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 (ß=2.63, 95% CI 0.72 to 4.54, p=0.007), which was more profound among atopic children (ß=3.56, 95% CI 0.04 to 7.07, p=0.047). Similarly, FEV1% predicted (ß=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.

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.

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.

Empowerment and turnover of nurse managers before and after a major health care reform in Cyprus: A cross sectional study.

AIM: This study aimed to investigate the perceived empowerment and turnover intention of middle nurse managers before and after the implementation of a major reform of the health care system in Cyprus, which also includes the transition of public hospitals towards administrative and financial autonomy. BACKGROUND: The empowerment of nurse managers is important since previous studies have shown that it is associated with performance at work and may have an impact on their turnover intention. METHODS: A repeated cross-sectional study was conducted in March 2019 (first phase) and was repeated in March 2020 (second phase), after the introduction of major changes. The target population was all nurse managers of the public hospitals. The final sample consisted of 175 (RR 94%) participants in the first phase and 178 (RR 95.6%) in the second. RESULTS: Measurements at both time points revealed moderate levels of perceived empowerment among Cyprus nurse managers. Empowerment score (17.95) appeared slightly lower at the repeat measurement compared to the first empowerment score (18), but the observed difference was not statistically significant (p = 0.184). Among the categories of empowerment opportunities was presenting statistically significant differences between the two phases. At the second phase, mean scores of empowerment were consistently lower among those who stated YES compared to those who stated NO in relation to (a) the intention to change department, (b) the intention to change profession and (c) the intention to change organization/hospital. CONCLUSIONS: This study demonstrated lower levels of empowerment among nurse managers with turnover intentions. It is therefore needed to be investigated further whether lower empowerment levels are the main reason for turnover intentions. It also suggests the need for senior management to create opportunities and to develop and implement interventions which aim to maintain and further improve the empowerment of the nurse managers and assess their effectiveness in terms of turnover intention in the organization. IMPLICATIONS FOR NURSING POLICY: The senior management of the hospitals needs to adopt retention strategies by establishing an empowered positive working environment for nurse managers. Nurse managers need to collaborate with the senior management and seek more access to opportunities, information, support and resources which will enable them to perform their duties with efficiency and be more effective.

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.

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.

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.

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.

Health related quality of life in adult primary Ciliary dyskinesia patients in Cyprus: development and validation of the Greek version of the QOL-PCD questionnaire.

BACKGROUND: The QOL-PCD questionnaire is a recently developed Health Related Quality of Life (HRQoL) instrument for Primary Ciliary Dyskinesia. The aim of this study was to translate the adult QOL-PCD questionnaire into Greek language and to conduct psychometric validation to assess its performance. METHODS: Forward translations to Greek and backward translation to English were performed, followed by cognitive interviews in 12 adult PCD patients. The finalized translated version was administered to a consecutive sample of 31 adult, Greek speaking PCD patients in Cyprus for psychometric validation, which included assessment of internal consistency, test-retest reliability, construct and convergent validity. Internal consistency was assessed by Cronbach's alpha test in terms of the overall and sub-scales. Test-retest reliability was assessed by repeat administration of the questionnaire within 2 weeks and calculation of the intra-class correlation (ICC). Construct validity was assessed by comparing different groups of patients based on a-priori hypotheses and convergent validity was evaluated by examining associations between the QOL-PCD and SF-36 questionnaires. RESULTS: Moderate to good internal consistency was observed (Cronbach's α: 0.46-0.88 across sub-scales) and test-retest reliability assessment demonstrated good repeatability for most scales (ICC: 0.67-0.91 across subscales). Patients of female gender, older age and lower lung function exhibited lower QOL-PCD scores in general, while high correlations for most QOL-PCD scales with corresponding SF-36 scales were observed, in particular for physical functioning (r = 0.78, p < 0.05). CONCLUSION: The adult version of QoL-PCD questionnaire has been translated according to international guidelines resulting to a cross-culturally validated Greek version which exhibited moderate to good metric properties in terms of internal consistency, stability, known-group and convergent validity.

The Greek versions of the TeamSTEPPS teamwork perceptions questionnaire and Minnesota satisfaction questionnaire "short form".

BACKGROUND: Teamwork and job satisfaction are important among the multidisciplinary team who care patients with chronic illnesses such as heart failure (HF) patients. TeamSTEPPS teamwork perceptions questionnaire (T-TPQ) and Minnesota Satisfaction Questionnaire "short form" (MSQ-short) are both self-report questionnaires which examine multiple dimensions of perceptions of teamwork and job satisfaction within healthcare settings, respectively. The aim of the study was to examine the psychometric properties of the Greek versions of the TeamSTEPPS Teamwork perceptions questionnaire (Gr-T-TPQ) and Minnesota Satisfaction Questionnaire "short form" (Gr-MSQ-short). METHODS: A methodological study was contacted in order to assess the construct validity and reliability of the Gr-T-TPQ and Gr-MSQ-short. For that reason, 292 questionnaires were administrated to Greek-Cypriot health care professionals (HCPs). Confirmatory factor analysis (CFA) was conducted for the data collected with the GrT-TPQ and Exploratory factor analysis (EFA) and CFA were also conducted for the data collected with the GrMSQ-short questionnaire. Cronbach's a was calculated as well. RESULTS: CFA of the data collected with Gr-T-TPQ confirmed the initial scale structure with excellent fit indices (× 2 (df) 1124.75 (550), p < 0.0001, AGFI = 0.986, TLI = 0.994, CFI = 0.994, RMSEA = 0.06, 90%, C.I.[0.055-0.065]). Furthermore, all dimensions were found to be correlated (r = 0.65 to r = 0.88) and internal consistency was found adequate (Cronbach's α = 0.96). Subscales also, demonstrated high internal consistency (α = 0.87-0.95). CFA for the data collected with Gr-MSQ-short, did not confirm the initial scale's dimensions. In EFA items 1, 5, 6, 12 and 18 were eliminated from the analysis due to low communalities and multiple components loading. The oblimin rotation with two factors was explaining 58% of the variance. These two factors identified were Supervisor/Autonomy and Task Enrichment. CONCLUSIONS: In general, the Gr-T-TPQ and Gr-MSQ-short are construct-valid instruments for measuring perceptions of teamwork and job satisfaction in Greek speaking HCPs' population.

Supportive Care Interventions to Promote Health-Related Quality of Life in Patients Living With Heart Failure: A Systematic Review and Meta-Analysis.

Supportive care (physical, psychosocial, and spiritual) may be beneficial as a coping resource in the care of patients with heart failure (HF). Nurses may provide individualised supportive care to offer positive emotional support, enhance the patients' knowledge of self-management, and meet the physical and psychosocial needs of patients with HF. The aim of this study was to examine the potential effectiveness of supportive care interventions in improving the health- related quality of life (HRQoL) of patients with HF. Related outcomes of depression and anxiety were also examined. A systematic search of PubMed, CINAHL, and the Cochrane Library was performed to locate randomised controlled trials (RCTs) that implemented any supportive care interventions in patients with HF published in the English language. Identified articles were further screened for additional studies. Ten (10) RCTs were selected for the meta-analysis. Effect sizes were estimated between the comparison groups over the overall follow-up period, and presented along with confidence intervals (CIs). Statistical heterogeneity for each comparison was estimated using Q (chi square test) and I2 statistics with 95% CIs. Statistical heterogeneity was observed in all study variables (i.e., HRQoL and dimensions). There was a positive, but not statistically significant, effect of social support on HRQoL (mean difference [MD], 5.31; 95% CI, -8.93 to 19.55 [p=0.46]). The results of the two dimensions suggested a positive and statistically significant effect of the supportive care interventions (physical: MD, 7.90; 95% CI, 11.31-4.50 [p=0.00]; emotional dimension: MD, 4.10; 95% CI, 6.14-2.06; [p=0.00]). The findings of the current study highlight the need to incorporate supportive care to meet the needs of patients with HF. Patients with HF have care needs that change continuously and rapidly, and there is a need of a continuous process in order to address the holistic needs of patients with HF at all times and not just in a cardiology department or an acute care setting. Patients with HF have multiple needs, which remain unmet. Supportive care is a holistic, ongoing approach that may be effective in identifying and meeting the care needs of patients with HF along with the patient. This review includes all interventions provided in individuals with HF, giving clinicians the opportunity to choose the most suitable ones in improving the clinical outcomes of their patients with HF.

Prevalence and course of disease after lung resection in primary ciliary dyskinesia: a cohort & nested case-control study.

BACKGROUND: Lung resection is a controversial and understudied therapeutic modality in Primary Ciliary Dyskinesia (PCD). We assessed the prevalence of lung resection in PCD across countries and compared disease course in lobectomised and non-lobectomised patients. METHODS: In the international iPCD cohort, we identified lobectomised and non-lobectomised age and sex-matched PCD patients and compared their characteristics, lung function and BMI cross-sectionally and longitudinally. RESULTS: Among 2896 patients in the iPCD cohort, 163 from 20 centers (15 countries) underwent lung resection (5.6%). Among adult patients, prevalence of lung resection was 8.9%, demonstrating wide variation among countries. Compared to the rest of the iPCD cohort, lobectomised patients were more often females, older at diagnosis, and more often had situs solitus. In about half of the cases (45.6%) lung resection was performed before presentation to specialized PCD centers for diagnostic work-up. Compared to controls (n = 197), lobectomised patients had lower FVC z-scores (- 2.41 vs - 1.35, p = 0.0001) and FEV1 z-scores (- 2.79 vs - 1.99, p = 0.003) at their first post-lung resection assessment. After surgery, lung function continued to decline at a faster rate in lobectomised patients compared to controls (FVC z-score slope: - 0.037/year Vs - 0.009/year, p = 0.047 and FEV1 z-score slope: - 0.052/year Vs - 0.033/year, p = 0.235), although difference did not reach statistical significance for FEV1. Within cases, females and patients with multiple lobe resections had lower lung function. CONCLUSIONS: Prevalence of lung resection in PCD varies widely between countries, is often performed before PCD diagnosis and overall is more frequent in patients with delayed diagnosis. After lung resection, compared to controls most lobectomised patients have poorer and continuing decline of lung function despite lung resection. Further studies benefiting from prospective data collection are needed to confirm these findings.

Mental health among single mothers in Cyprus: a cross-sectional descriptive correlational study.

BACKGROUND: International literature reveals that single mothers experience increased levels of chronic stress, which is mainly due to economic hardship and reduced levels of social support. Eventually this leads to psychological distress. While most of the studies commonly identify that mental health disorders are common among single mothers compared to their married counterparts, the magnitude of the problem might be even larger since diagnosis-specific tools may mask important levels of distress of milder intensity. This study aims to assess the level of mental distress experienced by single mothers as measured by the GHQ-28, and how it is influenced by socioeconomic factors, as well as the level of perceived social support. METHODS: Between January and March 2012, Greek speaking single mothers who reside in Cyprus were recruited by either personal conduct through Single Mothers' Association (SMA), or by using snowball sampling technic. Mental distress was assessed with the General Health Questionnaire (GHQ-28) and perceived social support with the Social Provision Scale (SPS). All scales were completed anonymously and voluntarily by 316 single mothers. Univariable and multivariable associations with socio-demographic characteristics were investigated using chi-square tests and in multivariable backward stepwise logistic regression models respectively. Odds ratio of psychological distress across decreasing levels of social support were estimated in logistic regression models. . RESULTS: As many as 44.6% of the sample appeared to experience psychological distress (GHQ-28 total score ≥ 5). Strong associations with all health assessment tools were observed with variables relating to the lowest monthly family income, the presence of economic difficulties, the higher educational level, the age group 35-44 years and pre-existing illness. Social support as perceived by the mothers displayed a strong negative independent association with psychological distress, even after adjusting confounders. CONCLUSION: This study highlights that single mothers are very likely to experience poor psychological well-being. With a steady rise in the proportion of single-parent families headed by a mother, these findings highlight a significant issue that would adversely affect many women and consequently their children and the community. It also emphasizes the necessity for interventions and strategies at community level in order to support this vulnerable population group.

Small-area socioeconomic deprivation indices in Cyprus: development and association with premature mortality.

BACKGROUND: Area-level measures of socioeconomic deprivation are important for understanding and describing health inequalities. The aim of this study was the development and validation of a small-area index of socioeconomic deprivation for Cypriot communities and the investigation of its association with the spatial distribution of all-cause premature adult mortality. METHODS: Six area-level socioeconomic indicators were used from the 2011 national population census (low educational attainment, unemployment, not owner occupied household, single-person household, divorced or widowed and single-parent households). After normalization and standardization of the geographically smoothed indicators, Principal Component Analysis (PCA) was used to construct indicator weights. The association between deprivation indices and the spatial distribution of all-cause premature adult mortality was estimated in Poisson log-linear spatial models. RESULTS: PCA resulted in two principal components explaining the 65.7% of the total variance. The first principal component included four indicators (low educational attainment, single-person households, divorced or widowed and single-parent households, the latter however with a negative loading) and it thought more likely to capture rural-related aspects of deprivation. The second principal component included the other two indicators (unemployment and not owner occupied households) and it is more likely to capture urban-related aspects of material deprivation. Restricting the analysis in the metropolitan areas of the island resulted in a different set of indicators for the urban-specific deprivation index. All developed indices were linearly associated with all-cause premature adult mortality. The all-cause premature adult mortality increased by 17% per 1 standard deviation (SD) increase in rural-related socioeconomic deprivation (95% CrI: 8-27%) and 8% per 1 SD increase in urban-related aspects of material deprivation (95% CrI: 3-15%) in the nationwide analysis and 9% per 1 SD increase in urban-specific socioeconomic deprivation (95% CrI: 4-15%) across metropolitan areas. CONCLUSIONS: The results of this study demonstrate that a set of small-area indices of socioeconomic deprivation across Cypriot communities have good construct and predictive validity. However, the study indicates that different aspects of socioeconomic deprivation may be important in rural and urban areas in Cyprus. The developed socioeconomic deprivation indices could offer a valid new tool for Cypriot public health research and policy in terms of identifying areas in greatest need, guiding resource allocation and developing area-targeted public health programmes and policies.

Evaluation of the psychometric properties of the Greek version of the Active Life with Asthma (Gr-ALMA) review: a descriptive methodological study.

BACKGROUND: Regular asthma reviews are recommended by international guidelines to improve the quality of life of asthma patients. To facilitate these reviews in primary care practice, there is a need for structured asthma review tools. AIM: The aim of this study was to assess the metric properties of the Greek-translated version of the Active Life with Asthma (ALMA) review. METHODS: A convenience sample of 156 asthmatic patients from three public hospitals participated in this methodological study with a descriptive cross-sectional correlation design. Participants responded to the 19-item ALMA questionnaire and provided socio-demographic and clinical information. The construct validity of the tool was explored in exploratory factor analysis and the internal consistency of scale and sub-scales was estimated using Cronbach's α. Convergence validity was assessed using the Asthma Control Questionnaire (ACQ), a commonly used asthma control measure, and concurrent criterion validity was assessed using the MiniAQoL, an asthma-specific quality of life questionnaire. Known-group validity was assessed based on observed differences in terms of frequency of hospitalizations or emergency visits in the past year. RESULTS: Amongst 156 participants, 95 (60.9%) were women and the median age was 50-65 years old. Exploratory factor analysis (KMO = 0.83 and Bartlett test < 0.001) with principal component extraction and orthogonal rotation revealed a clear structure of three factors with little cross-loading: physical, environmental and mental domains, as in the original study. Cronbach's alpha coefficient for internal consistency for the whole scale was 0.85, while for the sub-scales, these were: environmental a = 0.69, mental a = 0.76 and physical a = 0.85. Test-retest reliability based on the correlation between scores of 20 participants responding twice two weeks apart was r = 0.92. There was stong correlation in the expected direction between ALMA and ACQ (r = - 0.70) as well as miniAQoL (r = 0.71). Finally, there were statistically significant higher ALMA scores in participants who reported emergency visits and hospital admissions in the past year. CONCLUSION: In general, the ALMA showed good metric properties. It appears to be a reliable and valid tool which can be used as a measure for asthma control and self-management in clinical practice as well as future descriptive or intervention research studies.

Adapting the eHealth Literacy Scale for Carers of People With Chronic Diseases (eHeals-Carer) in a Sample of Greek and Cypriot Carers of People With Dementia: Reliability and Validation Study.

BACKGROUND: As the population ages, many more people will be in need of long-term care. According to a recent report by Alzheimer's Disease International and the Karolinska Institute, 84% of people with dementia are cared for at home and 16% in nursing homes. Several Web-based interventions have been developed to assist the work of carers at home. Measuring the levels of electronic health (eHealth) literacy is of top priority to facilitate inclusion of this population and develop training programs to enhance eHealth literacy skills. OBJECTIVE: This study aimed to adapt the eHealth Literacy Scale (eHeals) for carers of people with dementia, who speak Greek as their native language and live in Greece and Cyprus, and to test the reliability and validity of the scale for carers. METHODS: The content validity of the eHealth Literacy Scale for Carers of People With Chronic Diseases (eHeals-Carer) was assessed with an expert panel (N=10). A descriptive study with face-to-face interviews among 101 primary carers of people with dementia was conducted. In addition to the eHeals-Carer to assess their perceived eHealth literacy, participants responded to a brief questionnaire regarding characteristics of internet use and provided sociodemographic data. The internal consistency of the tool and the construct validity via an exploratory factor analysis (EFA) were explored. RESULTS: The Mean Item-Level Content Validity Index (CVI) and Scale-Level CVI Average was 0.93. The participants were mostly women (75.2%, 76/101), aged less than 60 years (67.3%, 68/101) with secondary education. The internal consistency was estimated at a Cronbach alpha of .83. Two factors were extracted from the EFA: information seeking questions 1 to 5 (factor 1) and evaluation questions 6 to 8 (factor 2). CONCLUSIONS: eHeals-Carer is the first perceived eHealth literacy tool adapted for carers of people with dementia. The use of Web-based services available for carers could help them and improve the health care system in the long term. In Greece and Cyprus, there is a lack of services, and improving the digital skills of carers could provide them with the means to support themselves at home and improve care provision. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.2196/resprot.8080.

The effect of l-Arginine on Ciliary Beat Frequency in PCD patients, non-PCD respiratory patients and healthy controls.

OBJECTIVES: Few studies have examined the potentially therapeutic effect of increasing the production of endogenous nitric oxide (NO) in Primary Ciliary Dyskinesia (PCD) and other chronic respiratory conditions. Nasal NO is low in PCD and has been found to correlate with compromised Ciliary Beat Frequency (CBF). In this study we assessed the effect of increasing l-Arginine, as the substrate of NO synthases, on CBF in biopsies of human respiratory ciliated epithelium. METHODOLOGY: A total of 28 suspect cases with chronic respiratory manifestations referred for PCD diagnostic testing and 8 healthy controls underwent nasal brushing. Obtained epithelial cells were divided between three culture medium 199 solutions, containing different levels of l-Arginine (0.33 mM as baseline, 1 mM and 10 Mm as increased levels). CBF measurements were obtained at 37 °C and 25 °C at 1, 3 and 24 h after sample acquisition. RESULTS: Among a total of 36 recruited subjects, 8 had PCD confirmed (PCD n = 8), 20 had PCD excluded (non-PCD n = 20) and 8 were healthy controls (Healthy Controls = 8). Among PCD subjects, ciliary motility was characterized by rotational (n = 5) or dyskinetic (n = 3) beating. At 37 °C, compared to baseline, higher levels of l-Arginine resulted in up to 9% CBF increase at 1 h (p = 0.007), up to 9% CBF increase at 3 h (p < 0.001) and up to 12% CBF increase at 24 h (p = 0.002). Similar although smaller scale increases were recorded at 25 °C. The effect of l-Arginine was time dependent (interaction p = 0.002) and was similar in PCD patients, non-PCD chronic respiratory patients and healthy controls (interaction p = 0.800). CONCLUSIONS: l-Arginine increases CBF and merits to be evaluated as a potential stimulator of mucociliary clearance in chronic respiratory conditions and congenital ciliary disorders with residual motility. Larger human studies are needed to confirm these findings.

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.

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 primary ciliary dyskinesia in consecutive referrals of suspect cases and the transmission electron microscopy detection rate: a systematic review and meta-analysis.

Diagnostic testing for primary ciliary dyskinesia (PCD) usually includes transmission electron microscopy (TEM), nasal nitric oxide, high-speed video microscopy, and genetics. Diagnostic performance of each test should be assessed toward the development of PCD diagnostic algorithms. We systematically reviewed the literature and quantified PCD prevalence among referrals and TEM detection rate in confirmed PCD patients. Major electronic databases were searched until December 2015 using appropriate terms. Included studies described cohorts of consecutive PCD referrals in which PCD was confirmed by at least TEM and one additional test, in order to compare the index test performance with other test(s). Meta-analyses of pooled PCD prevalence and TEM detection rate across studies were performed. PCD prevalence among referrals was 32% (95% CI: 25-39%, I2 = 92%). TEM detection rate among PCD patients was 83% (95% CI: 75-90%, I2 = 90%). Exclusion of studies reporting isolated inner dynein arm defects as PCD, reduced TEM detection rate and explained an important fraction of observed heterogeneity (74%, 95% CI: 66-83%, I2 = 66%). Approximately, one third of referrals, are diagnosed with PCD. Among PCD patients, a significant percentage, at least as high as 26%, is missed by TEM, a limitation that should be accounted toward the development of an efficacious PCD diagnostic algorithm.