratory factor, cluster and regression analysis were used to explore the dimensionality of the concept, neighborhood profiles and differences according to individual and area-level characteristics.

Results

With the exception of safety (M = 4.4, SD = 1.7 on a 1: large to 7: little improvement), 492 participants (mean age 42, 50% residents for &gt;10 years) from 266 postcodes (33% islandwide) did not rate other features favourably, with lowest scores for “influence and sense of control”. A clear dimensionality of Built, Physical, Social and Service environment supports the construct validity of the tool. People who rated their neighbourhood lower on a social position ladder were consistently more likely to rate all contextual neighrbourhood features less favourably. The social gradient was evident according to both individual sociodemographic characteristics and census-based area measures of built (e.g. pre-2001 housing) and socio-economic disadvantage (e.g. single-parent households) and appeared stronger in terms of the built (e.g. moving around) than the social environment (social contact, identity and belonging).

Conclusions

The “place standard” shows good metric properties and can be used as a public health research, and practice tool to profile the variability and document the inequity in the neighbourhood health environment as well as to support and enhance citizens' participation in the dialogue, which they generally rate lowest.

Key messages

The “Place Standard” offers a framework and a tool to profile the neighbourhood environment in research and public health practice. Generally unfavourable rating of health-related neighbourhood environment with evidence of social gradient across all features with larger differences in built environment.