Spatio-Temporal Variation of Lung Cancer in Crete, 1992-2013. Economic or Health Crisis?

(1) Background: This is the first population-based study in Greece, with the aim to measure the changing trends of lung cancer (LC) and the associated risk factors before and after the economic crisis. Among the main objectives were the identification of LC hot spots and high-risk areas; (2) Methods: The study was conducted in Crete, the biggest island in Greece. Data (5057 LC cases) were collected from the Cancer Registry of Crete (CRC). The age-standardized incidence and mortality rates (ASIR, ASMR/100,000/year) were estimated, while additional indexes were used, including the adjusted Charlson's comorbidity index (CCI%), the deprivation index (HPI-2), and the exposure to outdoor air pollution (OAP). The analysis was performed for two time periods (Period A: 1992-2008; Period B: 2009-2013); (3) Results: ASIR presented a significant increase during the economic crisis, while an even higher increase was observed in ASMR (Period A: ASMR = 30.5/100,000/year; Period B: ASMR = 43.8/100,000/year; p < 0.001). After 2009, a significant increase in the observed LC hot spots was identified in several sub-regions in Crete (p = 0.04). The risk of LC mortality increased even more for smokers (RR = 5.7; 95%CI = 5.2-6.3) and those living in highly deprived geographical regions (RR = 5.4; 95%CI = 5.1-5.8) during the austerity period. The multiple effect of LC predictors resulted in adjusted RRs ranging from 0.7 to 5.7 within the island (p < 0.05); (4) Conclusions: The increased LC burden after the onset of the economic crisis, along with a changing pattern of LC predictors stressed the urgent need of geographically oriented interventions and cancer control programs focusing on the most deprived or vulnerable population groups.

Evidence-Based Conceptual Collection of Methods for Spatial Epidemiology and Analysis to Enhance Cancer Surveillance and Public Health.

(1) Background: Although spatial statistics are often used by cancer epidemiologists, there is not yet an established collection of methods to serve their needs. We aimed to develop an evidence-based cancer-oriented conceptual collection of methods for spatial analysis; (2) Methods: A triangulation of approaches was used; literature review, consensus meetings (expert panel), and testing the selected methods on "training" databases. The literature review was conducted in three databases. This approach guided the development of a collection of methods that was subsequently commented on by the expert panel and tested on "training data" of cancer cases obtained from the Cancer Registry of Crete based on three epidemiological scenarios: (a) low prevalence cancers, (b) high prevalence cancers, (c) cancer and risk factors; (3) Results: The final spatial epidemiology conceptual collection of methods covered: data preparation/testing randomness, data protection, mapping/visualizing, geographic correlation studies, clustering/surveillance, integration of cancer data with socio-economic, clinical and environmental factors. Some of the tests/techniques included in the conceptual collection of methods were: buffer and proximity analysis, exploratory spatial analysis and others. All suggested that statistical models were found to fit well (R2 = 0.72-0.96) in "training data"; Conclusions: The proposed conceptual collection of methods provides public health professionals with a useful methodological framework along with recommendations for assessing diverse research questions of global health.

Participatory Action Research for Tackling Distress and Burnout in Young Medical Researchers: Normative Beliefs before and during the Greek Financial Crisis.

(1) Background: We aimed to explore Young medical researchers (YMR) normative beliefs and perceived causes of distress and burnout, prior and during the financial crisis in Greece, and to assess their views on Participatory Action Research (PAR) interventions towards tackling these disorders. (2) Methods: A Participatory Learning and Action (PLA) methodology was performed in two time periods (prior crisis: December 2008; during crisis: February-March 2017). In both time periods, three different groups (Group 1: females, Group 2: males, Group 3: mixed) of 5-7 participants and two sessions (≈1 h/session) per group took place in each site. Overall, 204 sessions with 1036 YMR were include in the study. (3) Results: Several socio-demographic characteristics of YMR altered during the crisis (lower income, higher smoking/alcohol consumption, etc.). The majority of YMR conceived distress and burnout as serious syndromes requiring professional support. Feeling very susceptible and the necessity for establishing PAR interventions were frequently reported during the crisis. Numerous (a) barriers and (b) cues to action were mentioned: (a) lack of time, money and support from friends/family/colleagues (b) being extensively informed about the intervention, participation of their collaborators, and raising awareness events. (4) Conclusions: The changing pattern of Greek YMR's beliefs and needs during the crisis stresses the necessity of interventions to tackle distress and burnout. Effectiveness of these interventions could be enhanced by the suggested cues to action that emerged from this study.

Screening for Depression in Cardiovascular Patients in Albania: Findings from the Country Check-Up Program.

This is a retrospective study conducted in Vlora from January 2016 to April 2017 and the aim was to report the prevalence of depression in cardiovascular (CVD) patients. Depression assessment was done using the Patient Health Questionnaire (PHQ)-9 (PHQ-9). Data were derived from the patient records and the standard recommended cut-off point of PHQ-9 ≥ 10 was used. In total, data of 300 patients were analyzed. Depressive symptoms (PHQ-9 ≥ 10) were observed at 6% of the participants. Trouble falling asleep or staying asleep or sleeping too much, feeling tired or having little energy and having little interest or pleasure in doing things were the most common symptoms reported. In multivariate analysis, only family status showed statistical significance. Unmarried (mean rank = 207.22) are more likely to have moderate or severe depression level (OR 3.529; C.I. 95% 1.017-12.238). Future research should focus on the needed actions after depression screening (i.e. referral, treatment etc.).

Primary healthcare personnel challenges and barriers on the management of patients with multimorbidity in Albania.

The number of people living with chronic conditions is increasing worldwide with most of these people receiving the needed healthcare services in primary healthcare (PHC) settings. The objective of this study was to explore the main challenges and barriers that PHC providers confront while treating multimorbid patients. This is a qualitative study utilising semi-structured individual in-depth interviews. The study took place in Vlora City, which is the biggest city located in south Albania. Τhe two biggest PHC centres of the city were enrolled. Purposive sampling method was used to recruit PHC practitioners. Main criteria of participation in the study were being fully employed at the enrolled primary care centres, having worked for at least 1 year and to deal with multimorbid patients in daily practice. Data collection took place from September 2019 to January 2020. In total, 36 semi-structured interviews took place with 23 (63.9%) nurses and 12 (33.3%) physicians (general practitioners/family doctors). Communication problems and disputes, lack of materials/equipment and the inappropriate infrastructure, miscommunication and problems in doctor-nurse relationships, coordination problems, lack of protocols and problems in the referral system were reported as the main challenges and barriers that the PHC personnel confront. The findings of this study are critical in understanding challenges that PHC personnel face when dealing with multimorbid patients in PHC settings. The emerged knowledge contributes significantly in a better understanding of the actual situation and to inform health policy makers on how to deal with the existing problems.

How trust affects performance of interprofessional health-care teams.

Interprofessional teamwork in health-care settings is considered a valuable means of enhancing patient management. Literature has highlighted the importance of trust in building effective health-care teams. The present study aimed to investigate and further understand the perceptions of health-care professionals regarding trust and performance within their working team, as well as to assess the association between them and team performance. "TRUST" questionnaire, a valid instrument for measuring the relationship of trust and team performance was distributed to the members of the perioperative teams located in two different hospitals (a University and a General Hospital) in Greece. Two multivariate linear regression models were developed to reveal the significant predictors of high performance per hospital. Among the major findings revealed were 1) trust and performance were closely related 2) slight yet significant variations were observed between the University and the General Hospital and 3) trust level, years of previous experience and number of team members were among the key predictors of effective team performance. This study conveys new knowledge on trust and performance within health-care settings with limited resources and is expected to guide future interventions aiming to enhance team performance.

Distress and burnout in young medical researchers before and during the Greek austerity measures: forerunner of a greater crisis?

PURPOSE: Distress and burnout are strongly correlated with austerity and financial recessions. Aim of this study was to assess distress and burnout among young medical researchers (YMR) in Greece before and during the financial crisis. METHODS: In total 2050 YMR affiliated in all the nursing and medical departments of Greece were enrolled (1025 in Period A: 2008 and 1025 in Period B: 2017). Distress and burnout were measured via DASS-21 and Maslach Burnout Inventory (MBI) questionnaires. RESULTS: Before the crisis, prevalence of distress and burnout among young medical researchers was 24 and 20%, respectively. During the financial crisis distress prevalence increased significantly (56%), while there has also been a tremendous increase in burnout occurrence (60%). Specific sociodemographic characteristics presented significantly increased rate of change (females, singles and divorced/widowers, living with family members, volunteers, smokers and heavy alcohol consumers). Distress and burnout scales were positively correlated (Spearman's r = 0.81; p = 0.01). Depression scores shifted from normal to moderate (rate of change = 13.1%), anxiety levels increased from normal to severe (rate of change = 14.3%) and tension/stress scores elevated from normal to severe (rate of change = 20.2%). CONCLUSIONS: It is evident that the current financial crisis and working conditions have a strong impact on health status of young medical researchers in Greece. The observed increased trends and the identified predictors could guide targeted and comprehensive interventions towards tackling distress among the medical researchers not only in Greece but also in other countries suffering from financial crisis.

Assessing refugee healthcare needs in Europe and implementing educational interventions in primary care: a focus on methods.

The current political crisis, conflicts and riots in many Middle Eastern and African countries have led to massive migration waves towards Europe. European countries, receiving these migratory waves as first port of entry (POE) over the past few years, were confronted with several challenges as a result of the sheer volume of newly arriving refugees. This humanitarian refugee crisis represents the biggest displacement crisis of a generation. Although the refugee crisis created significant challenges for all national healthcare systems across Europe, limited attention has been given to the role of primary health care (PHC) to facilitate an integrated delivery of care by enhancing care provision to refugees upon arrival, on transit or even for longer periods. Evidence-based interventions, encompassing elements of patient-centredness, shared decision-making and compassionate care, could contribute to the assessment of refugee healthcare needs and to the development and the implementation of training programmes for rapid capacity-building for the needs of these vulnerable groups and in the context of integrated PHC care. This article reports on methods used for enhancing PHC for refugees through rapid capacity-building actions in the context of a structured European project under the auspices of the European Commission and funded under the 3rd Health Programme by the Consumers, Health, Agriculture and Food Executive Agency (CHAFEA). The methods include the assessment of the health needs of all the people reaching Europe during the study period, and the identification, development, and testing of educational tools. The developed tools were evaluated following implementation in selected European primary care settings.

PTSD, burnout and well-being among rescue workers: Seeking to understand the impact of the European refugee crisis on rescuers.

Individuals who perform rescue and recovery duties, as part of their daily work activities, confront diverse stressors that can affect their mental state and overall well-being. The study aimed to assess the prevalence and the factors associated with self-assessed PTSD, perceived well-being and burnout among rescue workers operating at Lesvos during the European refugees crisis. 217 rescuers participated in the study, while the PTSD Checklist-Civilian Version (PCL-C), the Maslach Burnout Inventory (MBI) and the Well-being Index (WHO-5) were utilized. The prevalence of self-assessed PTSD and perceived burnout syndrome was 17.1% and 57% respectively, while 72.8% of the rescuers reported low levels of perceived well-being. Self-assessed PTSD was positively correlated with perceived burnout and inversely correlated with perceived well-being. Perceived burnout was also inversely correlated with perceived well-being. A number of significant predictors were identified for self-assessed PTSD, perceived burnout and well-being, including: family status, age, duration of shifts, collection of dead adults or dead children bodies. The impact of the refugee crisis is visible on the rescue workers that offer rescue and first aid services. There is an urgent need for implementing effective interventions focusing on the identified determinants in order to enhance the occupational psychological burden of rescuers.

Validation of the TRUST tool in a Greek perioperative setting.

The aim of this study was to translate, culturally adapt and validate the TRUST questionnaire in a Greek perioperative setting. The TRUST questionnaire assesses the relationship between trust and performance. The study assessed the levels of trust and performance in the surgery and anaesthesiology department during a very stressful period for Greece (economic crisis) and offered a user friendly and robust assessment tool. The study concludes that the Greek version of the TRUST questionnaire is a reliable and valid instrument for measuring team performance among Greek perioperative teams.

Operational integration in primary health care: patient encounters and workflows.

BACKGROUND: Despite several countrywide attempts to strengthen and standardise the primary healthcare (PHC) system, Greece is still lacking a sustainable, policy-based model of integrated services. The aim of our study was to identify operational integration levels through existing patient care pathways and to recommend an alternative PHC model for optimum integration. METHODS: The study was part of a large state-funded project, which included 22 randomly selected PHC units located across two health regions of Greece. Dimensions of operational integration in PHC were selected based on the work of Kringos and colleagues. A five-point Likert-type scale, coupled with an algorithm, was used to capture and transform theoretical framework features into measurable attributes. PHC services were grouped under the main categories of chronic care, urgent/acute care, preventive care, and home care. A web-based platform was used to assess patient pathways, evaluate integration levels and propose improvement actions. Analysis relied on a comparison of actual pathways versus optimal, the latter ones having been identified through literature review. RESULTS: Overall integration varied among units. The majority (57%) of units corresponded to a basic level. Integration by type of PHC service ranged as follows: basic (86%) or poor (14%) for chronic care units, poor (78%) or basic (22%) for urgent/acute care units, basic (50%) for preventive care units, and partial or basic (50%) for home care units. The actual pathways across all four categories of PHC services differed from those captured in the optimum integration model. Certain similarities were observed in the operational flows between chronic care management and urgent/acute care management. Such similarities were present at the highest level of abstraction, but also in common steps along the operational flows. CONCLUSIONS: Existing patient care pathways were mapped and analysed, and recommendations for an optimum integration PHC model were made. The developed web platform, based on a strong theoretical framework, can serve as a robust integration evaluation tool. This could be a first step towards restructuring and improving PHC services within a financially restrained environment.

Who is going to rescue the rescuers? Post-traumatic stress disorder among rescue workers operating in Greece during the European refugee crisis.

PURPOSE: During the European refugee crisis, numerous Greek and international rescue workers are operating in Lesvos, offering search, rescue, and first aid services. Exposure to stressful life events while engaging in this rescue work can result in developing Post-Traumatic Stress Disorder (PTSD). The study aimed to assess the prevalence of PTSD and explore potential differences between different categories of rescuers. METHODS: A cross-sectional study was conducted among 217 rescue workers. Participants were grouped according to affiliation: "Greek Professionals Rescuers/GPR", "International Professionals Rescuers/IPR" and "Volunteer Rescuers/VR". The PTSD Checklist-Civilian Version (PCL-C) was utilized. All tests were two-tailed (a = 0.05). Mann-Whitney, Kruskal-Wallis, and multivariate logistic regression were performed. RESULTS: Overall probable PTSD prevalence found was 17.1%. Rates varied significantly per rescuer's category; 23.1% in GPR, 11.8% in IPR, and 14.6% in VR (p = 0.02). GPR demonstrated the highest risk compared to IPR and VR (p < 0.001). Females had approximately two times higher risk. Other significant risk factors included marital status, age, and number of children. Lack of previous experience, longer operation period, longer shift hours, and handling dead refugees and dead children were also considered major risk factors. CONCLUSIONS: Rescue workers providing substantial aid to the refugees and migrants at Lesvos experience significant psychological distress. The present findings indicate the urgent need for targeted interventions. Further studies are needed to address long-term effects of the refugee crisis on rescuers, and explore effective measures to prevent PTSD.