Facilitators and barriers of empathetic behaviour in physiotherapy clinical practice: A qualitative focus group study

BACKGROUND

Empathy is an essential competence of a person-centered approach, and a recognisable ability for providing physiotherapy quality healthcare. Empathetic communication enhances the improvement of patient outcomes and their experience of treatment.

OBJECTIVE

The aim of the study was to present further insights considering facilitators and barriers of an empathetic communication between patients and physiotherapists.

METHODS

A qualitative focus group study was designed according to COREQ guidance for qualitative studies. Two focus groups were conducted. The first group included six patients and two individuals from non-governmental organizations, whereas three physiotherapists, two academic physiotherapist personnel and two undergraduate physiotherapy students participated in the second group. Both groups were audio recorded, and all data was verbatim transcribed for coding thematic analysis.

RESULTS

9 themes were revealed regarding empathetic facilitators (qualities of good communication, relationship building, interprofessional collaborative practice, positive environment, love for the healthcare profession and professionalism), while 8 themes were revealed regarding barriers (challenging situations, working conditions, burn out, depreciation of empathetic communication, lack of training, lack of professionalism, lack of personal development and health professionals' own personal problems).

CONCLUSION(S)

The enhancement of empathy can be accomplished in a trustworthy relationship between patient and clinicians where the development of proficient communication skills are prioritized. However, hindering factors associated with health professionals, patients and the health system should be surmounted.

ETHICAL APPROVAL NUMBER

339-ΣΕ8/10-1-2020.

Barriers and facilitators for adopting healthy lifestyles in breast cancer survivors: a scoping review protocol

OBJECTIVE

This scoping review will identify barriers and facilitators for the adoption of 7 healthy lifestyle components by female breast cancer survivors. This will be achieved by mapping the World Cancer Research Fund/American Institute for Cancer Research recommendations and the Lifestyle Medicine pillars.

INTRODUCTION

Adherence to healthy lifestyle components (including weight management, physical activity, healthy diet, restorative sleep, avoidance of risky substances, forming and maintaining healthy relationships, and stress management) may improve the quality of life of breast cancer survivors and reduce the risk of adverse patient outcomes. However, cancer survivors' adherence to recommendations of multiple healthy lifestyle components is low, and decreases over time.

INCLUSION CRITERIA

The review will consider peer-reviewed studies investigating barriers and facilitators for adopting any of the 7 healthy lifestyle components by female adult (18+ years old) breast cancer survivors (ie, from the time of diagnosis) in community, hospital, and/or cancer care settings, without any geographical restrictions. All study designs and articles published in English will be included.

METHODS

The review will follow the JBI methodology for scoping reviews. Databases to be searched will include MEDLINE (PubMed), Embase, CINAHL (EBSCOhost), PsycINFO (Ovid), and the Cochrane Library databases. Articles published from 2007 to the present will be considered since this was the year in which the World Cancer Research Fund/American Institute for Cancer Research recommendations were published. Two independent reviewers will screen the retrieved articles and extract the data. Barriers and facilitators for each lifestyle component will be grouped according to the Theoretical Domain Framework. A narrative summary will explicate the charted data.

REVIEW REGISTRATION

Open Science Framework https://osf.io/cn3va.

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.

Promoting and supporting breastfeeding in a protracted emergency setting-Caregivers' and health workers' perceptions from North-East Nigeria

Background

Breastfeeding (BF) should be protected, promoted, and supported for all infants in humanitarian settings. The re-establishment of exclusive BF is also a central part of the management of acutely malnourished infants under 6 months (<6 m). Médecins Sans Frontières (MSF) runs a nutrition project in Maiduguri, a protracted emergency setting in North-East Nigeria. This study aimed to explore caregivers' (CGs) and health workers' (HWs) perceptions of BF practice, promotion, and support among CGs with infants <6 m in this setting.

Methods

We conducted a qualitative study using in-depth interviews and focus group discussions combined with non-participant observations. Participants included CGs of young infants enrolled in MSF nutritional programs or who attended health promotion activities in a displacement camp. MSF HWs were involved at different levels in BF promotion and support. Data were collected involving a local translator and analyzed using reflexive thematic analysis directly from audio recordings.

Results

Participants described how feeding practices are shaped by family, community, and traditional beliefs. The perception of breastmilk insufficiency was common and led to early supplementary feeding with inexpensive but unsuitable products. Participants often linked insufficient breastmilk production with poor maternal nutrition and stress, in a context shaped by conflict and food insecurity. BF promotion was generally well received but could be improved if tailored to address specific barriers to exclusive BF. Interviewed CGs positively valued BF support received as part of the comprehensive treatment for infant malnutrition. One of the main challenges identified was the length of stay at the facility. Some participants perceived that improvements in BF were at risk of being lost after discharge if CGs lacked an enabling environment for BF.

Conclusion

This study corroborates the strong influence of household and contextual factors on the practice, promotion, and support of BF. Despite identified challenges, the provision of BF support contributes to improvements in BF practice and was positively perceived by CGs in the studied setting. Greater attention should be directed toward providing support and follow-up for infants <6 m and their CGs in the community.

Iodine status of pregnant women from the Republic of Cyprus

Iodine supply is crucial during pregnancy to ensure that the proper thyroid function of mother and baby support fetal brain development. Little is known about iodine status or its dietary determinants in pregnant women in the Republic of Cyprus. We therefore recruited 128 pregnant women at their first-trimester ultrasound scan to a cross-sectional study. We collected spot-urine samples for the measurement of urinary iodine concentration (UIC, µg/l) and creatinine concentration (Creat, g/l), the latter of which allows us to correct for urine dilution and to compute the iodine-to-creatinine ratio (UI/Creat). Women completed a FFQ and a general questionnaire. We used a General Linear model to explore associations between maternal and dietary characteristics with UI/Creat. The median UIC (105 µg/l) indicated iodine deficiency according to the WHO criterion (threshold for adequacy = 150 µg/l), and the UI/Creat was also low at 107 µg/g. Only 32 % (n 45) of women reported the use of iodine-containing supplements; users had a higher UI/Creat than non-users (131 µg/g v. 118 µg/g), though this difference was NS in the adjusted analysis (P = 0·37). Of the dietary components, only egg intake was significantly associated with a higher UI/Creat in adjusted analyses (P = 0·018); there was no significant association with milk, dairy products or fish intake. Our results suggest that pregnant women in Cyprus have inadequate iodine status and are at risk of mild-to-moderate iodine deficiency. Further research on dietary sources in this population is required.

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.

Knowledge, beliefs and experience of adopting healthy habits in pregnancy: a mixed methods study

Background

Early life exposures affect a child's obesity risk. The EARLY START uses participatory action research to develop an intervention for reducing early life obesogenic exposures. The initial phase uses a mixed methods approach to investigate pregnant mothers’ knowledge, beliefs, and experience of adopting healthy dietary and physical activity (PA) habits.

Methods

Cypriot pregnant women in 2021 completed a web-based questionnaire on: a) Adherence to Mediterranean diet (MD) (MEDAS tool); b) knowledge, beliefs on diet and PA. A subgroup participated in a structured focus group discussion of their experience/needs in adopting healthy habits. Data were analyzed using Descriptive and Thematic Content methods.

Results

Ninety-seven women participated, 73% &lt;35 y.o., 49% primigravida, 92% with tertiary education. Adherence to MD was moderate (median 6/14, IQR 2.5), 90% were eating &lt;3 portions of fruit/vegetables daily, 50% believed their diet was healthy and did not change habits in pregnancy. Most had access to information (94%), internet was the commonest source (74%), and the doctor the most trusted (47%). Mild and moderate-intensity PA were considered appropriate by many (60%) for the first and second half of pregnancy, respectively. Most (90%) were aware of the risks of excessive weight gain in pregnancy. Qualitative analysis showed that women value diet as “the main driver to holistically achieving a healthy pregnancy”. The main barrier was the “struggle between the will and ability”. PA was considered a “therapy” but the challenge was “to achieve the right balance”. Internet was described as “accessible but unreliable information source”. Women believed that needs can be met by “early, holistic recommendation-based interventions run by professionals”.

Conclusions

A huge gap exists between knowledge, beliefs, and practice of healthy behaviours in pregnancy. New interventions should meet gaps and needs using contextualized, timely, holistic, and reliable approaches.

Key messages

Breast cancer trends in women in Cyprus: a population-based study between 2004-2017

Background

In Cyprus, breast cancer (BC) is the first in incidence and second in mortality cancer in women. A national screening programme (NSP), targeting women 50-69 years, was introduced in 2007. The aim of this study is to provide a better understanding of cancer trends.

Methods

Data from the national population-based Cyprus Cancer Registry on adult women diagnosed with BC between 2004-2017 with follow-up until 2019 were analysed as follows: Joinpoint regression for age-adjusted (overall and by tumor stage at diagnosis - TSD) and age-specific rates (&lt;50, 50-59, 60-69, 70-79, ≥ 80) incidence and mortality rates; 5-year age-adjusted Net Survival (NS) rates, overall and by TSD. TSD was categorised as localised, regional, and distant.

Results

Age-adjusted incidence rate increased from 135.3 (2004) to 153.2 (2017) per 100,000, with an annual percentage change (APC) of 1.1% (95%CI: 0.4-1.9). The greatest increase was in the age groups ≥70 years. A positive time trend was found for localized cancers between 2006-2017, while for all other stages nonsignificant trends were detected. Age-adjusted mortality rate increased from 37.0 (2004) to 50.0 (2019) per 100,000 (APC: 2.7%; 95%CI: 1.9-9.4). Significant increases in mortality rates were detected in the age groups ≥70 years. By TSD, increased rates were found at localised and regional stages, however smaller increases were detected since 2007. NS rates for the most recent period (2014-2017) was 93% for localized, 81% for regional, and 32% for distant and did not significantly improve compared to the previous years.

Conclusions

Trends in BC incidence continues to increase, especially in the older age groups and for early-stage cancers. As expected, since the introduction of the NSP, the incidence of localised cancers increased whilst the incidence of advanced stage cancer decreased, albeit non-significantly. Survival trends did not change but mortality rates for localised and regional cancers increased at a slower pace.

Key messages

• The introduction of the national screening programme may have played an important role in the increasing BC incidence trends.

• Despite survival rates not improving since the introduction of the national screening programme, mortality rates for early-stage cancers show a less steep increase.

Interventions to support the re-establishment of breastfeeding and their application in humanitarian settings: A systematic review

In 1998, the World Health Organisation (WHO) published general guidelines proposing essential measures to achieve relactation. Yet, increased knowledge about the practical set-up of relactation support interventions in different contexts is needed, especially in humanitarian settings, where nonbreastfed infants are particularly at risk. This study aimed to compile and assess the characteristics, outcomes and factors influencing the implementation of relactation support interventions reported since the latest WHO recommendations. We conducted a systematic review following Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines, undertaking a search from Medline, Embase, PubMed Central, Web of Science, Global Health and CINAHL electronic databases. Studies published in English and Spanish, reporting characteristics and outcomes of relactation support provided to non-(breastfeeding) BF mothers with infants aged less than 6 months were included. Data were analysed by narrative synthesis and the Johanna Briggs Institute Critical Appraisal Tools were used for quality assessment. Overall, 16 studies met the inclusion criteria. Most were observational and conducted in middle-income countries, only one focused on humanitarian settings. Studies reported inpatient and community-based interventions, which generally followed WHO recommendations for relactation. In 13 out of 16 studies, over 80% of mothers restarted BF after receiving relactation support. Enabling factors included younger infant age, shorter lactation gap, mother's strong motivation, family support, and continuous skilled support. Although current literature suggests that intensive relactation support can contribute to re-establish BF, its application and effectiveness in humanitarian settings remain uncertain. Further research is needed to explore the effectiveness, feasibility and acceptability of different approaches to relactation support, especially in humanitarian settings.

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.

Premature mortality attributable to COVID-19: potential years of life lost in 17 countries around the world, January-August 2020

BACKGROUND

Understanding the impact of the burden of COVID-19 is key to successfully navigating the COVID-19 pandemic. As part of a larger investigation on COVID-19 mortality impact, this study aims to estimate the Potential Years of Life Lost (PYLL) in 17 countries and territories across the world (Australia, Brazil, Cape Verde, Colombia, Cyprus, France, Georgia, Israel, Kazakhstan, Peru, Norway, England & Wales, Scotland, Slovenia, Sweden, Ukraine, and the United States [USA]).

METHODS

Age- and sex-specific COVID-19 death numbers from primary national sources were collected by an international research consortium. The study period was established based on the availability of data from the inception of the pandemic to the end of August 2020. The PYLL for each country were computed using 80 years as the maximum life expectancy.

RESULTS

As of August 2020, 442,677 (range: 18-185,083) deaths attributed to COVID-19 were recorded in 17 countries which translated to 4,210,654 (range: 112-1,554,225) PYLL. The average PYLL per death was 8.7 years, with substantial variation ranging from 2.7 years in Australia to 19.3 PYLL in Ukraine. North and South American countries as well as England & Wales, Scotland and Sweden experienced the highest PYLL per 100,000 population; whereas Australia, Slovenia and Georgia experienced the lowest. Overall, males experienced higher PYLL rate and higher PYLL per death than females. In most countries, most of the PYLL were observed for people aged over 60 or 65 years, irrespective of sex. Yet, Brazil, Cape Verde, Colombia, Israel, Peru, Scotland, Ukraine, and the USA concentrated most PYLL in younger age groups.

CONCLUSIONS

Our results highlight the role of PYLL as a tool to understand the impact of COVID-19 on demographic groups within and across countries, guiding preventive measures to protect these groups under the ongoing pandemic. Continuous monitoring of PYLL is therefore needed to better understand the burden of COVID-19 in terms of premature mortality.

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.

Potential life years lost to COVID-19 in 17 countries during the pandemic period, up to August 2020

Background

COVID-19 pandemic is affecting populations and regions in different ways. In this study, we assess the Potential Years of Life Lost (PYLL) to COVID-19 across different regions.

Methods

We used age-group and sex-specific weekly COVID-19 deaths (from January to August 2020) from national primary sources of 17 countries from the C-MOR consortium (Australia, Brazil, Cape Verde, Colombia, Cyprus, France, Georgia, Israel, Kazakhstan, Peru, Norway, England & Wales, Scotland, Slovenia, Sweden, Ukraine, and the United States). PYLL were calculated by summing up the numbers of deaths in each age group multiplied by the remaining years of life up to age 80. Age-standardized PYLL rates (per 100,000 population), using the World (WHO 2000-2025) Standard population as the reference population, were estimated to facilitate comparison across countries.

Results

Countries in South America displayed the highest PYLL rates (567-1,377 PYLL/100,000). Countries in Asia & Middle East (besides Kazakhstan), Australia, and some European countries (Georgia, Norway, and Slovenia) observed <50 PYLL/100,000. Furthermore, the male to female PYLL rate ratio was above one in all countries [1.3 (Ukraine) - 14.4 (Cyprus)], besides Georgia (ratio = 0.5).

Conclusions

South America, and males were found to be the most affected by COVID-19. Ongoing monitoring of the COVID-19 mortality impact is essential in order to assess health system performances, control measures, and identify vulnerable populations. Differences in mortality burden among populations will help public health officials in their efforts to minimize the COVID-19 mortality burden on a local, and on a global level.

Key messages

Up to August 2020, COVID-19 was a cause of premature mortality in all the participating countries, with South America and males to be more affected.

The timing of the pandemic, seasonal trends, the control measures enforced, and underlying social conditions are probable explanations for the differences observed among countries.

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.

Excess all-cause mortality from January to August 2020: a temporal analysis in 20 countries

 

Analysis of all-cause mortality is an important tool to investigate the impact of the COVID-19 pandemic. This study aims to investigate the magnitude and potential determinants of excess all-cause mortality, from January until August 2020, using national mortality databases from 20 countries part of the C-MOR consortium. Excess weekly mortality for 2020 was calculated by comparing observed against expected weekly number of deaths for 2020. Expected 2020 weekly mortality was estimated using 2015-19 data based on a time series model adjusting for time trend and seasonality. The excess mortality was visualized against a stringency index (SI), based on nine government response indicators, downloaded from the Oxford COVID-19 Government Response Tracker. Brazil, Cyprus, France, Ireland, Italy, countries of the UK, Spain and the USA showed a substantial increase in the observed mortality during 2020, which lasted from 1 (Cyprus) to 7 (England and Wales, Scotland) weeks. Australia, Denmark and Georgia observed fewer than expected deaths, whereas in Austria, Estonia, Israel, Norway, Slovenia and Ukraine 2020 mortality was as expected. Italy, Spain, UK and Brazil enforced high SI measures at least after 3 weeks from the first COVID-19 death. Sweden and the USA did not apply high SI measures for the duration of this study. In Austria, Estonia, Israel, Norway, Cyprus, Georgia, Slovenia and Ukraine, measures of high SI were implemented within 2 weeks of the first COVID-19 death. The decreased mortality in Australia is probably attributed to different seasonality patterns coupled with strict control measures. Several but not all countries showed excess all-cause mortality. Excess mortality was shown to be influenced by the seasonality patterns of each country, as well as the promptness of governments to apply high SI control measures. As the pandemic continues, the lessons learned from the first months of the pandemic can prove useful to minimize increases in all-cause mortality.

Key messages

Some countries showed excess all-cause mortality between January and August 2020, whereas others displayed either negligible excess mortality or even a decrease in all-cause mortality.

Excess mortality may be partly attributed to delayed application of strict control measures whereas lack of excess mortality may be due to seasonality and/or strict control measures.

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.

Gut and airway microbiota and their role in COVID-19 infection and pathogenesis: a scoping review

Background

The SARS-CoV-2 virus is responsible for the COVID-19 pandemic. Researchers have been studying the pathogenesis of the virus with the aim to improve our current diagnosis and management strategies. The microbiota have been proposed to play a key role in the pathogenesis of the disease.

Purpose

To investigate and report on the current available evidence on any associations between the gut and/or airway microbiota and the pathogenesis of COVID-19.

Methods

Using a predefined protocol in compliance with the PRISMA guidelines, a search was conducted on MEDLINE, Science Direct, DOAJ and Cochrane databases on primary research studies assessing the association between COVID-19 infection and the gut and/or airway microbiota.

Results

Twenty-two studies were included in the current review; nineteen studies concluded an association between the gut and/or airway dysbiosis and SARS-CoV-2, while 3 studies failed to observe a significant association between the airway microbiome and SARS-CoV-2 infection. Specifically, most studies reported a decrease in microbial diversity and therefore development of intestinal dysbiosis in COVID-19-positive patients compared to healthy controls as well as a possible association between increased intestinal dysbiosis and disease severity.

Conclusion

During infection with SARS-CoV-2, there are significant changes in the composition of the gut and airway microbiota. Furthermore, the gut microbiota may have a more important role than the airway microbiota in COVID-19 infection. In the future, studies should be more carefully designed to derive more conclusive evidence on the role of the gut and airway microbiota following infection with SARS-CoV-2 which will lead to the formulation of better management strategies in combating COVID-19.

Supplementary Information

The online version contains supplementary material available at 10.1007/s15010-021-01715-5.

Social inequality in obesity in an Eastern Mediterranean population: evidence from a national health survey in Cyprus

Background

We aimed to explore socioeconomic factors associated with obesity among adults and to investigate social inequality in obesity prevalence in Cyprus.

Study design

Cross-sectional study.

Methods

We conducted a survey among 3,021 Greek-Cypriots aged 25-64 years, collecting self-reported demographics, health behaviors, socioeconomic characteristics and anthropometric measurements. We performed univariable and multivariable (adjusting for demographics and health behaviors) sexspecific Poisson's regression with robust variance, reporting adjusted prevalence ratios (PRs) and 95% confidence intervals.

Results

The prevalence of obesity was 22% among males and 17% among females. According to univariable analyses, higher obesity prevalence was associated with increased age, decreased physical activity and decreased alcohol consumption in both genders. In addition, obesity was associated with refugee status and former smoking in males and with a higher healthy diet score in females. There was a clear linear decrease in obesity prevalence each step up the socioeconomic hierarchy in both genders. In the fully adjusted model, a clear inverse gradient in obesity prevalence by educational attainment was observed in females (p=0.002), while, in males, lower obesity prevalence remained significantly associated with the highest level of family-net income and educational attainment (aPR:0.48; 95% CI:0.27-0.84 and aPR:0.46; 95% CI:0.25-0.81, respectively). Occupational social class was not associated with obesity.

Conclusions

TThis study highlights striking social inequalities in obesity in an Eastern Mediterranean population, which only recently moved from rural living to high levels of development. We recommend that public health interventions should address education- and income-related barriers, as a means of tackling health inequalities.

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

Excess all-cause mortality and COVID-19-related mortality: a temporal analysis in 22 countries, from January until August 2020

Background

This study aimed to investigate overall and sex-specific excess all-cause mortality since the inception of the COVID-19 pandemic until August 2020 among 22 countries.

Methods

Countries reported weekly or monthly all-cause mortality from January 2015 until the end of June or August 2020. Weekly or monthly COVID-19 deaths were reported for 2020. Excess mortality for 2020 was calculated by comparing weekly or monthly 2020 mortality (observed deaths) against a baseline mortality obtained from 2015–2019 data for the same week or month using two methods: (i) difference in observed mortality rates between 2020 and the 2015–2019 average and (ii) difference between observed and expected 2020 deaths.

Results

Brazil, France, Italy, Spain, Sweden, the UK (England, Wales, Northern Ireland and Scotland) and the USA demonstrated excess all-cause mortality, whereas Australia, Denmark and Georgia experienced a decrease in all-cause mortality. Israel, Ukraine and Ireland demonstrated sex-specific changes in all-cause mortality.

Conclusions

All-cause mortality up to August 2020 was higher than in previous years in some, but not all, participating countries. Geographical location and seasonality of each country, as well as the prompt application of high-stringency control measures, may explain the observed variability in mortality changes.

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.

Lifestyle habits of adults during the COVID-19 pandemic lockdown in Cyprus: evidence from a cross-sectional study

BACKGROUND

The COVID-19 pandemic and the widespread adoption of virus control measures have inevitably disrupted efforts to address lifestyle risk factors for non-communicable diseases (NCD). This study aimed to explore the effects of COVID-19 lockdown on all lifestyle medicine pillars, namely diet, physical activity, sleep, stress, social support and use of risky substances.

METHODS

This was a cross-sectional study on a convenient sample of adults who resided in Cyprus during the Spring 2020 lockdown. Participants completed an anonymous online questionnaire comprised of six validated tools regarding the following lifestyle behaviours before and during lockdown: adherence to the Mediterranean diet, physical activity, stress and social support levels, sleep pattern and use of risky substances such as smoking and alcohol. Paired before and during lockdown comparisons for each lifestyle pillar were undertaken using Wilcoxon Signed-Rank test and Bowker symmetry Test where response was numerical (non-parametric data) and categorical respectively. Furthermore, stratified analyses for sociodemographic characteristics were performed.

RESULTS

Out of 745 participants, 74% were female and median age was 39 years. Overall participants reported significantly higher perceived stress score (22 v 25, p <  0.01), lower social support score (71 v 68, p <  0.001), and worse sleep quality score (4 v 5, p <  0.01) during lockdown. Mediterranean diet (MD) adherence was moderate and increased significantly only in those practicing religious fasting (score of 6 v 7, p <  0.01). Total minutes spent sitting increased (120 v 180, p <  0.01) although overall physical activity score did not significantly change. Smoking intensity increased during lockdown whilst frequency of alcohol consumption decreased (ptrend = 0.03 and <  0.01, respectively).

CONCLUSION

Various lifestyle factors were adversely affected by the COVID-19 lockdown in Cyprus. Evidence from this study supports development of holistic lifestyle interventions during and following the pandemic to reduce short and long-term NCD risks by building on lifestyle behaviour strengths and addressing longstanding and emerging gaps and needs.

Extensive Testing and Public Health Interventions for the Control of COVID-19 in the Republic of Cyprus between March and May 2020

Coronavirus disease 2019 (COVID-19) has significantly affected the well-being of individuals worldwide. We herein describe the epidemiology of COVID-19 in the Republic of Cyprus during the first epidemic wave (9 March-3 May 2020). We analyzed surveillance data from laboratory-confirmed cases, including targeted testing and population screening. Statistical analyses included logistic regression. During the surveillance period, 64,136 tests (7322.3 per 100,000) were performed, 873 COVID-19 cases were diagnosed, and 20 deaths were reported (2.3%). Health-care workers (HCWs) represented 21.4% of cases. Overall, 19.1% of cases received hospital care and 3.7% required admission to Intensive Care Units. Male sex (adjusted Odds Ratio (aOR): 3.04; 95% Confidence Interval (CI): 1.97-4.69), increasing age (aOR: 1.56; 95%CI: 1.36-1.79), symptoms at diagnosis (aOR: 6.05; 95%CI: 3.18-11.50), and underlying health conditions (aOR: 2.08; 95%CI: 1.31-3.31) were associated with hospitalization. For recovered cases, the median time from first to last second negative test was 21 days. Overall, 119 primary cases reported 616 close contacts, yielding a pooled secondary attack rate of 12% (95%CI: 9.6-14.8%). Three population-based screening projects, and two projects targeting employees and HCWs, involving 25,496 people, revealed 60 positive individuals (0.2%). Early implementation of interventions with targeted and expanded testing facilitated prompt outbreak control on the island.

Geographical inequalities in breast cancer incidence, mortality and late stage at diagnosis in Cyprus

Background

A national breast cancer (BC) screening programme, targeting women 50-69 years old, was introduced in Cyprus in 2007. This study aims to assess rural/urban differences in BC incidence, tumour stage at diagnosis (TSD) and mortality, since 2004 and since the introduction of the screening programme.

Methods

Data were obtained for 6589 new cases of BC (diagnosis 2004-2016) from a national population-based cancer registry (1998-today) in Cyprus. TSD was recorded according to the Surveillance, Epidemiology, and End Results categories. We defined late TSD as regional or distant stage. Unknown stages were excluded. We linked cases to the population census data and place of residence (rural/urban) and calculated incidence and mortality rate ratios (RR) by place of residence. We conducted logistic regression to measure the association between place of residence and TSD or mortality, adjusting for sex, age, ethnicity, smoking and marital status. Adjusted odds ratios (aOR) and 95% confidence intervals (CI) are reported.

Results

Since 2004, 54.7% of BC cases were diagnosed at localised stage, 40.6% at regional stage and 4.7% at distant stage. Incidence, but not mortality, rate for all BC was higher in urban than in rural areas (RRincidece=1.22;95%CI=1.51-1.28 and RRmortality=1.10;95%CI=0.97-1.24). Rural place of residence was associated with higher odds of late TSD (aOR=1.34; 95%CI=1.15-1.58) and death (aOR=1.36; 95%CI=1.11-1.68). After the introduction of the screening programme, for the targeted age group, rural place of residence was still associated with higher odds of late TSD (aOR=1.31; 95%C= 1.03-1.67), but not with death (p &gt; 0.05).

Conclusions

Even though BC incidence is higher in urban than in rural areas, women residing in rural areas had higher odds of late TSD and death. The introduction of the national BC screening programme only slightly reduced geographical inequalities in TSD. Further studies are needed to understand and reduce the role of inequalities in TSD.

Key messages

Rural/Urban inequalities in TSD are evident among BC cases in Cyprus, diagnosed between 2004 and 2016. The introduction of the national BC screening programme reduced but did not overcome geographical inequalities in TSD.

Shaping Baby Buddy Cyprus: eHealth literacy for the transition to parenthood

Issue

The transition to parenthood presents opportunities to promote mother-child health. Though of varying quality, internet information-seeking is prevalent while attendance in antenatal classes is low. Digital innovation can support access to timely and valid information for all, key component of WHO's Respectful Maternity Care.

Description of the problem

”Baby Buddy Forward” assessed the cross-national transferability of the innovative Baby Buddy (UK) healthy pregnancy and early parenthood app to the medicalized and decentralized birth environment in Cyprus. Within a Participatory Action Research (PAR) framework, formative qualitative and quantitative methods were employed to engage with the professional and mums-to-be community and deliver a locally relevant resource to enhance user-provider communication and shared decision-making.

Results

We (a) assessed available resources in a structured quantitative and qualitative rating exercise, (b) identified gaps and priorities in an eDelphi survey (N = 275 mums and 193 professionals, re-rated at annual Midwifery conference), (c) gained in-depth understanding of information-seeking behaviours in a series of focus groups with a diverse set of mums-to-be (N = 100) and (d) explored perceptions about the use of internet for information in pregnancy and the quality of communication with professionals in a questionnaire survey (N = 200). New health communication 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.

Lessons

In a “changing landscape” of antenatal education, Baby Buddy functions as “proof of concept” for cross-national innovation exchange. Beyond a learning experience, the use of PAR provided ground for building transdisciplinary alliances and creating a public health digital resource to enhance the health literacy of new parents and support the educational role of maternal and child health professionals.

Key messages

Digital resources can reduce social disparities, enrich the user-provider exchange and support the educational role of professionals. PAR provides a framework for co-creation and sense of common purpose.

Developing a holistic contingency plan: Challenges and dilemmas for cancer patients during the COVID-19

During the first quarter of 2020 the world is experiencing a pandemic of Severe Acute Respiratory Syndrome-Coronavirus-2 (SARS-CoV-2), a novel beta coronavirus that is responsible for the 2019 novel coronavirus disease (COVID-19). The COVID-19 pandemic revealed that healthcare systems around the world were not prepared to deal with either the direct effects of the pandemic or with the indirect effects that are imposed on the health of patients with chronic disorders such as cancer patients. Some challenges and dilemmas currently faced during the pandemic include the management of cancer patients during the treatment and follow-up phases, the assessment of the safety of treatments currently used for the management of SARS-CoV-2 for use in cancer patients, the development of psychoeducation and emotional support for cancer patients and the safe conduct of clinical trials involving participation of cancer patients. Evidence from the literature supports the need for the urgent development of a holistic contingency plan which will include clear guidelines for the protection and comprehensive care of cancer patients. The implementation of such a plan is expected to have many beneficial effects by mainly minimizing the increased morbidity and mortality of cancer patients that could result as an adverse consequence of the COVID-19 or future pandemics.

Mixed-method study on internet use and information-seeking during transition to motherhood

Background

Traditional approaches to antenatal education have been questioned as to their effectiveness. The use of the internet for information-seeking is very prevalent, however sources are of varied quality. We explored the information-seeking behaviour of pregnant women in the context of health literacy skills and informed decision-making.

Methods

In a mixed-method descriptive study, 12 focus groups with a culturally diverse set of pregnant women and new mothers (N = 62), a non-participant observation study of antenatal education classes and a web-based questionnaire survey were performed (N = 200). The survey explored use and critical appraisal of internet sources of information, perceived role in assisting decision-making, user-provider interaction, alliance and autonomy in decision making.

Results

Six themes emerged: in a generally “unsupportive system”, pregnant women want to have a “confident voice” but find themselves “self-navigating” in parallel worlds of formal and informal information, using a process of “supplementing and filtering”, sometimes instinctively and selectively, ending up in a state of “doubt and faith” with regards to the trustworthiness of the information and physician dominance in communication, while the “art of communication” is essential to break the cycle. Internet information-searching is very prevalent, even though 60% characterize the information as misleading and 90% would like health professionals to recommend trusted sites. While the majority report discussing this information with their healthcare providers, only 57% characterize the reception as positive.

Conclusions

Women want to have control over decisions affecting their pregnancy. While the internet is a prevalent information source, they value the communication with their healthcare providers and want direction. Maternity healthcare professionals need to recognize the phenomenon, offer appropriate guidance and support shared decision-making.

Key messages

“Traditional” antenatal education arrangements are not effective in supporting informed decision-making. In a landscape of prevalent internet use, a shift is needed from current practices of unguided information-searching.

Social inequality in obesity in an Eastern Mediterranean population: a national health survey

Background

This study aimed to explore socioeconomic factors associated with obesity in the Republic of Cyprus.

Methods

We interviewed 3021 Greek-Cypriots aged 25-64 years through a multistage survey. We collected self-reported information on demographics, health behaviours (physical activity, smoking, alcohol consumption and dietary intake), socio-economic characteristics (educational attainment, household income and occupational social class) and anthropometric measurements. Obesity was defined as body mass index ≥30 kg/m2. For the association between obesity and each socio-economic indicator, we conducted sex-specific Poisson's regression with robust variance, adjusting for all demographics and health-related behaviours, reporting adjusted prevalence ratios (aPR) and 95% confidence intervals (CI).

Results

The prevalence of obesity was 22% and 17% among men and women, respectively. There was a significant trend of higher obesity prevalence with increasing age as well as with being widowed in both genders and being a refugee in men. Obesity prevalence decreased with increasing educational attainment (postgraduate vs. none/gymnasium: a PRmen=0.45; 95%CI=0.25-0.82; a PRwomen=0.41; 95%CI=0.18-0.95; p-trends&lt;0.005), and household income (&gt;€4000/month vs. ≤€1000/month: a PRmen=0.45; 95%CI=0.26-0.81; a PRwomen=0.45; 95%CI=0.22-0.92; p-trends&lt;0.005). Occupational social class did not show any clear association with obesity. After adjustment for health-behaviours as mediators the association between income and obesity in women was attenuated.

Conclusions

The current study highlights striking social inequalities in obesity among Cypriot men and women, characterised by a linear decrease in obesity prevalence each step up the socioeconomic hierarchy. We recommend that comprehensive and multifaceted public health interventions are considered to address income and education-related barriers resulting in higher obesity rates among specific population sub-groups.

Key messages

Among Greek Cypriot adults, obesity affects almost one in five whilst obesity prevalence shows gender-specific social inequalities. When investigating social inequalities in health, the choice of socioeconomic indicators should reflect the context of the population and gender-specific differences.

Update on the Anti-Cancer Potency of Tocotrienols and α-Tocopheryl Polyethylene Glycol 1000 Succinate on Leukemic Cell Lines

The natural isoforms of vitamin E γ-tocotrienol (γ-ΤΤ) and δ-tocotrienol (δ-ΤΤ) and the synthetic derivative α-tocopheryl polyethylene glycol 1000 succinate (TPGS) have promising anticancer potency in a variety of cancer cell lines and animal models of cancer. Ongoing clinical trials are investigating the anti-tumor effectiveness of TTs in combination with chemotherapeutic agents in patients suffering from breast, colon, non-small cell lung and ovarian cancers. Despite extensive research on different types of cancer, the anticancer potency of TTs and TPGS has not been thoroughly investigated in leukemias. Given the fact that certain types of leukemias have very low survival rates and that patients suffer significantly from the toxic side effects of chemotherapeutic drugs, there is a need to develop novel treatments with increased specificity against cancer cells and reduced toxicity to the patients. The aim of this review is to report current evidence on the anticancer potency of TTs and TPGS on leukemic cells lines and to discuss future studies that could be carried out to investigate the role of these agents in the management of leukemias.

eDelphi survey to shape the content of a digital resource to enhance parental health literacy

Background

Information-seeking on the internet is very prevalent, in contrast to low attendance of antenatal classes. In addition to varying quality, few digital resources are developed using participatory research approaches.

Methods

Antenatal learning needs were explored in a modified Delphi survey among the professional community and parents-to-be/new parents. A list of 174 topics was developed using the Nominal Group Technique among antenatal educators and representatives of local professional associations. In an online survey, the relative importance of each was rated on a 5-point scale by the wider professional community and general public. Topics rated by ≥ 80% as at least “very important” or by ≥ 50% as “essential” by either group were shortlisted and re-rated by delegates of the annual Midwifery conference.

Analysis

193 health professionals (77.7% midwives) and 275 mothers-to-be/new mothers (56.4% attendance of antenatal classes) participated in the online survey. Based on pre-set criteria, 95 topics (54.6%) were identified, 55 (31.6%) nominated by both groups. Among 18 themes, those with the highest number of nominated topics were: Breastfeeding, Prematurity, Giving birth, Caring for Baby and Mental health & well-being. There was good agreement between the two groups (r = 0.88) and in the top 20 single topics, thirteen were common. Priorities were largely unchanged in the last round, but a number of new topics emerged, including pre-eclampsia and domestic abuse. On a 1-10 scale, health literary of expectant parent was rated at M = 5.7 (SD 1.5) by professionals.

Conclusions

In a “changing landscape” of antenatal education, new technologies provide opportunities for broader reach. This formative research study explored the perceived learning needs and local priorities in order to shape the content of Baby Buddy, a public health digital intervention to enhance the health literacy of new parents and support the educational role of health professionals.

Key messages

Local needs and priorities for a digital parenthood platform were identified using a Delphi method. Participatory formative research can maximize the potential though co-creation and co-ownership.

Investigation into the metric properties of the workplace social capital questionnaire and its association with self-rated health and psychological distress amongst Greek-Cypriot registered nurses: cross-sectional descriptive study

Background

Social capital can been described as an individual or a collective attribute, with structural and cognitive components, and a bonding, bridging and linking typology. While extensively studied in the community, studies in occupational settings are sparse by comparison. Furthermore, there is no uniformity in its measurement. This study investigated the construct validity of a Workplace Social Capital questionnaire (WSC), originally developed in the Finnish Public Sector occupational cohort, in a different socio-cultural setting (Cyprus), language (Greek) and occupational group (Registered Nurses). It also explored its criterion concurrent validity according to observed association with self-rated health and psychological distress.

Methods

Participants were 10% of all registered nurses (N = 362) who responded to the 8-item WSC scale during a nationwide educational programme. A unidimensional model was compared with the postulated two-factor (structural vs cognitive) and three-factor model (bonding, bridging, linking) in Confirmatory Factor Analyses. The association with self-rated health (0–100 Visual Analogue Scale) and mental distress (GHQ-12 ≥ 4) was assessed in linear and logistic regression models.

Results

A bonding (Cronbach’s a = 0.76), bridging (a = 0.78) and linking (a = 0.89) structure explained 77.6% of the variance and was a better fit as indicated by goodness of fit indices. Elevated odds of mental distress and poorer self-rated health were observed among participants with the lowest levels of perceived workplace social capital. In adjusted models, associations appeared stronger with bonding social capital (adjOR of mental distress = 2.71 95% CI = 1.08, 6.79) while those with the highest scores rated their health higher by 8.0 points on average (95% CI = 2.1, 13.8). Low linking social capital was also associated with poorer health but no consistent associations were observed with bridging.

Conclusion

While associations appeared stronger with bonding and linking, this may reflect a weakness of the measure to fully capture bridging social capital. Even though, this aspect might need strengthening, the WSC showed good metric properties in a different setting, language and occupational group. Cross-national and cognitive validation studies are needed.

Prevalence of breast-feeding and exclusive breast-feeding at 48 h after birth and up to the sixth month in Cyprus: the BrEaST start in life project

OBJECTIVE

To assess the prevalence and sociodemographic determinants of breast-feeding (BF) and exclusive breast-feeding (EBF) in Cyprus up to the sixth month.

DESIGN

Cross-sectional and longitudinal descriptive study. BF and EBF were estimated based on mothers' self-reported BF status in line with Step 7 of the WHO/UNICEF Baby-Friendly Hospital Initiative questionnaire and based on 24 h recall.

SETTING

Maternity wards in all public hospitals and twenty-nine (of thirty-five) private maternity clinics nationwide.

SUBJECTS

Consecutive sample of 586 mothers recruited within 48 h from birth, followed up by telephone interview at the first, fourth and sixth month.

RESULTS

Although 84·3 % of mothers initiated BF before discharge, prevalence of BF at the sixth month was 32·4 %, with the highest reduction observed between the first and fourth months. Prevalence of EBF at 48 h was 18·8 % and fell gradually to 5·0 % at the sixth month. Mothers with higher educational attainment or higher family income were more likely to breast-feed until the sixth month. In terms of EBF, an association was observed only with education, which persisted until the sixth month. Other than social gradient, mode of delivery was the strongest determinant of BF initiation, exclusivity and continuation. Mothers who gave birth vaginally were three to four times more likely to initiate BF (OR=3·1; 95 % CI 1·7, 5·4) and EBF (OR=4·3; 95 % CI 2·7, 6·8).

CONCLUSIONS

The low prevalence of BF and EBF in Cyprus, together with the fact that caesarean section rates are currently among the highest in Europe, suggest the need for further research to understand this multidimensional phenomenon and for interdisciplinary policy action to protect, promote and support BF.

Shared genetic variants between serum levels of high-density lipoprotein cholesterol and wheezing in a cohort of children from Cyprus

Background

In a cohort of children in Cyprus, we recently reported low levels of high density lipoprotein cholesterol (HDL-C) to be associated with asthma. We examined whether genetic polymorphisms that were previously linked individually to asthma, obesity, or HDL-C are associated with both asthma and HDL-C levels in the Cyprus cohort.

Methods

We assessed genotypes frequencies in current-wheezers (n = 190) and non-asthmatic controls (n = 671) and HDL-C levels across several genotypes. Binary logistic regression models were used to assess the effect of genotypes on wheezing risk and examined whether this effect is carried out through changes of HDL–C.

Results

Of the 16 polymorphisms tested, two polymorphisms TNFa rs3093664 and PRKCA rs9892651 presented significant differences in genotype distribution among current-wheezers and controls. Higher HDL-C levels were noted in carriers of genotype GG of polymorphism TNFa rs3093664 that was protective for wheezing Vs AG and AA genotypes (65.3 Vs 51.8 and 53.3 mg/dl, p-value < 0.001 and p-value for trend = 0.028). In polymorphism PRKCA rs9892651, HDL-C levels were lower in carriers of CC and TC genotypes that were more frequent in current-wheezers Vs TT genotype (52.2 and 52.7 Vs 55.2 mg/dl, p-value = 0.042 and p-value for trend = 0.02). The association of TNFa rs3093664 with wheezing is partly mediated by its effect on HDL-C whereas association of PRKCA rs9892651 with wheezing appeared to be independent of HDL-C.

Conclusions

We found evidence that two SNPs located in different genetic loci, are associated with both wheezing and HDL-C levels, although more studies in other populations are needed to confirm our results.

Electronic supplementary material

The online version of this article (doi:10.1186/s13052-016-0276-1) contains supplementary material, which is available to authorized users.

Association of Serum Vitamin D with Asthma and Atopy in Childhood: Review of Epidemiological Observational Studies

During the last decades, vitamin D deficiency has re-emerged worldwide affecting not only population's bone health, but also several other conditions including asthma and allergies. Increasing number of published epidemiological studies in the last seven years have examined the role of vitamin D deficiency in childhood in several outcomes including asthma diagnosis, asthma disease severity, allergic sensitization and atopy. This review presents evidence on this association from a systematic search in the literature of all available observational studies and their limitations. A total of 33 studies were identified: 3 prospective, 16 case-control and 14 cross-sectional studies. Overall, most of the case-control studies tend to report that asthmatics have lower vitamin D levels/status as compared to healthy children, although most of these studies are mainly descriptive in nature and tend to provide only crude, unadjusted comparisons. Studies that investigated the association of vitamin D with the prevalence, development and/or severity of asthma gave mixed findings, with the exception of studies that focused on vitamin D and severity of asthma which suggest a positive association of vitamin D levels with better asthma control, reduced use of asthma medication, fewer asthma exacerbations and lower utilisation of health care facilities for urgent treatment. Insufficient evidence also exists for the association of inadequate vitamin D status with higher risk of atopic sensitization. The lack of adequate number of prospective studies, the variable definitions for case ascertainment, the wide age range of the participants, and commonly the inadequate control for confounders make inferences difficult. Future studies are needed with a prospective design and repeated measurements of vitamin D to provide critical information on the timing and dosage of future vitamin D supplementation interventions.

Association of vitamin D receptor gene polymorphisms and vitamin D levels with asthma and atopy in Cypriot adolescents: a case–control study

Background: Polymorphisms in the vitamin D receptor (VDR) gene have been studied in immune-related disorders either as independent contributors or in combination with vitamin D concentration. Vitamin D and VDR have been independently linked to asthma susceptibility. We investigated whether VDR variants were associated independently or in relation to vitamin D levels with asthma in Cypriot adolescents. Methods: We studied 190 current wheezers, 69 of which were categorized as active asthmatics and 671 healthy controls. We determined three VDR genotypes (BsmI, TaqI, ApaI) and measured serum 25(OH)D levels. Logistic regression and stratified analyses by the presence of hypovitaminosis D (≤20 ng/ml) were used to evaluate the association of the VDR variants with asthma. Results: The distribution of TaqI genotypes was significantly different between controls and current wheezers (p = 0.030) or active asthmatics (p = 0.014). The tt genotype was over-represented in wheezers (19.2 %) and asthmatics (21.3 %) compared to respective controls (12.9 %). No difference was observed between controls, current wheezers and active asthmatics in the genotypic distribution of BsmI and ApaI polymorphic sites. After stratification by the presence of hypovitaminosis D, a significant association was detected between tt genotype of TaqI polymorphism with wheezing (OR: 1.97, 95 % CI: 1.12, 3.46) and asthma (OR: 2.37, 95CI%: 1.02, 5.52) only in those with normal vitamin D levels (>20 ng/ml) but not in subjects with low vitamin D. Conclusions: The minor TaqI genotype of VDR is associated with asthma in Cypriot adolescents. This polymorphism may contribute to asthma susceptibility primarily under conditions of normal vitamin D levels (>20 ng/ml).

Association of vitamin D receptor gene polymorphisms and vitamin D levels with asthma and atopy in Cypriot adolescents: a case-control study

Background

Polymorphisms in the vitamin D receptor (VDR) gene have been studied in immune-related disorders either as independent contributors or in combination with vitamin D concentration. Vitamin D and VDR have been independently linked to asthma susceptibility. We investigated whether VDR variants were associated independently or in relation to vitamin D levels with asthma in Cypriot adolescents.

Methods

We studied 190 current wheezers, 69 of which were categorized as active asthmatics and 671 healthy controls. We determined three VDR genotypes (BsmI, TaqI, ApaI) and measured serum 25(OH)D levels. Logistic regression and stratified analyses by the presence of hypovitaminosis D (≤20 ng/ml) were used to evaluate the association of the VDR variants with asthma.

Results

The distribution of TaqI genotypes was significantly different between controls and current wheezers (p = 0.030) or active asthmatics (p = 0.014). The tt genotype was over-represented in wheezers (19.2 %) and asthmatics (21.3 %) compared to respective controls (12.9 %). No difference was observed between controls, current wheezers and active asthmatics in the genotypic distribution of BsmI and ApaI polymorphic sites. After stratification by the presence of hypovitaminosis D, a significant association was detected between tt genotype of TaqI polymorphism with wheezing (OR: 1.97, 95 % CI: 1.12, 3.46) and asthma (OR: 2.37, 95CI%: 1.02, 5.52) only in those with normal vitamin D levels (>20 ng/ml) but not in subjects with low vitamin D.

Conclusions

The minor TaqI genotype of VDR is associated with asthma in Cypriot adolescents. This polymorphism may contribute to asthma susceptibility primarily under conditions of normal vitamin D levels (>20 ng/ml).

Electronic supplementary material

The online version of this article (doi:10.1186/s40248-015-0025-0) contains supplementary material, which is available to authorized users.

Gender differences in objectively assessed physical activity in asthmatic and non-asthmatic children

OBJECTIVE

To compare objectively assessed physical activity levels, between asthmatic children and non-asthmatic controls.

METHODS

From a random community sample of 794 children aged 8-9 years, in a case-control design, 104 children with ever doctor's diagnosis of asthma and 99 non-asthmatic controls were recruited and had assessment of physical activity with biaxial accelerometers for 7 days.

RESULTS

Children with active (also reporting at least one episode of wheezing in the last 12 months) and inactive (no wheezing in past 12 months) asthma appeared to have similar physical activity and sedentary activity levels compared to non-asthmatic children. However, girls with active asthma had significantly lower moderate-to-vigorous physical activity (MVPA) levels than their peers with adjusted geometric mean ratio of 0.59 (95% CI: 0.369, 0.929, P-value = 0.024). No difference in physical and sedentary activity levels was observed between asthmatic and non-asthmatic boys. The difference between genders in the comparison of MVPA levels in asthmatics and controls was statistically significant (P-value of likelihood ratio test [LRT] for effect modification by gender = 0.034).

CONCLUSIONS

Unlike boys, girls with active asthma appear to be less active than their healthy peers, and this gender difference might explain the inconsistent evidence from previous reports on physical activity levels in asthmatic children. Further studies are needed to confirm the gender interaction in the childhood asthma-physical activity relation and the implications on current guidelines for physical exercise prescriptions in asthmatic children.