Changing food choices: the option for high-protein foods and the move away from the Mediterranean diet.

PURPOSE:  The growing importance placed on health and physical well-being by consumers continues to influence food industry choices. The food market therefore, pandering to the desires for a lean and athletic body, offers new products deemed more healthy and able to impact body image. It is evidenced, thus, a change in food choices and habits, with more attention to the quality and nutrient content of the products consumed, in which protein is assuming increasing importance. The purpose of the study is to highlight important changes in eating habits and in particular the increase in the consumption of high-protein foods, attributable to the focus on physical fitness and thinness, resulting in a decreasing adherence to the Mediterranean diet and the progressive loss of its positive impact on health. METHODS AND RESULTS: This analysis is based on CIRCANA srl data on food consumption trends (change percentage of quantity and value sales) in recent years. Specifically, between January and September 2022 vs. 2021, there was a 21.6% increase in the sale of high-protein products, significantly higher than all the previous ones. CONCLUSIONS: The past few years have seen the gradual discovery of new products, at first little-known and niche, which are becoming major players on the national food consumption scene. The trend is toward a growing preference for high-protein foods and diets with the gradual abandonment of the Mediterranean and an increased risk of nutritional deficiencies, obesity, and cardiovascular disease. LEVEL OF EVIDENCE: Level IV, evidence obtained from multiple time series with or without the intervention.

Governing Integrated Health and Social Care: An Analysis of Experiences in Three European Countries.

Purpose: Achieving greater health and social care integration is a policy priority in many countries, but challenges remain. We focused on governance and accountability for integrated care and explored arrangements that shape more integrated delivery models or systems in Italy, the Netherlands and Scotland. We also examined how the COVID-19 pandemic affected existing governance arrangements. Design/methodology/approach: A case study approach involving document review and semi-structured interviews with 35 stakeholders in 10 study sites between February 2021 and April 2022. We used the Transparency, Accountability, Participation, Integrity and Capability (TAPIC) framework to guide our analytical enquiry. Findings: Study sites ranged from bottom-up voluntary agreements in the Netherlands to top-down mandated integration in Scotland. Interviews identified seven themes that were seen to have helped or hindered integration efforts locally. Participants described a disconnect between what national or regional governments aspire to achieve and their own efforts to implement this vision. This resulted in blurred, and sometimes contradictory, lines of accountability between the centre and local sites. Flexibility and time to allow for national policies to be adapted to local contexts, and engaged local leaders, were seen to be key to delivering the integration agenda. Health care, and in particular acute hospital care, was reported to dominate social care in terms of policies, resource allocation and national monitoring systems, thereby undermining better collaboration locally. The pandemic highlighted and exacerbated existing strengths and weaknesses but was not seen as a major disruptor to the overall vision for the health and social care system. Research limitations: We included a relatively small number of interviews per study site, limiting our ability to explore complexities within sites. Originality: This study highlights that governance is relatively neglected as a focus of attention in this context but addressing governance challenges is key for successful collaboration.

Role of Portion Size in the Context of a Healthy, Balanced Diet: A Case Study of European Countries.

Over the past decades, a generalised increase in food portion sizes has probably contributed to the growing global obesity epidemic. Increasing awareness of appropriate portion sizes could contribute to reversing this trend through better control of calorie intake. In this study, a comparison of standard portion sizes in European countries for various food categories shows a wide variability of their importance for food, nutrient, and energy consumption according to government and institutional websites. On the other hand, the overall averages appear to be largely in line with the values indicated by the Italian Society of Human Nutrition, which is the most comprehensive and detailed document among those evaluated. The exceptions are milk and yoghurt, for which the reference portions in Europe are generally higher, and vegetables and legumes, for which portions are smaller than those reported in the Italian document. Moreover, the portion sizes of staple foods (e.g., pasta and potatoes) vary according to different food traditions. It is reasonable to consider that the creation of harmonised standard reference portions common to the European countries, based on international guidelines and scientific evidence, would significantly contribute to consumers' nutritional education and ability to make informed choices for a healthy diet.

Drawing a pandemic vulnerabilities' map: The SoNAR-global Vulnerabilities Assessment digital and its output.

This paper describes the process, advantages and limitations of a qualitative methodology for defining and analyzing vulnerabilities during the COVID-19 pandemic. Implemented in Italy in two sites (Rome and outside Rome, in some small-medium sized municipalities in Latium) in 2021, this investigation employed a mixed digital research tool that was also used simultaneously in four other European countries. Its digital nature encompasses both processes of data collection. Among the most salient is that the pandemic catalyzed new vulnerabilities in addition to exacerbating old ones, particularly economic. Many of the vulnerabilities detected, in fact, are linked to previous situations, such as the uncertainties of labor markets, having in COVID-19 to the greatest negative effects on the most precarious workers (non-regular, part-time, and seasonal). The consequences of the pandemic are also reflected in other forms of vulnerability that appear less obvious, having exacerbated social isolation, not only out of fear of contagion, but because of the psychological challenges posed by containment measures themselves. These measures created not mere discomfort, but behavioral changes characterized by anxiety, fearfulness, and disorientation. More generally, this investigation reveals the strong influence of social determinants throughout the COVID-19 pandemic, creating new forms of vulnerability, as the effects of social, economic, and biological risk factors were compounded, in particular, among already marginalized populations.

Cross-sectional study to develop and describe psychometric characteristics of a patient-reported instrument (PROFFIT) for measuring financial toxicity of cancer within a public healthcare system.

OBJECTIVES: To measure and explain financial toxicity (FT) of cancer in Italy, where a public healthcare system exists and patients with cancer are not expected (or only marginally) to pay out-of-pocket for healthcare. SETTING: Ten clinical oncological centres, distributed across Italian macroregions (North, Centre, South and Islands), including hospitals, university hospitals and national research institutes. PARTICIPANTS: From 8 October 2019 to 11 December 2019, 184 patients, aged 18 or more, who were receiving or had received within the previous 3 months active anticancer treatment were enrolled, 108 (59%) females and 76 (41%) males. INTERVENTION: A 30-item prefinal questionnaire, previously developed within the qualitative tasks of the project, was administered, either electronically (n=115) or by paper sheet (n=69). PRIMARY AND SECONDARY OUTCOME MEASURES: According to the protocol and the International Society for Pharmacoeconomics and Outcomes Research methodology, the final questionnaire was developed by mean of explanatory factor analysis and tested for reliability, internal consistency (Cronbach's α test and item-total correlation) and stability of measurements over time (test-retest reliability by intraclass correlation coefficient and weighted Cohen's kappa coefficient). RESULTS: After exploratory factor analysis, a score measuring FT (FT score) was identified, made by seven items dealing with outcomes of FT. The Cronbach's alpha coefficient for the FT score was 0.87 and the item-total correlation coefficients ranged from 0.53 to 0.74. Further, nine single items representing possible determinants of FT were also retained in the final instrument. Test-retest analysis revealed a good internal validity of the FT score and of the 16 items retained in the final questionnaire. CONCLUSIONS: The Patient-Reported Outcome for Fighting FInancial Toxicity (PROFFIT) instrument consists of 16 items and is the first reported instrument to assess FT of cancer developed in a country with a fully public healthcare system. TRIAL REGISTRATION NUMBER: NCT03473379.

Social networks and eating disorders during the Covid-19 pandemic.

OBJECTIVE: The purpose of this study is to assess the increase both in the use of the Internet and social media and in Google searches regarding eating disorders (ED) in Italy during the Covid-19 pandemic. Our aim is also to verify the possible impact of such an increase on ED, since patients treated for ED by the National Health Service (NHS) have increased in the first 6 months of 2020 as well. METHOD: We used data from Wearesocial surveys on Internet users in the first 6 months of 2020 and the Google searches related to the query of "food disorders" and "body shaming." The first results of a project of the Italian Ministry of Health on ED have been considered too. RESULTS: The social media users in July 2020 increased to 60% of the Italian population; a tendential increase in Google searches on these issues has emerged. Finally, new patients of NHS with ED showed a high increase in the first 6 months of 2020 (+40.9%). CONCLUSION: Considering the contents diffused on the Internet, it is fundamental to watch over net usage in the adolescent population and those with ED, because massive access to social media can be considered almost as a risk factor.

What women think about menopause: An Italian survey.

INTRODUCTION: Menopause is a critical period for most women who experience associated symptoms while they are still socially and individually active. OBJECTIVES: The objective of this study is to report how Italian women perceive and approach menopause. MATERIALS AND METHODS: A survey of 1028 Italian women aged 45-65 years was conducted by the Italian Center for Studies of Social Investments (CENSIS) through anonymous interviews using two methods: CATI (Computer Assisted Telephone Interviewing) and CAWI (Computer Assisted Web Interviewing). PRINCIPAL OUTCOME MEASURES: Principal outcome measures were women's perceptions and experiences of menopause and its treatments. RESULTS: The global consciousness and understanding of menopause was common (82.8 %) among Italian women and it was usually considered a physiological condition (77 %). Overall, 74.6 % of the sample were postmenopausal. Hot flushes were reported to be the most frequent (37.9 %) and bothersome symptoms (43.1 %) while 12.9 % of the women were asymptomatic. As for menopausal therapies, 24.5 % were on treatment; herbal medications were the most common remedy (63.3 %) whereas 7.6 % of the women took hormone replacement therapy (HRT). About half of the sample (50.4 %) had not sought help from the Italian National Health System (INHS). Medical expertise in the field of menopause was thought to be moderately satisfactory by 54.5 % of the sample. CONCLUSIONS: Italian women consider menopause a physiological condition. Most postmenopausal women had experienced symptoms but relied on non-hormonal treatments. The median women's satisfaction with the role of the INHS and medical competence suggests the need to improve current knowledge and awareness concerning menopause.

A qualitative analysis and development of a conceptual model assessing financial toxicity in cancer patients accessing the universal healthcare system.

PURPOSE: This paper illustrates a conceptual model for a new patient-reported outcome measure (PROM) aimed at measuring financial toxicity (FT) in oncological setting in Italy, where citizens are provided universal healthcare coverage. METHODS: Focus groups with overall 34 patients/caregivers in three different Italian centers (from Northern, Centre, and Southern Italy) and an open-ended survey with 97 medical oncologists were undertaken. Transcripts from focus groups and the open-ended survey were analyzed to identify themes and links between themes. Themes from the qualitative research were supplemented with those reported in the literature; concepts identified formed the basis for item development that were then tested through the importance analysis (with 45 patients) and the cognitive debriefing (with other 45 patients) to test relevance and comprehension of the first draft PRO instrument. RESULTS: Ten domains were extracted by analyzing 156 concepts generated from focus groups and the open-ended survey. After controlling for redundancy, 55 items were generated and tested through the importance analysis. After controlling comprehension and feasibility through cognitive debriefing interviews, a first version of the questionnaire consisting of 30 items was devised. CONCLUSIONS: This qualitative study represents the first part of a study conducted to develop a new PROM to assess FT in Italy, by using a bottom-up approach that makes the most of patients' experiences and the health system analysis. TRIAL REGISTRATION: clinicaltrials.gov NCT03473379 first posted on March 22, 2018.

Changes in food choice following restrictive measures due to Covid-19.

BACKGROUND AND AIMS: Following the Covid-19 proliferation beyond the borders of China at the beginning of 2020, containment measures have been taken by different countries around the globe. Citizens were forced to stay at home. The aim of this study is twofold. First, we will provide an analysis of food consumption in Italy during the emergency from a social stance. Secondly, we will consider the risks in relation to health of these food product choices. METHODS AND RESULT: This analysis is based on IRi's data on consumption trends (percentage increase in sales in value) during the first period of the spread of coronavirus, from 23rd of February through the 29th of March, 2020. The sample includes 10 769 stores. There was an increase in the consumption of pasta, flour, eggs, long-life milk and frozen foods, in comparison to a reduction of fresh food goods. The sales of snacks have dropped in relation to the production of homemade bread, pizza and cakes. CONCLUSION: The increase in the consumption of some types of food is linked with their symbolic value and its tendency to carry on at home some external socialization habits. But be careful: these habits are not always healthy.

Unmet needs influence health-related quality of life in people with multiple sclerosis.

BACKGROUND: People with MS are a heterogeneous population with varying difficulties and needs that are influenced by the individual experience of the disease, symptoms and disease course. The aim of the present study was to identify factors that influence health-related quality of life in a sample of subjects with MS, specifically health and social care-related needs and demographic and disease characteristics. METHODS: Individuals with a definite diagnosis of MS were identified through MS out-patient clinics and local branches of the Italian MS Society. The EQ-5D-3L utility index was used to describe health profiles and as an overall measure of perceived HRQoL. The number of unmet health and social care-related needs was used to describe the impact of unmet needs on HRQoL. Multiple regression analyses were performed using a hierarchical approach. RESULTS: Data was analyzed from 1013 subjects. Overall, 83% of subjects reported at least one health or social care-related need as being unmet and subjects with a higher number of unmet needs had lower HRQoL (p < 0.001). The number of unmet needs was entered at the first step with a statistically significant effect (Cox-Snell R2 0.15, BIC 870.9, AIC 851.2). Clinical variables, included in the second step, contributed significantly to explaining the variability between models (Cox-Snell R2 0.43, BIC 481.0, AIC 446.6), and the addition of socio-demographic factors further accounted for variability (Cox-Snell R2, 0.46, BIC 461.0, AIC 402.0). CONCLUSIONS: The study demonstrated that a higher number of both health and social care-related unmet needs predicted lower HRQoL. The health profile of the sample identified all domains of the EQ-5D-3L as being important in determining HRQoL. Data confirms that unmet needs alone are significantly related to reduced HRQoL, although the multifactorial and complex nature of MS makes it a challenge to identify the combination of aspects that fully predict variability in quality of life.

Correction to: Nutrition behaviour and compliance with the Mediterranean diet pyramid recommendations: an Italian survey­based study.

The article "Nutrition behaviour and compliance with the Mediterranean diet pyramid recommendations: an Italian survey­based study", written by "Renata Bracale, Concetta M. Vaccaro, Vittoria Coletta, Claudio Cricelli, Francesco Carlo Gamaleri, Fabio Parazzini and Michele Carruba" was originally published electronically on the publisher's internet portal on 8th November 2019 without open access.

Nutrition behaviour and compliance with the Mediterranean diet pyramid recommendations: an Italian survey-based study.

PURPOSE: Adopting a Mediterranean-like dietary pattern may help in preventing several chronic diseases. We assessed the eating behaviour and compliance with the Mediterranean diet pyramid recommendations in Italy. METHODS: This is a cross-sectional study conducted in subjects aged ≥ 20 years. A 14-question survey based on the updated Mediterranean diet pyramid was launched online from April 2015 to November 2016. At test completion, a personalized pyramid displaying the possible deficiencies and/or excesses was generated, that could be the basis to plan diet and lifestyle modifications. RESULTS: Overall, 27,540 subjects completed the survey: the proportion of females (75.6%), younger subjects (20.7%) and people with a University degree (33.1%) resembled those of the Italian population of Internet users rather than of the general population. 37.8% of participants declared a sedentary lifestyle, including 29.6% of those aged 20-29 years. A lower-than-recommended intake of all food categories included in the Mediterranean diet pyramid, along with excess of sweets, red and processed meats, emerged, that may affect health in the long term. Low adherence to recommendations was observed especially among females and older people. Notably, a discrepancy surfaced between the responders' perceived and actual behaviour toward the regular consumption of fruits and vegetables (81.8% vs 22.7-32.8%, respectively). CONCLUSIONS: The nutritional habits and lifestyle of Italian participants are poorly adherent to the Mediterranean diet recommendations. The personalized pyramid tool may help in raising the awareness of individuals and their families on where to intervene, possibly with the support of healthcare professionals, to improve their behaviour. LEVEL OF EVIDENCE: Level V, cross-sectional descriptive study.

Value based healthcare for rare diseases: efficiency, efficacy, equity.

The paper reviews the literature available on value based health care and relates it to rare diseases. Starting from the economic definition of value and healthcare evaluation, efficacy and efficiency, it includes the equity dimension to define value-based healthcare. It embraces also the cultural framework associated to the concepts of health and disease, normal and pathological, right or wrong for the patient. The paper highlights that a prevention and recovery view and global evaluation of costs/benefits ratio for rare diseases make difficult and limited the applicability of the value-based approach to rare diseases. Since epidemiology of rare diseases identified a series of difficulties in applying value-based public health strategies to rare diseases, the paper underlines the necessity of new culture of health and well-being, radically re-examining how to organise the delivery of prevention, and healthcare services, and finding alternative ways of empowering and giving voice to vulnerable and marginalised groups.

Development and validation of a patient-reported outcome tool to assess cancer-related financial toxicity in Italy: a protocol.

INTRODUCTION: Financial toxicity (FT) is a well-recognised problem in oncology. US-based studies have shown that: (a) cancer patients have a 2.7 times risk of bankruptcy; (b) patients who declare bankruptcy have a 79% greater hazard of death; (c) financial burden significantly impairs quality of life (QoL) and (d) reduces compliance and adherence to treatment prescriptions. The aim of the project is to develop and validate a patient-reported-outcome (PRO) measure to assess FT of cancer patients in Italy, where, despite the universal health coverage provided by the National Health Service, FT is an emerging issue. METHODS AND ANALYSIS: Our hypothesis is that a specific FT measure, which considers the relevant sociocultural context and healthcare system, would allow us to understand the main determinants of cancer-related FT in Italy, in order to address and reduce these factors. According to the International Society for Pharmaco-economics and Outcomes Research guidelines on PROs, the project will include the following steps: (1) concept elicitation (from focus groups with patients and caregivers; literature; oncologists; nurses) and analysis, creating a coding library; (2) item generation (using a format that includes a question and a response on a 4-point Likert scale) and analysis through patients' cognitive interviews of item importance within different coding categories to produce the draft instrument; (3) factor analysis and internal validation (with Cronbach's alpha and test-retest for reliability) to produce the final instrument; (4) external validation with QoL anchors and depression scales. The use of the FT measure in prospective trials is also planned. ETHICS AND DISSEMINATION: The protocol is approved by the ethical committees of all the participating centres. The project will tentatively produce a validated tool by the spring 2021. The project might also represent a model and the basis for future cooperation with other European countries, with different healthcare systems and socioeconomic conditions. TRIAL REGISTRATION NUMBER: NCT03473379.

Disparity between perceived needs and service provision: a cross-sectional study of Italians with multiple sclerosis.

BACKGROUND: Assessing the coverage by public or private resources in meeting health-related and social-related needs may be useful for service planning and guide optimization of care, important especially in view of an increase in the prevalence of multiple sclerosis (MS). METHODS: An ad hoc questionnaire assessed satisfaction of health-related and social care-related needs in a cross-sectional study of 1014 people with MS identified through MS outpatient clinics and local branches and social media channels of the Italian MS Society. RESULTS: 87.1% and 79.8% of the responders had experienced at least one health-related or social-related need, respectively. The study demonstrated significant gaps between perceived needs and service provision. Rehabilitation, residential care, and psychological support were most frequently unsatisfied health-related needs, while the more commonly unmet social-related needs were financial support, elimination of architectural barriers, workplace adaptations, and career guidance. The multivariate analysis highlighted that the satisfaction of health-related needs was primarily associated with geographic area of residence. Social-related needs correlated with both clinical and sociodemographic aspects. CONCLUSION: The results provide insight into the range of interventions, care, and support people with MS report to be important to them at different points in their disease trajectory. More emphasis should be put on the inequitable distribution of NHS services in different geographic areas of Italy as well as on particularly fragile subgroups of the MS population (older individuals, and those with higher levels of disability) because the care of these individuals continues to be assumed by the family.

A comparison between the costs of dialysis treatments in Marche Region, Italy: Macerata and Tolentino hospitals.

BACKGROUNDS: The main aim of this study was to estimate the costs of different dialysis modalities through the analysis of administrative databases in the Macerata and Tolentino hospitals, in Italy. METHODS: We retrospectively analyzed two main categories: medical direct costs (all the monetary costs whose consumption is wholly referable to dialysis treatment) and non-medical direct costs (all the costs that make treatment possible but that are outside the medical care sector), related to 2013. Attention was focused on the analysis of the extracorporeal dialysis methods (HD, HDF/AFB, HDF/MID/HFR) and the peritoneal dialysis (APD, CAPD). RESULTS: An analysis overall of economic costs (direct costs + indirect costs) for dialysis treatment, shows that the cost per week for Continuous Ambulatory Peritoneal Dialysis (CAPD) technique is less expensive for health-care budgets, followed by Automated Peritoneal Dialysis (APD). Regarding the extracorporeal dialysis methods, the treatment more affordable is HD. CONCLUSIONS: Results obtained confirm that peritoneal dialysis technique is more convenient for health-care budget than extracorporeal dialysis. Furthermore, this study allowed to develop a methodology that could be a reference for similar studies.

Unmet care needs of people with a neurological chronic disease: a cross-sectional study in Italy on Multiple Sclerosis.

BACKGROUND: Community-based studies are required to accurately describe the supportive services needed by people with multiple sclerosis (MS). METHODS: A total of 1205 people with MS participated in a cross-sectional study evaluating their unmet health and social care needs through a questionnaire collecting information used in the study. It was specifically developed by a multi-disciplinary team. RESULTS: Overall, 79% of the responders declared at least one health or social care needs. The most prevalent health care need was the psychological support (27.5%), whereas the transport was the social care need more frequent (over 41%) in our sample. The multivariate analysis highlighted that unmet health care needs depended mainly on clinical factors such as disease stage, influenced by disease duration, and disability degree, whereas the social care needs were related to both clinical and socio-demographic factors. CONCLUSION: These findings suggest that MS needs significantly change over time during the disease development and to find the best way to personalize PwMS management is crucial. Moreover, more public funding directed at improving the health-related quality of life of people with MS is needed. For this reason, we think that these results will provide important information and baseline data on how to build the national service strategies thereby making healthcare planning more efficient.

Stroke knowledge in Italy.

Stroke knowledge improves public behavior in terms of prevention, symptom recognition, and timely response. Contemporary data on stroke awareness in the Italian general population are lacking. This study surveyed public knowledge of risk factors, warning signs, and proper reactions to stroke among Italian adults. A population-based telephone survey was carried out in a sample of 1,000 residents aged ≥18 years in May-June 2010. The questionnaire included close-ended questions focused on stroke symptoms, risk factors, and treatment options. We examined the prevalence and distribution of stroke knowledge in the community and generated multivariable logistic regression models. Among the 1,000 participants (481 men, mean age 48.8 ± 17.2), only the 55.8 % correctly identified the brain as the affected organ in stroke. The most common risk factor for stroke identified by respondents was hypertension (67.6 %), the most common warning sign was hemiparesis (68.7 %), the 43.5 % could list >1 warning sign. Multivariate analyses indicate that education and previous stroke experience are the only independent predictors of stroke knowledge. Only 26.2 % reported to know about the availability of t-PA treatment. An ambulance would be called by 59 % of respondents in the event of a stroke. Respondents with a high level of education are more likely to call an ambulance in case of stroke. This study provides the first comprehensive data describing stroke knowledge among Italian adults: the general level is suboptimal and is associated only with education and previous family experience of stroke. Public education could potentially improve treatment and prevention.

[A Censis survey on atrial fibrillation awareness in the general population and among general practitioners and affected patients in Italy]. / Indagine Censis sulla conoscenza in Italia della fibrillazione atriale a livello dei cittadini, dei medici di medicina generale e dei pazienti.

BACKGROUND: Atrial fibrillation (AF) is the most common arrhythmia in clinical practice, particularly in the elderly. AF is considered an independent predictor of mortality and risk factor for stroke. AF-related stroke is usually severe and associated with a high rate of mortality and disability. Despite its prevalence, AF is a poorly known disease and it is underestimated by the general population. The aim of the Censis survey was to analyze the levels of AF knowledge and information in the Italian population and the level of AF risk awareness by general practitioners and AF patients. METHODS: The survey included structured interviews with a sample of 1000 Italian citizens aged ≥18 years, 300 general practitioners, and 1200 AF patients. RESULTS: The analysis confirmed low levels of knowledge of AF. In particular, the results showed that only one third of Italians know AF that is however perceived as a severe disease. In this subgroup, the risk of stroke associated with AF is known by 65%, but it is also widespread the wrong concept that AF is associated with an increased risk of myocardial infarction. The lack of knowledge of AF and its complications by the Italian population is due to educational gaps of general practitioners. In particular, only 50% of the Italian general practitioners perceive the thromboembolic risk of paroxysmal AF as comparable to that of permanent AF. In addition, there is an underuse of the scores for thromboembolic and hemorrhagic risk stratification recommended by current guidelines and a frequent use of antiplatelet therapy rather than oral anticoagulant therapy. There is also a low level of knowledge and awareness of the disease among AF patients. However, the majority of AF patients are aware of the importance of antithrombotic prophylaxis for stroke prevention. CONCLUSIONS: This study demonstrates limited knowledge and awareness of AF in the general population and also among general practitioners and affected patients.