A Dietary Intervention in Adults with Overweight or Obesity Leads to Weight Loss Irrespective of Macronutrient Composition.

Obesity is a critical public health issue, necessitating effective weight loss interventions. While various dietary regimens have been explored, individual responses to interventions often vary. This study involved a 3-month dietary intervention aiming at assessing the role of macronutrient composition and the potential role of genetic predisposition in weight loss among Greek adults. This randomized clinical trial followed the CONSORT principles, recruiting 202 participants overall; 94 received a hypocaloric, high-protein diet and 108 received a high-carbohydrate, hypocaloric diet. Genetic predispositions were assessed through 10 target variants known for their BMI associations. Participants' weight and BMI values were recorded at baseline and post-intervention (n = 202 at baseline, n = 84 post-intervention) and an imputation method was applied to account for the observed missing values. Participants experienced a statistically significant weight loss across all dietary regimens (p < 0.001). Genetic analyses did not display statistically significant effects on weight loss. No significant differences in weight loss were observed between macronutrient groups, aligning with the POUNDS Lost and DIETFITS studies. This study underscores the importance of dietary interventions for weight loss and the potential contributions of genetic makeup. These findings contribute to obesity management within the Greek population and support the need for further research in personalized interventions.

The impact of an exercise and sport intervention on cognitive function and pain among forcibly displaced individuals at risk for PTSD: a secondary analysis of the SALEEM randomized controlled trial.

BACKGROUND: In response to the global scope of forced displacement, international organizations highlight the need of scalable solutions to support individuals' health and integration into host societies. Exposure to high mental and physical stress perceived before, during, and after displacement can impair functional capabilities, essential for adapting to a new environment. This secondary analysis examined the impact of an exercise and sport intervention on cognitive function and pain severity among individuals living in a refugee camp in Greece. METHODS: We implemented a randomized controlled trial involving n = 142 (52.8% women) forcibly displaced individuals from Southwest Asia and Sub-Saharan Africa. Participants were randomly assigned to a waitlist or a 10-week co-designed exercise and sport intervention with a 1:1 allocation rate between groups and sexes. Assessments at baseline and follow-up included the Flanker task, the Oddball paradigm, pain severity via visual analog scales, and the Åstrand-Rhyming indirect test of maximal oxygen uptake. We analyzed the intervention effects using structural equation modeling. RESULTS: Our findings did not indicate a direct intervention effect on cognitive function or pain (p ≥ .332). However, the intervention group significantly improved cardiorespiratory fitness, ß = .17, p = .010, which was associated with faster reaction times in cognitive tasks, ß = - .22, p = .004. Moreover, there was some evidence that adherence might be linked to reduced pain severity, ß = - .14, p = .065. CONCLUSIONS: Exercise and sport did not directly impact cognitive function and pain severity among a sociodemographically diverse sample living in a refugee camp, suggesting the need for complementary measures. Nevertheless, our results indicate that improvements in cardiorespiratory fitness benefit aspects of attention. TRIAL REGISTRATION: The study was approved by the local ethics committee of the University of Thessaly (no. 39) and registered prospectively on February 8, 2021 at the ISRCTN registry (no. 16291983).

Clinical Phenotyping for Prognosis and Immunotherapy Guidance in Bacterial Sepsis and COVID-19.

OBJECTIVES: It is suggested that sepsis may be classified into four clinical phenotypes, using an algorithm employing 29 admission parameters. We applied a simplified phenotyping algorithm among patients with bacterial sepsis and severe COVID-19 and assessed characteristics and outcomes of the derived phenotypes. DESIGN: Retrospective analysis of data from prospective clinical studies. SETTING: Greek ICUs and Internal Medicine departments. PATIENTS AND INTERVENTIONS: We analyzed 1498 patients, 620 with bacterial sepsis and 878 with severe COVID-19. We implemented a six-parameter algorithm (creatinine, lactate, aspartate transaminase, bilirubin, C-reactive protein, and international normalized ratio) to classify patients with bacterial sepsis intro previously defined phenotypes. Patients with severe COVID-19, included in two open-label immunotherapy trials were subsequently classified. Heterogeneity of treatment effect of anakinra was assessed. The primary outcome was 28-day mortality. MEASUREMENTS AND MAIN RESULTS: The algorithm validated the presence of the four phenotypes across the cohort of bacterial sepsis and the individual studies included in this cohort. Phenotype α represented younger patients with low risk of death, ß was associated with high comorbidity burden, and δ with the highest mortality. Phenotype assignment was independently associated with outcome, even after adjustment for Charlson Comorbidity Index. Phenotype distribution and outcomes in severe COVID-19 followed a similar pattern. CONCLUSIONS: A simplified algorithm successfully identified previously derived phenotypes of bacterial sepsis, which were predictive of outcome. This classification may apply to patients with severe COVID-19 with prognostic implications.

Prevalence of Neospora caninum and associated risk factors in semi-intensive female water buffaloes reared in Greece, using an ELISA kit on milk samples.

Neospora caninum is an apicomplexan (family: Sarcocystidae) protozoan parasite with a global distribution. In the N. caninum life cycle, dogs and other related canids are the definitive hosts, while other animals such as water buffaloes (Bubalus bubalis) constitute the intermediate host for this parasite. In many countries, the water buffalo is of high economic importance, providing valuable high-quality products for human needs. Although knowledge concerning the prevalence of this parasite in intermediate animal host populations is crucial, data from water buffalo are scarce. Keeping this in mind, the aim of this study was to examine the presence and assess the prevalence rates of N. caninum infection in water buffaloes in Northern Greece, where this animal husbandry sector started to raise, as well as to determine associated risk factors, with the application of a commercially available Neospora ISCOM ELISA test kit, developed for the detection of antibodies against N. caninum in milk samples The study was conducted during January-June 2023 in a total of 172 individual raw milk samples, collected from dairy buffaloes, reared under a semi extensive system, in three different farms. Information on the status of N. caninum infection in buffaloes from Greece was so far unknown with a lack of epidemiological or risk factors associated. For the detection of N. caninum, the commercially available Neospora ISCOM ELISA test kit (SANOVIR ®, Svanova Biotech AB, Uppsala, Sweden) was utilized. Results demonstrated the presence of N. caninum in water buffaloes from Greece for the first time. All positive N. caninum animal were asymptomatic, with absence of any disease signs. The overall prevalence of infection was 22.10%, whereas the main risk factors include the presence of dogs as well as the low biosecurity measures.

Towards the new primary care reform in Greece: a focus on patients' expectations, views and perceptions from rural healthcare centres.

INTRODUCTION: Patient perception of quality of care is an essential component in evaluating healthcare delivery. This article reports data from primary health care (PHC) centers before Greece's most recent PHC reform. The study was undertaken to offer some baseline information about patient experience, support the decision-making processes taking place, and provide valuable input for future policy-making comparisons in Greece. METHODS: The research was conducted across the 16 PHC centers of Epirus, a region of north-western Greece, from June to September 2017, with 532 patients rating the importance of different aspects of three main healthcare domains (clinical behavior, support and services, and organization of care) of PHC provision. The Greek version of the European Task Force on Patient Evaluations of General Practice (EUROPEP) questionnaire was implemented for research purposes. Univariate comparisons were performed for patients with and without chronic disease, using Pearson's χ2 test for categorical data. RESULTS: Study findings support that the organization of care domain is of highest importance and priority, with clinical behavior and support and services following closely. Among recruited patients, on average, only 2.1% of patients with a chronic disease were satisfied (rated 4 or 5 on the Likert scale) with the organization of care aspects under consideration, compared to 18.4% of patients without a chronic disease. Furthermore, only 4% of patients with a chronic disease were satisfied with the aspects examined in the clinical behavior domain, compared to 27% of patients without a chronic disease. Finally, 18% of sampled patients with a chronic disease reported being satisfied with the quality of support and services provided, compared to 38% of patients without a chronic disease. CONCLUSION: It is necessary to back up available past information to afterwards estimate reform imprinting on expectations and perceptions. The items and aspects of EUROPEP, in line with the new tasks of the personal doctor within the PHC system that patients perceive as most essential, can be used to prioritize quality improvement activities to strengthen PHC delivery in Greece. Communication skills, practices, and behavioral change skills seem to need more attention for an efficient PHC model.

Oral health among refugees and asylum seekers utilizing Médecins du Monde clinics in mainland Greece, 2016-2017.

BACKGROUND: The oral health of refugees and asylum seekers is understudied. However, oral health has important implications for overall health and wellbeing. This study addresses this gap by characterizing oral health care utilization in Médecins du Monde (MdM) clinics across mainland Greece from 2016 - 2017. METHODS: A retrospective cross-sectional study design was used to estimate proportional morbidities for caries, extraction, developmental, periodontal disease, preventive, and other oral health outcomes. The association between physical health conditions and consultations of interest - upper respiratory tract infections (URTIs) and reproductive health consultations - and oral health were compared using odds ratios (OR) and 95% confidence intervals (CIs). Oral health outcomes between Afghans and Syrians were compared using odds ratios and 95% CIs. RESULTS: Caries (39.44%) and extractions (28.99%) were highly prevalent in our study population. The utilization of preventive dental consultations (37.10%) was high, particularly among males. Individuals with at least one upper respiratory tract infection (OR = 1.52; 95% CI: 1.30 - 1.77; Or = 1.90; 95% CI: 1.53 - 2.36) and women and girls with reproductive health consultations (OR = 1.30; 95% CI: 1.03 - 1.66; OR = 2.03; 95% CI: 1.49 - 2.76) were more likely to have any dental or caries specific consultations. The observed patterns in oral health needs differed between Afghans and Syrians, with Afghans more likely to have preventive screenings and less likely to have caries, extractions, or other conditions. CONCLUSIONS: Displaced populations utilizing MdM dental clinics had high levels of oral health needs, particularly for caries and extractions. The connection between oral and overall health was seen in the study population, and these findings reinforce the public health importance of oral health for improving health and wellbeing of displaced populations. Evidence-informed policy, practice, and programming inclusive of oral health are needed to address both oral and overall health of refugees and asylum seekers in Greece. Future research should investigate not only oral health care needs but also knowledge and beliefs that inform utilization patterns among displaced populations.

Investigating the role of source and source trust in prebunks and debunks of misinformation in online experiments across four EU countries.

Misinformation surrounding crises poses a significant challenge for public institutions. Understanding the relative effectiveness of different types of interventions to counter misinformation, and which segments of the population are most and least receptive to them, is crucial. We conducted a preregistered online experiment involving 5228 participants from Germany, Greece, Ireland, and Poland. Participants were exposed to misinformation on climate change or COVID-19. In addition, they were pre-emptively exposed to a prebunk, warning them of commonly used misleading strategies, before encountering the misinformation, or were exposed to a debunking intervention afterwards. The source of the intervention (i.e. the European Commission) was either revealed or not. The findings show that both interventions change four variables reflecting vulnerability to misinformation in the expected direction in almost all cases, with debunks being slightly more effective than prebunks. Revealing the source of the interventions did not significantly impact their overall effectiveness. One case of undesirable effect heterogeneity was observed: debunks with revealed sources were less effective in decreasing the credibility of misinformation for people with low levels of trust in the European Union (as elicited in a post-experimental questionnaire). While our results mostly suggest that the European Commission, and possibly other public institutions, can confidently debunk and prebunk misinformation regardless of the trust level of the recipients, further evidence on this is needed.

The use of minimum common data set in the development of the Greek Fragility Hip Fracture Registry in the Greek health care setting: the first year of its pilot implementation.

The first Fragility Hip Fracture Registry has been established in Greece. The in-hospital length of stay was 10.8 days and was significantly influenced by the delayed surgical fixation. The increased age, the higher ASA grade, and the male gender influenced negatively the 30-day mortality, which reached 7.5%. BACKGROUND: The increased incidence of fragility hip fractures constitutes a great challenge to the health care professionals and causes a significant burden on national health care systems around the globe. Fragility hip fracture registries have been used in many countries in order to document the cotemporary situation in each country and to identify potential weaknesses of the local health care systems. AIM: The aim of the herein study is to present the results of the pilot implementation of the first fragility hip fracture registry in Greece, which was developed by the Greek Chapter of Fragility Fracture Network (FFN Gr), and use the neural networks in the analysis of the results. MATERIALS AND METHODS: Seven orthopaedic departments from six different hospitals in Greece participated in the present pilot study. All fragility hip fractures from September 2022 until December 2023 were prospectively collected and documented using a central database. For this purpose, the 22 points of minimum common data set, proposed by the Global Fragility Fracture Network, with the addition of the 30-day mortality was used. RESULTS: A total of 1009 patients who sustained a fragility hip fracture were included in the study. The mean age of the cohort was 82.2 ± 8.6 years with the majority of patients being female (72%). Sixty percent (60%) of the patients had an extracapsular hip fracture, with a mean ASA grade 2.6 ± 0.8. Intramedullary nailing and hip hemiarthroplasty were the surgical treatments of choice in the majority of extra- and intra-capsular hip fractures respectively. The mean hospital length of stay of the patients was 10.8 ± 8.5 days, and the 30-day mortality was 7.5%. The multivariant analysis revealed that the age, the ASA grade and the male gender had a significant contribution to the 30-day mortality. The neural network model had a significant under-the-curve predictive value (0.778), with age being the most important predictive factor. The length of stay was significantly influenced only by the delayed surgical fixation (more than 36 h from admission). CONCLUSIONS: The present pilot study provides evidence that establishing a fragility hip fracture registry in Greece is feasible and demonstrates that the minimum common data set can be used as the base of any new registry. In Greece, patients with a fragility hip fracture stay in the hospital for approximately 11 days and have 7.5% 30-day mortality. Unfortunately, due to the logistics of the public healthcare system, they do not receive surgical fixation in a timely manner, which is a factor that negatively affects their length of in-hospital stay.

Effect of SARS-CoV-2 shedding rate distribution of individuals during their disease days on the estimation of the number of infected people. Application of wastewater-based epidemiology to the city of Thessaloniki, Greece.

During the COVID-19 pandemic, wastewater-based epidemiology has proved to be an important tool for monitoring the spread of a disease in a population. Indeed, wastewater surveillance was successfully used as a complementary approach to support public health monitoring schemes and decision-making policies. An essential feature for the estimation of a disease transmission using wastewater data is the distribution of viral shedding rate of individuals in their personal human wastes as a function of the days of their infection. Several candidate shapes for this function have been proposed in literature for SARS-CoV-2. The purpose of the present work is to explore the proposed function shapes and examine their significance on analyzing wastewater SARS-CoV-2 shedding rate data. For this purpose, a simple model is employed applying to medical surveillance and wastewater data of the city of Thessaloniki during a period of Omicron variant domination in 2022. The distribution shapes are normalized with respect to the total virus shedding and then their basic features are investigated. Detailed analysis reveals that the main parameter determining the results of the model is the difference between the day of maximum shedding rate and the day of infection reporting. Since the latter is not part of the distribution shape, the major feature of the distribution affecting the estimation of the number of infected people is the day of maximum shedding rate with respect to the initial infection day. On the contrary, the duration of shedding (total number of disease days) as well as the exact shape of the distribution are by far less important. The incorporation of such wastewater surveillance models in conventional epidemiological models - based on recorded disease transmission data- may improve predictions for disease spread during outbreaks.

Source apportionment of particle-bound polycyclic aromatic hydrocarbons (PAHs), oxygenated PAHs (OPAHs), and their associated long-term health risks in a major European city.

Many studies have drawn attention to the associations of oxygenated polycyclic aromatic hydrocarbons (OPAHs) with harmful health effects, advocating for their systematic monitoring alongside simple PAHs to better understand the aerosol carcinogenic potential in urban areas. To address this need, this study conducted an extensive PM2.5 sampling campaign in Athens, Greece, at the Thissio Supersite of the National Observatory of Athens, from December 2018 to July 2021, aiming to characterize the levels and variability of polycyclic aromatic compounds (PACs), perform source apportionment, and assess health risk. Cumulative OPAH concentrations (Σ-OPAHs) were in the same range as Σ-PAHs (annual average 4.2 and 5.6 ng m-3, respectively). They exhibited a common seasonal profile with enhanced levels during the heating seasons, primarily attributed to residential wood burning (RWB). The episodic impact of biomass burning was also observed during a peri-urban wildfire event in May 2021, when PAH and OPAH concentrations increased by a factor of three compared to the monthly average. The study period also included the winter 2020-2021 COVID-19 lockdown, during which PAH and OPAH levels decreased by >50 % compared to past winters. Positive matrix factorization (PMF) source apportionment, based on a carbonaceous aerosol speciation dataset, identified PAC sources related to RWB, local traffic (gasoline vehicles) and urban traffic (including diesel emissions), as well as an impact of regional organic aerosol. Despite its seasonal character, RWB accounted for nearly half of Σ-PAH and over two-thirds of Σ-OPAH concentrations. Using the estimated source profiles and contributions, the source-specific carcinogenic potency of the studied PACs was calculated, revealing that almost 50 % was related to RWB. These findings underscore the urgent need to regulate domestic biomass burning at a European level, which can provide concrete benefits for improving urban air quality, towards the new stricter EU standards, and reducing long-term health effects.

Implication of Apolipoprotein E gene variants in pediatric-onset multiple sclerosis: Possible association with disease susceptibility and its clinical characteristics, in a Hellenic cohort.

BACKGROUND: Apolipoprotein E (ApoE) plays a major role in lipid homeostasis and myelination in the central nervous system. Although ApoE gene variants have been linked with cognitive impairment in the setting of Multiple sclerosis (MS), no association with disease susceptibility was found, while similar studies in pediatric-onset MS (POMS) are limited. OBJECTIVE: This study aims to explore the role of ApoE gene variants in the POMS susceptibility of a Hellenic cohort and any association with disease features. METHODS: 112 POMS, fulfilling the revised IPMSSG 2013 criteria, 391 adult-onset MS (AOMS) and 200 healthy controls (HCs), were enrolled. After DNA extraction, ApoE genotyping was performed by a polymerase chain reaction and sequence-specific-oligonucleotide technique. RESULTS: ApoE2/E3 genotype and ApoE2 allele were found to be significantly more frequent among POMS patients compared to HCs [(20.5% vs 11 %, OR [95 %]: 2.1 (1.1-4.0), p = 0.03)], and [(11% vs 5.3 %, OR [95 %]: 2.3 (1.2-4.1), p = 0.01)], respectively. Additionally, significantly lower frequencies of the ApoE3/E3 genotype and the ApoE3 allele were observed in POMS patients compared to HCs (59.8% vs 79 %, OR [95 %]:0.40 (0.24-0.65), p = 0.0005 and 79% vs 89 % 0.46, OR [95 %]: (0.30-0.73), p = 0.001)], respectively. CONCLUSIONS: The ApoE2 allele may represent a novel risk factor for POMS development.

First detection of Cupriavidus gilardii in a bovine neonatal diarrhea outbreak.

BACKGROUND: Cupriavidus gilardii is an aerobic, gram-negative, motile, glucose-nonfermenting bacillus, first described in 1999. Typically, it exhibits low pathogenicity in humans, causing opportunistic infections primarily in individuals with compromised immune systems. This bacterium has been also found in various environmental sources such as plants and contaminated soils. Notably, there have been no documented cases of C. gilardii infections in animals. CASE PRESENTATION: This case report outlines a bovine neonatal diarrhea outbreak that occurred in Northern Greece, during which C. gilardii was isolated. Faecal samples from 5-day-old calves were collected and transported to the laboratory for further examination. Bacterial culture and next generation sequencing techniques were employed to confirm the presence of this bacterium in the samples. Following the isolation and identification of C. gilardii from the samples, an autogenous vaccine was produced and administered to the cows within the farm. Subsequent to vaccination, a progressive reduction in calf diarrhea and deaths was observed, leading to their eventual complete resolution. To the best of our knowledge, this represents the first documentation of C. gilardii isolation from cases of bovine neonatal diarrhea. CONCLUSION: This case report presents the first isolation case of C. gilardii from animal samples and more specifically from calf faecal samples. It represents an important observation, providing evidence that this opportunistic human pathogen could contribute to clinical symptoms in animals.

Drivers and Barriers Influencing Adherence to the Mediterranean Diet: A Comparative Study across Five Countries.

Given the global decline in adherence to the Mediterranean Diet (MD), even within its native region, it is key to identify the factors influencing this trend to mitigate the negative health outcomes associated with westernized diets. To this end, 4025 individuals (49.6% women, 42.6 ± 14.2 y/o) from Greece, Italy, Morocco, Slovenia, and Tunisia remotely completed a series of measures assessing motives, attitudes, and psychosocial factors related to MD adherence, which was evaluated using the MEDAS questionnaire. The results suggested medium-to-low adherence across all countries, with the highest adherence in Italy and Morocco and the lowest in Slovenia. Structural equation modeling revealed that positive attitudes toward the healthiness of food were the strongest predictors of adherence, whereas picky eating was a significant negative predictor in all countries except Greece. Adherence to the MD was positively influenced by health motivations in Morocco and weight control in Slovenia and Greece, while sensory appeal negatively influenced adherence in Italy. Additionally, price and convenience were significant barriers in Tunisia and Greece, whereas a preference for local and seasonal foods promoted adherence in Morocco and Greece. Overall, our findings underscore the need for country-specific interventions and policies that address distinct local factors and motivations to ease favorable shifts in dietary patterns toward MD principles.

Alpine viper in changing climate: thermal ecology and prospects of a cold-adapted reptile in the warming Mediterranean.

In a rapidly changing thermal environment, reptiles are primarily dependent on in situ adaptation because of their limited ability to disperse and the restricted opportunity to shift their ranges. However, the rapid pace of climate change may surpass these adaptation capabilities or elevate energy expenditures. Therefore, understanding the variability in thermal traits at both individual and population scales is crucial, offering insights into reptiles' vulnerability to climate change. We studied the thermal ecology of the endangered Greek meadow viper (Vipera graeca), an endemic venomous snake of fragmented alpine-subalpine meadows above 1600 m of the Pindos mountain range in Greece and Albania, to assess its susceptibility to anticipated changes in the alpine thermal environment. We measured preferred body temperature in artificial thermal gradient, field body temperatures of 74 individuals in five populations encompassing the entire geographic range of the species, and collected data on the available of temperatures for thermoregulation. We found that the preferred body temperature (Tp) differed only between the northernmost and the southernmost populations and increased with female body size but did not depend on sex or the gravidity status of females. Tp increased with latitude but was unaffected by the phylogenetic position of the populations. We also found high accuracy of thermoregulation in V. graeca populations and variation in the thermal quality of habitats throughout the range. The overall effectiveness of thermoregulation was high, indicating that V. graeca successfully achieves its target temperatures and exploits the thermal landscape. Current climatic conditions limit the activity period by an estimated 1278 h per year, which is expected to increase considerably under future climate scenarios. Restricted time available for thermoregulation, foraging and reproduction will represent a serious threat to the fitness of individuals and the persistence of populations in addition to habitat loss due to mining, tourism or skiing and habitat degradation due to overgrazing in the shrinking mountaintop habitats of V. graeca.

The earliest evidence of large animal fossil collecting in mainland Greece at Bronze Age Mycenae.

Fossils of large animals have long influenced social practices and ideologies in human societies, including the fantastic myths of giants, heroes, and gods in ancient Greece. It has been estimated that purposeful fossil collecting in Greece began in the Late Bronze Age. However, previous archaeological finds of fossils from mainland Greece were not well documented in secure contexts that dated this far back in time. Herein, we present a newly recognized fossilized astragalus bone recently found in the legacy collections of the archaeological site of Mycenae. It was originally recovered by excavations in the 1970s and recently reanalyzed at the Mycenae Museum. Our analysis explored the available evidence of the find location, the state of fossil preservation, and the species represented. The results suggest that a fossilized rhinoceros (Stephanorhinus) astragalus was collected in the past, possibly from afar. Evidence indicates it was brought to Mycenae, where it was deposited near an interesting array of artifacts in a basement storage area of the Southwest Quarter, sometime in the thirteenth century BCE. This find represents the earliest secure evidence of large animal fossil use by people in mainland Greece, dating to the Late Bronze Age.

ENhancinG vAGinal dElivery in Greece through educational and behavioral interventions among maternity care providers regarding labor management: the ENGAGE stepped-wedge randomized prospective trial protocol.

BACKGROUND: There is an emerging need to systematically investigate the causes for the increased cesarean section rates in Greece and undertake interventions so as to substantially reduce its rates. To this end, the ability of the participating Greek obstetricians to follow evidence-based guidelines and respond to other educational and behavioral interventions while managing labor will be explored, along with barriers and enablers. Herein discussed is the protocol of a stepped-wedge designed intervention trial in Greek maternity units with the aforementioned goals in mind, named ENGAGE (ENhancinG vAGinal dElivery in Greece). METHODS: Twenty-two selected maternity units in Greece will participate in a multicenter stepped-wedge randomized prospective trial involving 20,000 to 25,000 births, with two of them entering the intervention period of the study each month (stepped randomization). The maternity care units entering the study will apply the suggested interventions for a period of 8-18 months depending on the time they enter the intervention stage of the study. There will also be an initial phase of the study lasting from 8 to 18 months including observation and recording of the routine practice (cesarean section, vaginal birth, and maternal and perinatal morbidity and mortality) in the participating units. The second phase, the intervention period, will include such interventions as the application of the HSOG (the Hellenic Society of Obstetrics and Gynecology) Guidelines on labor management, training on the correct interpretation of cardiotocography, and dealing with emergencies in vaginal deliveries, while the steering committee members will be available to discuss and implement organizational and behavioral changes, answer questions, clarify relevant issues, and provide practical instructions to the participating healthcare professionals during regular visits or video conferences. Furthermore, during the study, the results will be available for the participating units in order for them to monitor their own performance while also receiving feedback regarding their rates. Τhe final 2-month phase of the study will be devoted to completing follow-up questionnaires with data concerning maternal and neonatal morbidities that occurred after the completion of the intervention period. The total duration of the study is estimated at 28 months. The primary outcome assessed will be the cesarean section rate change and the secondary outcomes will be maternal and neonatal morbidity and mortality. DISCUSSION: The study is expected to yield new information on the effects, advantages, possibilities, and challenges of consistent clinical engagement and implementation of behavioral, educational, and organizational interventions described in detail in the protocol on cesarean section practice in Greece. The results may lead to new insights into means of improving the quality of maternal and neonatal care, particularly since this represents a shared effort to reduce the high cesarean section rates in Greece and, moreover, points the way to their reduction in other countries. TRIAL REGISTRATION: NCT04504500 (ClinicalTrials.gov). The trial was prospectively registered. Ethics Reference No: 320/23.6.2020, Bioethics and Conduct Committee, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece.