Adherence to facemask use in public places during the autumn-winter 2020 COVID-19 lockdown in Greece: observational data.

BACKGROUND: Wearing facemasks is of proven efficacy as a public health protective measure against COVID-19. Currently there are no observational data concerning the wearing of facemasks and the adherence to guidelines concerning their handling. METHODS: Registration of the way passers-by were wearing facemasks at 26 different locations of five major cities in Greece. The results were correlated with the rate of COVID-19 deaths in the region. RESULTS: In total, 119,433 passers-by were registered, 57,043 females (47.8%) and 62,390 males (52.2%). From the total sample, 81.1% were wearing the mask properly, 10.8% had their nose out, 6.2% were wearing it under the jaw, and 1.9% had no mask at all . There was a significant difference between males and females concerning any use of mask. Inappropriate use of was correlated with COVID-19 death rate in the studied region. CONCLUSION: Our findings suggest that under conditions of mandatory wearing and in central locations of major cities, during walking, proper use of masks is suboptimal, but still contributes with some protection. Fear and risk perception seem to be strong factors contributing to adherence to proper mask wearing.

Evaluation of the Efficiency in Public Health Centers in Greece Regarding the Human Resources Occupied: A Bootstrap Data Envelopment Analysis Application.

In this paper, the overall efficiency of health centers in Greece is measured by applying the input-oriented model of Data Envelopment Analysis. In addition, four different models were subjected to the input-oriented Data Envelopment Analysis to investigate the contribution of each category of human resources to the efficiency results of the health centers. The bootstrap technique was performed to generate confidence intervals for the models. Data for 155 health centers in Greece were provided by the Ministry of Health. The health centers submitted in the analysis obtained an average efficiency value of 0.932. The average results of the partial models in terms of each input show that the efficiency values achieved by the health centers are mostly influenced by the number of physicians and the number of managers employed. The second factor influencing the efficiency values of the health centers are the number of nursing staff occupied in the health centers. Non-medical staff employed in the health centers had the least contribution to the efficiencies measured. This paper provides important information for the stakeholders and the Government of Greece so as to better allocate the personnel employed in primary health care according to the efficiencies attained by the health centers.

SARS-CoV-2 Sero-Surveillance in Greece: Evolution over Time and Epidemiological Attributes during the Pre-Vaccination Pandemic Era.

BACKGROUND: Nation-wide SARS-CoV-2 seroprevalence surveys provide valuable insights into the course of the pandemic, including information often not captured by routine surveillance of reported cases. METHODS: A serosurvey of IgG antibodies against SARS-CoV-2 was conducted in Greece between March and December 2020. It was designed as a cross-sectional survey repeated at monthly intervals. The leftover sampling methodology was used and a geographically stratified sampling plan was applied. RESULTS: Of 55,947 serum samples collected, 705 (1.26%) were found positive for anti-SARS-CoV-2 antibodies, with higher seroprevalence (9.09%) observed in December 2020. Highest seropositivity levels were observed in the "0-29" and "30-49" year age groups. Seroprevalence increased with age in the "0-29" age group. Highly populated metropolitan areas were characterized with elevated seroprevalence levels (11.92% in Attica, 12.76% in Thessaloniki) compared to the rest of the country (5.90%). The infection fatality rate (IFR) was estimated at 0.451% (95% CI: 0.382-0.549%) using aggregate data until December 2020, and the ratio of actual to reported cases was 9.59 (7.88-11.33). CONCLUSIONS: The evolution of seroprevalence estimates aligned with the course of the pandemic and varied widely by region and age group. Young and middle-aged adults appeared to be drivers of the pandemic during a severe epidemic wave under strict policy measures.

Behavioral and Cultural Insights, a Nationwide Study Based on Repetitive Surveys of WHO Behavioral Insights Tool in Greece Regarding COVID-19 Pandemic and Vaccine Acceptance.

Monitoring behavioral and cultural insights during the pandemic is a useful tool to identify factors related to COVID-19 vaccine acceptance and confront the pandemic's vast impact. Data were collected using a questionnaire designed according to the "survey tool and guidance" provided by the World Health Organization (WHO). Surveys were conducted by a market research company for five consecutive months, with a sample of 1000 individuals recruited per survey. Vaccination acceptance increased from 55.2% to 67.2%, while the percentage of undecisive individuals decreased from 16.3% to 10.6%. The proportion of vaccine resistant participants remained relatively steady (25−30%). Knowledge about the pandemic and compliance with preventive measures was high (>90%). Factors associated with vaccination included: Increased age, male gender, influenza vaccination, following authorities' recommendations, being informed by HCWs or formal information sources, care for others, concern about the country's economic recession and health system overload. Pandemic fatigue was reflected across the surveys, indicated by a decrease in the intention to self-isolate and remain at home when ill. Despite the decrease of undecisive individuals, a firm core of vaccine resistant individuals may be responsible for the relatively lower vaccine coverage compared to northern EU countries. Study results could be useful for developing approaches tailored to a reluctant population.

Emotional intelligence scores in children and adolescents with subclinical hypothyroidism-correlation with serum serotonin and thyroid-stimulating hormone (TSH) concentrations.

INTRODUCTION: Thyroxine is essential for nervous system development. Subclinical hypothyroidism (SCH), also known as mild thyroid failure, is associated with impaired cognitive function in children and mood disorders in adults. Serotonin is also involved in brain development as well as in mood and behavior modulation. The possible interaction between thyroid function tests, serum serotonin concentrations, and emotional intelligence (EI) was studied. METHODS: A total of 224 schoolchildren from the Peloponnese, Greece, aged 11-19, were included in the study, of whom 26.3% had SCH. Emotional quotients (EQ), such as well-being, self-control, emotionality, and sociability, were assessed using the TEIQue-ASF questionnaire, and TSH, fT4, and serum serotonin concentrations were also evaluated. RESULTS: Children and adolescents with SCH had a lower EQ total score (p < 0.001), EQ well-being score (p = 0.025), EQ self-control score (p = 0.029), EQ emotionality score (p = 0.029), and EQ sociability score (p = 0.010) and lower serum serotonin concentrations (p < 0.001). CONCLUSIONS: Children and adolescents with SCH exhibited lower EI scores and lower serum serotonin concentrations when compared with age-matched healthy controls.

Mental health and conspirasism in health care professionals during the spring 2020 COVID-19 lockdown in Greece.

INTRODUCTION: The aim of the study was to investigate mental health and conspiracy theory beliefs concerning COVID-19 among health care professionals (HCPs). MATERIAL AND METHODS: During lockdown, an online questionnaire gathered data from 507 HCPs (432 females aged 33.86 ± 8.63 and 75 males aged 39.09 ± 9.54). STATISTICAL ANALYSIS: A post-stratification method to transform the study sample was used; descriptive statistics were calculated. RESULTS: Anxiety and probable depression were increased 1.5-2-fold and were higher in females and nurses. Previous history of depression was the main risk factor. The rates of believing in conspiracy theories concerning the COVID-19 were alarming with the majority of individuals (especially females) following some theory to at least some extend. CONCLUSIONS: The current paper reports high rates of depression, distress and suicidal thoughts in the HCPs during the lockdown, with a high prevalence of beliefs in conspiracy theories. Female gender and previous history of depression acted as risk factors, while the belief in conspiracy theories might act as a protective factor. The results should be considered with caution due to the nature of the data (online survey on a self-selected but stratified sample).

Total productivity change of Health Centers in Greece in 2016-2018: a Malmquist index data envelopment analysis application for the primary health system of Greece.

BACKGROUND: This paper attempts to evaluate the primary health care system by evaluating health centres in Greece. METHODS: Malmquist Index Data Envelopment Analysis is applied to study the total productivity of 155 health centres in Greece during 2016-2018. The data were collected from the Ministry of Health and submitted to quality tests to ensure validity and avoid bias. RESULTS: This paper measures the productivity of each of the 155 health centres in Greece and how it shifted during 2016-2018. In addition, the overall productivity change of the 155 health centres over time is calculated and analysed as being due to technical efficiency or technological efficiency. The analysis of the mean values showed a decrease of 0.9% in the overall productivity factor from 2016 to 2017 and a decrease of 5.2% from 2017 to 2018. The overall decrease in the productivity of the 155 health centres was 3.1%. From 2016 to 2018, 59 health centres changed their productivity mainly due to technological change and 91 changed mainly due to technical efficiency change. One health centre showed regression to its total productivity due to equal regression of its technical efficiency and technology. CONCLUSIONS: The method used is nonparametric data envelopment analysis along with the Malmquist index to include panel data in the analysis. Meaningful results were extracted by indicating the number of health centres that improved their productivity, regressed in productivity, or remained constant through the period 2016-2018. This paper may contribute to improving health centres' efficiency and productivity. Furthermore, valuable results can be extracted for the National Health Care System to match available resources that correspond to each health centre's needs, as well as for manager planners and stakeholders in primary health care.

Factors Associated with Healthcare Workers' (HCWs) Acceptance of COVID-19 Vaccinations and Indications of a Role Model towards Population Vaccinations from a Cross-Sectional Survey in Greece, May 2021.

A Knowledge, Attitudes and Practices (KAP) study was conducted at the end of May 2021 engaging 1456 healthcare workers (HCWs) from 20 hospitals throughout Greece. Acceptance of vaccination against coronavirus disease 2019 (COVID-19) was estimated at 77.7%, with lower vaccine acceptance identified in nurses compared to physicians. Fears related to vaccine safety, lack of information and general knowledge about vaccinations, influenza vaccine acceptance, education level and years of practice were among the factors independently associated with vaccine acceptance. A strong association was identified between vaccination of HCWs in each health region and the population coverage, indicating that HCWs may be role models for the general population. Information campaigns should continue despite decisions taken regarding mandatory vaccinations.

Repeated Leftover Serosurvey of SARS-CoV-2 IgG Antibodies in Greece, May to August 2020.

A serosurvey of IgG antibodies against SARS-CoV-2 was conducted in Greece between May and August 2020. It was designed as a cross-sectional survey and was repeated at monthly intervals. The leftover sampling methodology was used and a geographically stratified sampling plan was applied. Of 20,110 serum samples collected, 89 (0.44%) were found to be positive for anti-SARS-CoV-2 antibodies, with higher seroprevalence (0.35%) observed in May 2020. The highest seroprevalence was primarily observed in the "30-49" year age group. Females presented higher seroprevalence compared to males in May 2020 (females: 0.58% VS males: 0.10%). This difference reversed during the study period and males presented a higher proportion in August 2020 (females: 0.12% VS males: 0.58%). Differences in the rate of seropositivity between urban areas and the rest of the country were also observed during the study period. The four-month infection fatality rate (IFR) was estimated to be 0.47%, while the respective case fatality rate (CFR) was at 1.89%. Our findings confirm low seroprevalence of COVID-19 in Greece during the study period. The young adults are presented as the most affected age group. The loss of the cumulative effect of seropositivity in a proportion of previous SARS-CoV-2 infections was indicated.

Molecular Epidemiology of SARS-CoV-2 in Greece Reveals Low Rates of Onward Virus Transmission after Lifting of Travel Restrictions Based on Risk Assessment during Summer 2020.

The novel coronavirus severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) spread rapidly during the first months of 2020 and continues to expand in multiple areas across the globe. Molecular epidemiology has provided an added value to traditional public health tools by identifying SARS-CoV-2 clusters or providing evidence that clusters based on virus sequences and contact tracing are highly concordant. Our aim was to infer the levels of virus importation and to estimate the impact of public health measures related to travel restrictions to local transmission in Greece. Our phylogenetic and phylogeographic analyses included 389 full-genome SARS-CoV-2 sequences collected during the first 7 months of the pandemic in Greece and a random collection in five replicates of 3,000 sequences sampled globally, as well as the best hits to our data set identified by BLAST. Phylogenetic trees were reconstructed by the maximum likelihood method, and the putative source of SARS-CoV-2 infections was inferred by phylogeographic analysis. Phylogenetic analyses revealed the presence of 89 genetically distinct viruses identified as independent introductions into Greece. The proportion of imported strains was 41%, 11.5%, and 8.8% during the three periods of sampling, namely, March (no travel restrictions), April to June (strict travel restrictions), and July to September (lifting of travel restrictions based on thorough risk assessment), respectively. The results of phylogeographic analysis were confirmed by a Bayesian approach. Our findings reveal low levels of onward transmission from imported cases during summer and underscore the importance of targeted public health measures that can increase the safety of international travel during a pandemic. IMPORTANCE Our study based on current state-of-the-art molecular epidemiology methods suggests that virus screening and public health measures after the lifting of travel restrictions prevented SARS-CoV-2 onward transmission from imported cases during summer 2020 in Greece. These findings provide important data on the efficacy of targeted public health measures and have important implications regarding the safety of international travel during a pandemic. Our results can provide a roadmap about prevention policy in the future regarding the reopening of borders in the presence of differences in vaccination coverage, the circulation of the virus, and the presence of newly emergent variants across the globe.

COVID-19 Outbreak on a Passenger Ship and Assessment of Response Measures, Greece, 2020.

We describe response measures to an outbreak involving 128 (33.4%) coronavirus disease cases (46.1% asymptomatic) among 383 persons onboard a passenger ship. Multivariate analysis indicated that dining in certain rooms and bar areas, nationality, working department (for crew members), and quarantining onboard the ship were significantly associated with infection.

Transmission Dynamics of SARS-CoV-2 during an Outbreak in a Roma Community in Thessaly, Greece-Control Measures and Lessons Learned.

A COVID-19 outbreak occurred among residents of a Roma settlement in Greece (8 April-4 June 2020). The aim of this study was to identify factors associated with an increased risk of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and to evaluate the effectiveness of control measures implemented. Data were analyzed from individuals that were tested for SARS-CoV-2 during contact tracing, population screening or hospital visits. RT-PCR was used for the detection of SARS-CoV-2 in oropharyngeal samples. Risk factors for household secondary attack rates (SAR) and hospitalization with COVID-19 were examined using chi-square tests, Fisher's exact tests and logistic regression analyses. During the outbreak, 142 cases, 20 hospitalizations and 1 death were recorded, with a total of 2273 individuals tested. The risk of hospitalization was associated with age (OR: 1.04, 95% CI: 1.02-1.07) and Cycle threshold (Ct) values (OR for a decrease in Ct values by 1: 1.18, 95% CI: 1.07-1.31). Household SAR was estimated at 38.62% (95% CI: 32.50-45.01%). After the designation of an isolation facility for cases, household SAR declined from 74.42% to 31.03%. Household size was associated with the risk of infection (OR: 2.65, 95% CI: 1.00-7.07). The presence of COVID-19 symptoms among index cases was correlated with higher transmission (OR: 23.68, 95% CI 2.21-253.74) in multivariate analysis, while age was found to be associated with SAR only in univariate analysis. Roma communities can be particularly vulnerable to the spread of SARS-CoV-2. In similar settings, symptomatic cases are more important transmitters of SARS-CoV-2. Within these communities, immediate measures should be implemented to mitigate disease spread.

Incidence of Deep Vein Thrombosis and Its Effect on Health-Related Quality of Life Among Nurses of Greek Public Hospitals: A Multicenter Study.

BACKGROUND: Vein thrombosis (VTE) is a collective term for deep vein thrombosis (DVT) and pulmonary embolism (PE). The aim of this study was to investigate the impact of DVT and its association with health-related quality of life among Greek nurses. METHODS: This is a multicenter descriptive correlation study. The sample of the study was nursing staff working in Greek public hospitals. The diagnosis of DVT was set by Hicks's clinical criteria. RESULTS: The study included 6304 nurses with a mean age of 47.4 ± 4.9 years. Diagnosed by a physician, DVT had 544 (8.6%) participants. The mean score of the overall dimension of physical health-related quality of life was 68.1 ± 21.9 and the overall score of mental health scale was 53.3 ± 10.4. The odds of DVT occurrence increased dramatically for female gender (CI: 27.76, 95% CI: 8.12-94.89, p = 0.001). Increased odds were found also for advanced age (CI: 1.21, 95% CI: 1.09-1.33, p = 0.001), advanced BMI (CI: 1.06, 95% CI: 1.02-1.10, p = 0.001), and smoking (CI: 2.72, 95% CI: 1.51-4.90, p = 0.001). Moreover, previous pregnancy (CI: 1.66, 95% CI: 1.21-2.29, p = 0.002), work experience (CI: 1.13, 95% CI: 1.03-1.23, p = 0.008), and Rhesus (CI: 2.55, 95% CI: 1.11-5.84, p = 0.027) were found to be risk factors for DVT. CONCLUSIONS: Nurses are potentially a professional group for developing deep vein thrombosis, and given the high incidence found in this study, as well as the lower proportion of nurses who were undiagnosed while meeting the clinical criteria of Hick, it is essential for nurses to check their lower extremities for DVT annually.

Self-reported changes in anxiety, depression and suicidality during the COVID-19 lockdown in Greece.

INTRODUCTION: There are only a few published empirical data on COVID-19's effects on the mental health. MATERIAL AND METHODS: During lockdown, an online questionnaire registered demographic, health data, previous psychiatric history, current anxiety, depression and suicidality, believing in conspiracy theories and other domains. Data from 3399 persons were used (81.08% females; aged 34.02 ± 9.72 and 18.27% males; aged 36.38±10.33). Distress and clinical depression were identified with the use of cut-off and a previously developed algorithm respectively. STATISTICAL ANALYSIS: A post-stratification method was used; descriptive statistics were calculated. Chi-square tests, multiple forward stepwise linear regression analyses and Factorial Analysis of Variance (ANOVA) tested relations among variables. RESULTS: Clinical depression was present in 9.31% of the stratified sample, while 8.5% had severe distress; increased anxiety was present in more than 45%. Suicidal thoughts increased in 10.40% and decreased in 4.42%. Beliefs in conspiracy theories were widely prevalent; at least half of cases were following various misconceptions. A model for the development of depression was created with general health status, previous history of depression, self-harm and suicidal attempts, family responsibility, economic change, and age acting as risk factors, while keeping a daily routine, pursuing religiousness/spirituality, and believing in conspiracy theories acting as protective factors. CONCLUSIONS: The model developed here revealed multiple vulnerabilities and an interplay leading from simple anxiety to clinical depression and suicidality through distress. This could be of practical utility since most of these factors are modifiable. Future research, as well as interventions, should focus specifically on them.

Nationwide Survey in Greece about Knowledge, Risk Perceptions, and Preventive Behaviors for COVID-19 during the General Lockdown in April 2020.

BACKGROUND: The aim of this study was to investigate the knowledge, attitudes, and practices of the Greek general population toward coronavirus disease 2019 (COVID-19) during the lockdown period in April 2020, to examine factors associated with misperceptions and to determine behavioral patterns that may require interventions. METHODS: A cross-sectional study of the general Greek population (N = 1858) was conducted. A geographically stratified cluster sampling was implemented. A questionnaire was composed consisting of 35 questions. Data collection took place from 15 April to 2 May 2020. A random-digit dialing survey was conducted by 29 interviewers. RESULTS: The majority of respondents (62.7%) answered ≥12/17 questions correctly. Participants aged 18-44 years, male gender, specific occupations (freelancer, unemployed, housewife, retiree) and those who sought information about COVID-19 from less than two sources received lower aggregated scores on knowledge questions. Regarding attitudes toward future vaccination, 18.9% declared that were against it, while 81.1% that they may consider or will be vaccinated. About 40% were not using a face mask and only 42% washed their hands appropriately. CONCLUSION: Adjusting information campaigns targeting especially people below 45 years of age can help to sensitize them and realise their role to control the spread. Further targeted surveys are needed to adjust/design prevention campaigns.

Factors determining different death rates because of the COVID-19 outbreak among countries.

BACKGROUND: During the coronavirus disease 2019 (COVID-19) pandemic, all European countries were hit, but mortality rates were heterogenous. The aim of the current paper was to identify factors responsible for this heterogeneity. METHODS: Data concerning 40 countries were gathered, concerning demographics, vulnerability factors and characteristics of the national response. These variables were tested against the rate of deaths per million in each country. The statistical analysis included Person correlation coefficient and Forward Stepwise Linear Regression Analysis (FSLRA). RESULTS: The FSLRA results suggested that 'days since first national death for the implementation of ban of all public events' was the only variable significantly contributing to the final model, explaining 44% of observed variability. DISCUSSION: The current study suggests that the crucial factor for the different death rates because of COVID-19 outbreak was the fast implementation of public events ban. This does not necessarily mean that the other measures were useless, especially since most countries implemented all of them as a 'package'. However, it does imply that this is a possibility and focused research is needed to clarify it, and is in accord with a model of spreading where only a few superspreaders infect large numbers through prolonged exposure.

Reliability and Validity of the Greek Version of the Iowa Infant Feeding Attitude Scale Among Pregnant Women.

INTRODUCTION: A modifiable factor related to breastfeeding is breastfeeding attitudes. The Iowa Infant Feeding Attitude Scale (IIFAS) is used to evaluate this factor. Although the breastfeeding rates in Greece are declined there is not available any validated instrument to evaluate infant feeding attitudes. AIM: to determine the psychometric properties of the Greek adaptation of the IIFAS in a sample of pregnant women. MATERIALS AND METHODS: Pregnant women (N=203) from a University Hospital in Athens, Greece, were administered the Greek version of the IIFAS, while being in hospital, and their infant feeding mode at six months postpartum was recorded by telephone. The reliability of the scale was assessed by using corrected item-total correlations and Cronbach's alpha. Construct validity of the scale was assessed by using confirmatory factor analysis and predictive validity by using t-tests. Multiple linear regression analyses in a stepwise method (p for removal was set at 0.1 and p for entry was set at .05) was performed in order to find variables independently associated with IIFAS total score. RESULTS: The mean IIFAS score was 70.0 (SD=7.6). The corrected item-total correlation ranged from 0.22 to 0.51. Cronbach's alpha was equal to 0.71. The confirmatory factor analysis indicated an adequate fit of the one-factor model. Concerning the predictive validity of IIFAS it was significant for breastfeeding at six months. The mean IIFAS score was significantly greater (p=0.001) for women that had exclusive breastfeeding at six months (mean (SD): 68.4(6.6)) as compared with those that did not (mean (SD): 64.0(7.5)). Higher IIFAS scores were found in older women, with higher educational level and in those that had breastfed children in their social environment. CONCLUSION: The Greek version of the IIFAS demonstrated satisfying reliability and validity for measuring women's infant feeding attitudes in the Greek context. Also, the results of the present study provide further evidence of the international applicability of the IIFAS.

Nursing staff and patients' length of stay.

PURPOSE: The purpose of this paper is to investigate the effect of nurse staffing, nurse education and work experience on patients' length of stay (LOS) in the Greek public hospitals. DESIGN/METHODOLOGY/APPROACH: A cross-sectional study, with retrospective administrative data, was implemented. From all seven Regional Health Authorities of Greece, 25 general surgical units in 17 public hospitals participated in the study. FINDINGS: All over the hospitals were studied, 32,287 patients ⩾17 years old and 203 nursing staff, who were working in the study units, were included in the analysis. According to the multivariate linear regression model, increased years of experience as a nurse (b= -0.04, 95% CI= -0.06 to -0.02, p=0.001) and increased percentage of registered nurse to the total nursing staff (b= -1.18, CI= -1.88 to -0.47, p=0.03) were associated with decreased patient LOS. ORIGINALITY/VALUE: This was the first extended study in Greece, which explored the relationship between nurse staffing, nurse education, work experience and the LOS. The role that nurse staffing play together with its characteristics in the provision toward the quality healthcare services has already been recognized worldwide. The findings revealed the great shortage of nursing staff and the significant correlation between the work experience and educational level to patients' LOS.

Modifiable factors affecting inpatient violence in an acute child and adolescent psychiatric unit: A 16-year retrospective study.

Violent incidents in acute inpatient units for children and adolescents are a major and persistent problem. The demographic, clinical, and modifiable (environmental-organizational) risk factors that affect inpatient violence in an Acute Child and Adolescent Psychiatric Unit were investigated via a retrospective study. Data were collected from nursing and medical reports and the unit's census and included 100 days per year for 16 years. Incidents of violence and assault types were recorded, and variables such as the diagnostic category of assailants, total number of patients, and staffing factors during the incident were examined. Of the 2390 violent incidents recorded, 50% were attributed to cases of physical violence towards another patient, 17% to physical violence towards nursing staff, 19% to physical violence towards self and 14% to destruction of property. According to the final multivariable model, for each additional patient in the unit, the risk of a violent event increased by 9.51%; for each additional offender patient, the risk increased by 14.06%; the number of assistant nurses was associated with a 25.03% increased risk; and, after 2006, the risk increased by 68.99%. The most significant factor associated with a 59.98% decreased risk was the total number of nursing staff. All variables significantly and independently contributed to the model. Acute inpatient psychiatric units with a small number of hospitalized patients, adequate, well-trained and specialized nursing staff, and the hospitalization of different types of patients in separate wards or units are expected to facilitate a reduction in the frequency of violent incidents.