The psychological impact of COVID-19 pandemic on primary health care professionals in Greece.

Pandemics precipitate feelings of discomfort and anxiety in healthcare professionals. This study investigates the prevalence of anxiety and depression among public primary health care professionals (PHCPs) in Greece, along with the demographic risk factors, during the second wave of the COVID-19 pandemic, in order to address work exhaustion and protect frontline professionals' psycho-emotional balance. This cross-sectional study was conducted from June 2021 to August 2021, using an online questionnaire (demographic data, GAD-7, PHQ-9). Eligible participants (medical, nursing, allied professionals) were PHCPs employed in Greek public PHC facilities. Analysis involved descriptive statistics to present sociodemographic characteristics, participants' experience with COVID-19, anxiety and depression levels. Univariate analysis was performed to evaluate the association between sociodemographic factors and the anxiety and depression levels, and multivariable logistic regression was used to investigate the presence of predictive factors for anxiety and depression. In total, 236 PHCPs participated in the study, with a mean age of 46 (SD 9.3) years and a mean professional experience of 14.71 (SD 9.2) years. Most participants were women (71.4%) and the majority were General Practitioners (38.9%) and Nurses (35.2%). Anxiety (33.1% mild, 29.9% moderate/ severe) and depression (33.9% mild, 25.9% moderate/ severe) were prevalent among PHCPs. The female gender is the most important predictor of anxiety manifestations (OR:3.50, 95%CI:1.39-10.7; p=0.014). Participants older than 50 years have a lower risk of both anxiety (OR=0.46, 95%CI:0.20-0.99; p=0.049) and depression (OR=0.48, 95%CI:0.23-0.95; p=0.039). PHCPs working in rural facilities have a lower risk of anxiety (OR:0.34, 95%CI:0.137-0.80; p=0.016). Previous infection with SARS-CoV-2 was not associated either with anxiety (p=0.087) or with depression (p=0.056). Notably, having a friend, relative, or coworker who was hospitalized for COVID-19 or died from it, was not associated with the presence of anxiety or depressive symptoms. Additionally, living with someone in a high-risk group for severe SARS-CoV-2, living with children or being at high risk for severe COVID-19 was not associated with higher GAD-7 and PHQ-9 scores. Findings indicate concerning levels of psychological distress among PHCPs. Early recognition of emotional discomfort in PHCPs and the prompt intervention could reinforce PHCPs' resilience against the pandemic.

Prevalence of rheumatoid arthritis in Greece: results from the national health examination survey EMENO.

Rheumatoid arthritis (RA) is considered the most common form of autoimmune arthritis. The disease's prevalence is around 0.5-1% worldwide, but it seems to vary among different populations. The aim of this study was to estimate the prevalence of self-reported diagnosed RA in the general adult population in Greece. The data were derived from the Greek Health Examination Survey EMENO, a population-based survey performed between 2013 and 2016. Of the 6006 participants (response rate 72%), 5884 were eligible for this study. Prevalence estimates were calculated according to the study design. Prevalence of self-reported RA was estimated to be overall 0.5% (95% CI 0.4-0.7) being approximately three times higher in women than in men (0.7% vs 0.2%, p value = 0.004). A decrease in the prevalence of RA was observed in urban areas of the country. In contrast, higher disease rates were reported in individuals with lower socioeconomic status. Multivariable regression analysis showed that gender, age, and income were related to the occurrence of the disease. Osteoporosis and thyroid disease were the two comorbidities observed at statistically significant higher rates in individuals with self-reported RA. The prevalence of self-reported RA in Greece is similar to that reported in other European countries. Gender, age, and income are the main factors related to the disease's prevalence in Greece.

Twenty-first century epidemiology of dyslipidemia in Greece: EMENO national epidemiological study.

BACKGROUND: Greece was recently reclassified from low- to medium-risk country in terms of cardiovascular disease, with 27% of cardiovascular deaths attributed to hypercholesterolemia. EMENO nationwide survey (2013-2016) assessed the epidemiology of dyslipidemia in the general population in Greece. METHODS: A random sample of adults was drawn by multistage stratified random sampling based on 2011 census. Standardized questionnaires and blood tests for total cholesterol (TC), low-density (LDL-C), and high-density lipoprotein cholesterol (HDL-C), and triglycerides were used. Hypercholesterolemia was defined as TC ≥ 240/200 mg/dL and/or the use of lipid-lowering drugs, hyper-LDL-cholesterolemia as LDL-C ≥160/130/100 mg/dL and/or the use of drugs, hypo-HDL-cholesterolemia as HDL-C <40 mg/dL, and hypertriglyceridemia as triglycerides ≥150 mg/dL. Weighted analysis was applied to adjust for study design, age/sex distribution discrepancies between sample and population and nonresponse. RESULTS: Of 6,006 individuals recruited, 4,298 were analyzed (mean [SD] age 49.2 [18.5] years, men 48.5%, BMI 28.2 [5.7] kg/m2). Mean TC, LDL-C, HDL-C, and TG were 193.9 [44.4], 118.5 [37.6], 49.1 [14.9], and 130.8 [94.4] mg/dL, respectively. The prevalence of hypercholesterolemia was 27.6/52.4% for thresholds ≥240/200 mg/dL, and of hyper-LDL-cholesterolemia was 26.3/46.7/74% for thresholds ≥160/130/100 mg/dL, with no differences between sexes. The prevalence of hypo-HDL-cholesterolemia was 27.5% (men/women 38.1/17.5%, p < 0.001) and of hypertriglyceridemia was 27.8% (men/women 32.6/23.4%, p < 0.001). Lipid-lowering drugs were used by 14.1% of the participants (men/women 12.6/15.6%, p < 0.001). CONCLUSIONS: More than 50% of adults in Greece have some type of dyslipidemia (mainly TC ≥ 200 mg/dL) and 14% are treated. Nationwide programmes are needed to manage dyslipidemia and halt the increasing rate of cardiovascular disease in Greece.

Hepatitis B, C and human immunodeficiency virus knowledge among the general greek population: results from the Hprolipsis nationwide survey.

BACKGROUND: Although several studies on hepatitis B (HBV), C (HCV) and human immunodeficiency virus (HIV) infection have been conducted in Greece, little is known on the knowledge level of the Greek population towards these three infections. Our aim was to assess the knowledge level of the adult Greek general population about the HBV, HCV and HIV. METHODS: Data were derived from the first general population health survey, Hprolipsis. The sample was selected by multistage stratified random sampling. A standardized questionnaire was administered by trained interviewers during home visits. A knowledge score was constructed based on responses to 17 per infection selected items and categorized in three levels; high (12-17 correct replies) medium (6-11) and low (0-5). Among 8,341 eligible individuals, 6,006 were recruited (response rate: 72%) and 5,878 adults (≥ 18 years) were included in the analysis. The statistical analysis accounted for the study design. RESULTS: Only 30.4%, 21.6%, and 29.6% of the participants had a high overall knowledge level of HBV, HCV and HIV, respectively. These low percentages were mainly attributed to the high levels of misconception about transmission modes (65.9%, 67.2%, and 67.9%, respectively). Results showed that increasing age and living out of the big metropolitan cities were associated with decreased odds of having higher knowledge. Female gender, higher education level, higher monthly family income, higher medical risk score, history of testing and being born in Greece or Cyprus, were associated with increased odds of having higher knowledge. CONCLUSIONS: There are significant knowledge gaps in the Greek general population regarding modes of transmission, preventive measures and treatment availability for HBV, HCV and HIV. There is an urgent need for large scale but also localized awareness activities targeted to less privileged populations, to fill the gaps in knowledge and increase population engagement in preventive measures.

Thyroid dysfunction in Greece: Results from the national health examination survey EMENO.

BACKGROUND: Nationwide data on thyroid disease prevalence in Greece is lacking. Using the national health examination survey EMENO data resources, we aimed to estimate the prevalence of hypothyroidism and hyperthyroidism and associated risk factors in adults living in Greece. METHODS: A random sample of the adults (≥18 years) living in Greece was drawn by multi-stage stratified random sampling based on the 2011 census. During home visits, trained interviewers administered a standardized questionnaire to study participants. All participants answered questions concerning demographic parameters (e.g., age, sex, degree of urbanization, income) and questions concerning smoking habits, alcohol, dietary habits and psychological parameters such as anxiety and thyroid disease. Weighted logistic regression models were fitted to assess factors associated with thyroid disease. RESULTS: In total, 6006 individuals were recruited in the Greek Health Examination Survey EMENO (response rate 72%) of whom 5981 were eligible for this study. The prevalence of thyroid disease was 9%, where 0.4% was related to hyperthyroidism and 8.6% to hypothyroidism. The prevalence of thyroid disease was higher in women (14.9%) than men (2.7%) (p<0.001). The highest rates of thyroid disease were observed in former iodine-deficient areas. A decrease in the prevalence of thyroidopathies with increasing alcohol consumption was found. Thyroid disease was associated with anxiety in men. Multivariable regression analysis showed that age, geographic area, and smoking were related to thyroid disease. CONCLUSION: The prevalence of thyroid disease in Greece is higher in women. Age, habits, and characteristics of geographic areas determine the distribution of thyroidopathies in Greece.

Perceived risk and pandemic response awareness in low-capacity public primary health care in Greece.

INTRODUCTION: Primary health care (PHC), the cornerstone of health systems, has an important role in infectious disease control. The SARS-CoV-2 (COVID-19) pandemic has put a burden on health systems worldwide and especially on healthcare workers at the first line delivering their services in remote areas of Greece. This study investigates preparedness and awareness level of primary healthcare workers (PHCWs) and their risk perception in managing the pandemic during its initial phase. METHODS: A cross-sectional survey was conducted in public PHC units in Greece. A web-based 14-item questionnaire, tested in a pilot study, was administered by a pre-existing panel of the Education and Research Network in PHC of Aristotle University of Thessaloniki, Greece. Associations were assessed between epidemic response awareness, risk perception, participant demographics and work settings. Participants were grouped by profession in first-line physicians (general practitioners, internal medicine specialists, pediatricians), first-line non-physicians (nurses, health visitors, paramedics) and second-line PHCWs (dentists, microbiologists, administrators, midwifes, laboratory technicians, nutritionists and social workers). Univariate logistic regression and multivariable analysis were performed and linear regression was performed to examine the effect of participants' awareness of the preparedness plan to their working area characteristics. RESULTS: A total of 441 PHCWs participated in the survey. Risks were perceived at a lower level by second-line PHCWs than by first-line PHCWs (B=-0.78, 95% confidence interval (CI) -1.49- -0.08; p=0.028). Older PHCWs had less concerns than younger PHCWs (B=-0.04, 95%CI -0.08- -0.01; p=0.025) and more experienced participants had more concerns than less experienced (B=0.04, 95%CI 0.00,0.07; p=0.050). PHCWs in rural settings presented with more preparedness awareness, compared to PHCWs in urban areas (B=1.10, 95%CI 0.28,1.92; p=0.008), while PHCWs living with high risk individuals showed less situation awareness (-0.55, 95%CI -0.95-0.16; p=0.006). CONCLUSION: PHCWs in rural areas revealed a relatively high awareness of the response measures and management protocol requirements that were in place, compared to their colleagues in urban areas. As expected, first-line PHCWs directly exposed to emergencies expressed more concerns than second-line PHCWs. Learning from the challenges occurring during the initial phase of the pandemic could help PHC facilities address COVID-19 effectively and PHCWs' sense of security and confidence could be augmented, even when working in remote areas of the country. When planning training, distributing equipment and proposing protocols, the characteristics of the area and the needs of PHCWs, and population should be cautiously considered.

Opportunistic screening for hypertension: what does it say about the true epidemiology?

This study aimed to assess the reliability of opportunistic screening programs in estimating the prevalence, treatment, and control rate of hypertension in the general population. Two recent epidemiological surveys obtained data on hypertension in the adult general population in Greece. The EMENO (2013-2016) applied a multi-stage stratified random sampling method to collect nationwide data. The MMM (2019) collected data through opportunistic (voluntary) screening in five large cities. Hypertension was defined as blood pressure (BP) ≥ 140/90 mmHg (single occasion; average of 2nd-3rd measurement; electronic devices) and/or use of antihypertensive drugs. Data from a total of 10,426 adults were analyzed (EMENO 4,699; MMM 5,727). Mean age (SD) was 49.2 (18.6)/52.7 (16.6) years (EMENO/MMM, p < 0.001), men 48.6/46.5% (p < 0.05) and body mass index 28.2 (5.7)/27.1 (5.0) kg/m2 (p < 0.001). The prevalence of hypertension in ΕΜΕΝΟ/MMM was 39.6/41.6% (p < 0.05) and was higher in men (42.7/50.9%, p < 0.001) than in women (36.5/33.6%, p < 0.05). Among hypertensive subjects, unaware were 31.8/21.3% (EMENO/MMM, p < 0.001), aware untreated 2.7/5.6% (p < 0.001), treated uncontrolled 35.1/24.8% (p < 0.001), and treated controlled 30.5/48.3% (p < 0.001). In conclusion, the prevalence of hypertension was similar with random sampling (EMENO) and opportunistic screening (MMM). However, opportunistic screening underestimated the prevalence of undiagnosed hypertension and overestimated the rate of hypertension treatment and control. Thus, random sampling national epidemiological studies are necessary for assessing the epidemiology of hypertension. Screening programs are useful for increasing awareness of hypertension in the general population, yet the generalization of such findings should be interpreted with caution.

Prevalence of tobacco smoking and association with other unhealthy lifestyle risk factors in the general population of Greece: Results from the EMENO study.

INTRODUCTION: The EMENO (National Morbidity and Risk Factors) survey is one of the first and most representative population-based surveys in Greece due to its study design and sampling procedure. We aimed to estimate the prevalence of smoking, secondhand smoking (SHS) and their potential associations with other socioeconomic and unhealthy lifestyle risk factors. METHODS: EMENO is a cross-sectional health status survey conducted in Greece from May 2013 to June 2016. The survey was performed using face-to-face interviews and enrolled 6006 adults. Data were collected through questionnaires administered by trained interviewers. Current smoking (CS) and SHS were based on self-reporting. Analysis accounted for study design. RESULTS: Information on smoking was available for 5862 individuals (97.6%). Overall, 37.8% were current and 16.1% former smokers. More males (44.3%) than females (31.6%) were current smokers. CS increased during adulthood and declined sharply in the elderly (p<0.001). Smoking initiation by the age of 17 years was reported by 48.7% of males and 36.2% of females. Multivariable analysis showed that higher alcohol consumption (>7 glasses/ week, OR=2.52; 95% CI: 1.97-3.23) and lower education level in men were positively associated with ever smoking. Moreover, women aged >35 years and respondents with low adherence to the Mediterranean diet (MD) (high/ low, OR= 0.35; 95% CI: 0.21-0.58) had higher odds to be current smokers than former smokers. Finally, the overall prevalence of exposure to SHS at work, home and public places was 38.8%, 30% and 44.6 %, respectively. CONCLUSIONS: Unhealthy lifestyles of smokers, increased rates of CS in vulnerable groups, such as females and young adults, and early age of smoking initiation constitute alarming public health issues in Greece.

Primary care professionals' experiences during the first wave of the COVID-19 pandemic in Greece: a qualitative study.

BACKGROUND: The coronavirus outbreak (COVID-19) tested health care systems worldwide. This qualitative study aimed to explore and understand the experiences, beliefs and concerns of Primary Care Professionals (PCPs) regarding the preparedness and response of primary care to the first wave of the pandemic in Greece, a country where a public structured primary care system has been developing. METHODS: We conducted semi-structured telephone interviews with 33 PCPs (General Practitioners, community General Internal Medicine Specialists, community Paediatricians and nurses) recruited from all regions of Greece after the first wave of the pandemic (June 2020). Interviews were transcribed verbatim, data were anonymised and analysed. Thematic analysis was applied developing a conceptual framework. RESULTS: Four main themes were identified: a) Primary care unit adaptation and issues faced during the pandemic; b) Management of suspected COVID-19 cases; c) Management of non-suspected cases; d) Consequences of the pandemic. In the first phase of the pandemic, remote management of suspected cases and their referral to the hospital were preferred as a result of a shortage of personal protective equipment and inaccessibility to coronavirus testing in primary care. Due to the discontinuation of regular medical services and the limited in-person contact between doctors and patients, chronic disease management and prevention programmes were left behind. Social and emotional consequences of the pandemic, such as workplace stigma, isolation and social seclusion, deriving from fear of viral transmission, as well as burnout symptoms and exhaustion were commonly experienced among PCPs. Positive consequences of the pandemic were considered to be the recognition of the importance of an empowered public healthcare system by citizens and the valuable insight, knowledge and experience professionals gained in times of crisis. CONCLUSIONS: Primary care has a key role to play during and after the pandemic by using its information infrastructure to identify at-risk groups, detect new cases of COVID-19, provide care according to needs, and carry out vaccination programmes. Central coordination and empowerment of primary care will increase its effectiveness, via public awareness, holistic patient management, and unburdening of hospitals.

Living in Roma Settlements in Greece: Self-Perceived Health Status, Chronic Diseases and Associated Social Determinants of Health.

We aimed to assess the self-perceived health status and the presence of chronic diseases of adult Roma living in settlements in Greece, and to explore associated social determinants of health. Data were derived from the Hprolipsis Health Survey. Multivariable regression models were applied. In total, 534 adults, 287 women, and 247 men were recruited from twelve Roma settlements in four prefectures. Although 62% of the participants perceived their health status as good/very good, about half of them had been diagnosed with at least one chronic disease. Several structural and intermediary social determinants of health were found to be significantly associated with the health outcomes; prefecture, settlement type, sex, age group, living with a partner, presence of depression symptoms, food insecurity, and alcohol consumption were associated with self-perceived health status; settlement type, sex, age group, presence of anxiety symptoms, food insecurity and number of persons living in the house with the presence of a chronic disease. This is one of the few studies assessing the self-perceived health status and presence of chronic diseases in Roma settlements in Greece and investigating the associated social determinants of health in the world. Community-based participatory action research and health literacy programs are needed to mitigate health inequalities in Roma settlements.

Feasibility and impact of a short training course on frailty destined for primary health care professionals.

BACKGROUND: There is an unmet need for training primary health care professionals on frailty, especially in countries where geriatrics is still emerging. PURPOSE: We aimed to evaluate the feasibility and efficacy of a training course for primary health care professionals on the detection, assessment, and management of frailty. METHODS: A single-day training course, developed and facilitated by three physicians trained in geriatrics abroad, was organized by the Aristotle University of Thessaloniki Primary Hearth Care Research Network. Primary health care professionals' attitudes, knowledge, and everyday practices regarding frailty were assessed by self-administered anonymous questionnaires (using Likert-type scales) at three time-points (before, upon completion of the training course, and 3 months afterward). RESULTS: Out of 31 participants (17 physicians, 12 nurses, 2 health visitors; 87.1% women; mean age 46.4 years), 31(100%) filled in the first, 30(97%) the second, and 25(81%) the third questionnaire. Improvements were reported in familiarization with the frailty syndrome (p = 0.041) and in self-perception of knowledge and skills to detect (p < 0.001) and manage (p < 0.001) frailty, that were also sustained 3 months afterward (p = 0.001 and p = 0.003 respectively). Improvement was also observed in the attitude that frailty is an inevitable consequence of aging (p = 0.007) and in the frequency of application of screening (but not management) strategies, 3 months following the workshop compared to baseline (p = 0.014). Participants reported less disagreement with the statement that systematic screening for frailty was unfeasible in their daily practice at 3 months compared to baseline (p = 0.006), mainly due to time restrictions. CONCLUSION: A short skill-oriented training course can significantly and sustainably improve primary health care professionals' attitudes and practices regarding frailty.

Prevalence, awareness, treatment and control of hypertension in Greece: EMENO national epidemiological study.

OBJECTIVE: The evidence on the epidemiology of hypertension in Greece is limited. The prevalence and control of hypertension was assessed in randomly selected adults of the general population in Greece within the nationwide epidemiological study EMENO. METHOD: On the basis of 2011 census, EMENO applied a multistage stratified random sampling method involving 577 areas throughout Greece (2013-2016). Participants were assessed at home visits with standardized questionnaires, blood tests and triplicate seated blood pressure (BP) measurements (validated upper-arm automated oscillometric device Microlife BPA100 Plus). Hypertension was defined as BP at least 140/90 mmHg (average of second--third measurement) and/or use of antihypertensive drugs. Sampling weights were applied for study design and post-stratification weights to match the age/sex distribution to the general population in Greece. Nonresponse was adjusted by inverse probability weighting. RESULTS: A total of 6006 individuals were recruited and 4699 with valid data were analysed [mean (SD) age 49.2 (18.6) years, men 48.6%, BMI 28.2 (5.7) kg/m2]. The prevalence of hypertension was 39.6% and was higher in men than women (42.7 vs. 36.5%, P < 0.001). Among patients with hypertension, 31.8% were unaware (men/women 39.2/23.6%, P < 0.001), 2.7% aware but untreated (men/women 2.9/2.5%, P = NS), 35.1% treated uncontrolled (32.1/38.3%, P < 0.01) and 30.5% treated controlled (25.8/35.6%, P < 0.001). CONCLUSION: The prevalence of hypertension in Greece seems to be rising and affects 40% of the adults. One-third of them are undiagnosed and only 30% are controlled with treatment. Nationwide programmes are needed to prevent hypertension and improve its awareness and control aiming at reducing the rate cardiovascular diseases.

Prevalence of diabetes and pre-diabetes in Greece. Results of the First National Survey of Morbidity and Risk Factors (EMENO) study.

AIMS: To report the results of the first national Health Examination Survey (HES) on the prevalence of diabetes, its pharmacologic treatment and level of control, as well as pre-diabetes in Greece. METHODS: Data were derived from the National Survey of Morbidity and Risk Factors (EMENO), in a randomly selected, representative sample of the adult Greek population. Sampling weights were applied to adjust for study design and post-stratification weights to match sample age/sex distribution to the population. Non-response was adjusted by inverse probability weighting. Weighted prevalence estimates are provided. RESULTS: A total of 4393 persons with HbA1c and/or fasting plasma glucose measurements were included. Total diabetes prevalence was 11.9% (95% CI: 10.9-12.9), known diabetes 10.4% (9.5-11.4), and unknown 1.5% (1.1-1.9), with considerable increase in older age groups and no difference between genders. Pre-diabetes prevalence was 12.4% (11.4-13.6). The majority of persons with known diabetes were receiving metformin. Of those with known diabetes (and measured HbA1c), 70.9% were well controlled (HbA1c <7.0%). CONCLUSIONS: This first representative national HES showed high prevalence of diabetes in Greece, with low prevalence of unknown diabetes. Pre-diabetes prevalence is also substantial. These results will hopefully enable national authorities develop tailored and efficient strategies for disease prevention and management.

Perceptions, attitudes and training needs of primary healthcare professionals in identifying and managing frailty: a qualitative study.

PURPOSE: Although frailty can be delayed or prevented by appropriate interventions, these are often not available in countries lacking formal education and infrastructure in geriatrics. The aim of this study was to: (a) explore ideas, perceptions and attitudes of primary health care (PHC) professionals towards frailty in a country where geriatrics is not recognised as a specialty; (b) explore PHC professionals' training needs in frailty; and (c) define components of a frailty educational programme in PHC. METHODS: Qualitative design, using two focus groups with PHC professionals conducted in Thessaloniki, Greece. Focus groups were audio recorded and transcribed. Data were analysed with thematic analysis. RESULTS: In total 31 PHC professionals (mean age: 46 years; gender distribution: 27 females, 4 males) participated in the study (physicians n = 17; nurses n = 12; health visitors n = 2). Four main themes were identified: (1) Perceptions and understanding of frailty; (2) Facilitators and barriers to frailty identification and management; (3) Motivation to participate in a frailty training programme; (4) Education and training. The main barriers for the identification and management of frailty were associated with the healthcare system, including duration of appointments, a focus on prescribing, and problems with staffing of allied health professionals, but also a lack of education. Training opportunities were scarce and entirely based on personal incentive. Professionals were receptive to training either face-to-face or online. A focus on learning practical skills was key. CONCLUSION: Education and training of professionals and interdisciplinary collaboration are essential and much needed for the delivery of person-centred care for people with frailty living in the community.

High prevalence of cardiovascular risk factors in adults living in Greece: the EMENO National Health Examination Survey.

BACKGROUND: Nationwide data on cardiovascular risk factors prevalence is lacking in Greece. This work presents the findings of the national health examination survey EMENO (2013-2016) regarding the prevalence of hypertension, hypercholesterolemia, diabetes, obesity and smoking. METHODS: A random sample of adults (≥18 years) was drawn by multistage stratified random sampling based on 2011 Census. All EMENO participants with ≥1 measurement of interest [blood pressure (BP), fasting glucose, HbA1c, total cholesterol (TC), Body Mass Index (BMI)] were included. Hypertension was defined as BP ≥ 140/90 mmHg and/or antihypertensive treatment; diabetes as fasting glucose≥126 mg/dL and/or HbA1c ≥ 6.5% or self-reported diabetes; hypercholesterolemia as TC ≥ 190 mg/dL. Sampling weights were applied to adjust for study design and post-stratification weights to match sample age and sex distribution to population one. Non-response was adjusted by inverse probability weighting. RESULTS: Of 6006 EMENO participants, 4822 were included (51.5% females, median age:47.9 years). The prevalence of hypertension was 39.2%, higher in men (42.4%) than in women (36.1%); of hypercholesterolemia 60.2%, similar in men (59.5%) and women (60.9%); of diabetes 11.6%, similar men (12.4%) and women (10.9%); of obesity 32.1%, higher in women (33.5% vs 30.2%), although in subjects aged 18-40 year it was higher in men; of current smoking 38.2%, higher in men (44.0%) than in women (32.7%). The prevalence of all risk factors increased substantially with age, except smoking, which followed an inverse U shape. CONCLUSIONS: The burden of cardiovascular risk factors among Greek adults is alarming. There is considerable preventive potential and actions at health care and societal level are urgently needed.

Cardiovascular risk factors in HIV infected individuals: Comparison with general adult control population in Greece.

BACKGROUND: Although combined antiretroviral therapy has substantially improved the prognosis of people living with HIV (PLHIV), mortality remains higher compared to the general population, mainly due to higher prevalence of non-HIV-related comorbidities, including cardiovascular diseases (CVD). We assessed the prevalence of CVD risk and its contributing factors in adult PLHIV versus general population controls in Greece. SETTINGS: Cross-sectional comparison of PLHIV (Athens-Multicenter-AIDS-Cohort-Study; AMACS) versus general population controls (National health examination survey; EMENO). METHODS: All HIV-infected adults with ≥1 measurement of interest (blood pressure, lipids, glucose, weight, height) between 2012-2014 and all EMENO participants (2014-2016) were included. Ten-year total CVD risk was estimated using the Framingham (FRS) or the Systematic Coronary Risk Evaluation (SCORE) equations. RESULTS: 5839 PLHIV (median age:41.6 years, 85.4% males) and 4820 controls (median age:48 years, 48.4% males) were included. Adjusting for age, sex and origin, PLHIV were more likely to be current smokers (adjusted OR:1.53 [95% CI:1.35-1.74]) and dyslipidemic (aOR:1.18; [1.04-1.34]), less likely to be obese (aOR:0.44 [0.38-0.52], with no differences in hypertension, diabetes or high (≥20%) FRS but with greater odds of high (≥5%) SCORE (aOR:1.55 [1.05-2.30]). Further adjustment for educational level, anti-HCV positivity and BMI showed higher prevalence of hypertension in PLHIV. CONCLUSIONS: Despite the relative absence of obesity, PLHIV have higher prevalence of traditional CVD risk factors and higher risk of fatal CVD compared to general population. Regular screening and early management of CVD risk factors in PLHIV should be of high priority for CVD prevention.

Design and Development of a Viral Hepatitis and HIV Infection Screening Program (Hprolipsis) for the General, Greek Roma, and Migrant Populations of Greece: Protocol for Three Cross-Sectional Health Examination Surveys.

BACKGROUND: Although infectious diseases are globally on the decline, they remain a major global public health problem. Among them, the hepatitis B virus (HBV) or hepatitis C virus (HCV) and HIV infection are of primary interest. Valid prevalence data on these infections are sparse in Greece, especially for vulnerable populations. OBJECTIVE: This study aimed to present the design and methods of Hprolipsis, an integrated viral hepatitis and HIV screening program administered to adults (≥18 years) from the general, Greek Roma, and migrant populations. Its aims were to estimate the prevalence of HBV, HCV, and HIV; assess infectious disease knowledge level; design, implement, and assess population-specific awareness actions; and offer individual counseling and referral when indicated and HBV vaccination to susceptible Roma and migrants. METHODS: Multistage, stratified, random sampling based on the 2011 Census was applied to select the general population sample, and nonprobability multistage quota sampling was used for Roma and migrant sample selection. Trained personnel made home (general population) or community (Roma and migrants) visits. Collected blood samples were tested for Hepatitis B surface Antigen, Hepatitis B core Antibody, Hepatitis B surface Antibody, Hepatitis C Antibody, and HIV 1,2 Antibody. The surveys were conducted during May 2013 and June 2016. To estimate an HCV prevalence of 1.5% with 0.3 precision, the required general population sample size was estimated to be 6000. As migrants constitute 10% of the whole Greek population, the migrant sample size was set to 600. A feasible sample size of 500 Greek Roma was set. RESULTS: In total, 6006 individuals from the general population (response rate 72%), 534 Greek Roma, and 612 migrants were recruited. Blood test results are available for 4245 individuals from the general population, 523 Roma, and 537 migrants. CONCLUSIONS: Hprolipsis is the first nationwide survey on HBV, HCV, and HIV. Its results will enhance our understanding of the health needs and disease burden of these diseases in the 3 studied populations. Its implementation provided useful recommendations for future studies, particularly in vulnerable populations. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/13578.

National Survey of Morbidity and Risk Factors (EMENO): Protocol for a Health Examination Survey Representative of the Adult Greek Population.

BACKGROUND: Main causes of death in Greece are cardiovascular diseases (CVDs), malignant neoplasms, respiratory diseases, and road traffic crashes. To assess the population health status, monitor health systems, and adjust policies, national population-based health surveys are recommended. The previous health surveys that were conducted in Greece were restricted to specific regions or high-risk groups. OBJECTIVE: This paper presents the design and methods of the Greek Health Examination Survey EMENO (National Survey of Morbidity and Risk Factors). The primary objectives are to describe morbidity (focusing on CVD, respiratory diseases, and diabetes), related risk factors, as well as health care and preventive measures utility patterns in a random sample of adults living in Greece. METHODS: The sample was selected by applying multistage stratified random sampling on 2011 Census. Trained interviewers and physicians made home visits. Standardized questionnaires were administered; physical examination, anthropometric and blood pressure measurements, and spirometry were performed. Blood samples were collected for lipid profile, glucose, glycated hemoglobin, and transaminases measurements. The survey was conducted from May 2013 until June 2016. RESULTS: In total, 6006 individuals were recruited (response rate 72%). Of these, 4827 participated in at least one physical examination, 4446 had blood tests, and 3622 spirometry, whereas 3580 provided consent for using stored samples for future research (3528 including DNA studies). Statistical analysis has started, and first results are expected to be submitted for publication by the end of 2018. CONCLUSIONS: EMENO comprises a unique health data resource and a bio-resource in a Mediterranean population. Its results will provide valid estimates of morbidity and risk factors' prevalence (overall and in specific subdomains) and health care and preventive measures usage in Greece, necessary for an evidence-based strategy planning of health policies and preventive activities. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/10997.

Discrepancies and misconceptions of perceived colorectal cancer screening barriers between primary health professionals and unscreened population. A comparative study in Greece.

PURPOSE: Our study aimed to compare the views of healthy eligible unscreened adults, to those of primary care providers in Greece, about colorectal cancer (CRC) screening perceived barriers. METHODS: A sample of 791 unscreened adults (50-75 years) from a recent nationwide health survey in Greece were interviewed about CRC screening barriers, and the main reason for not adhering to colonoscopy and fecal occult blood test (FOBT) was assessed. Results were compared to a concurrent survey of 161 primary care professionals (PCPs) from the same region and the agreement with the general population was assessed with odds ratios (OR) and 95% confidence intervals (CI). RESULTS: General population stated as a primary barrier for colonoscopy, at a significant higher frequency than the PCPs (p<0.001), lack of symptoms (44.5 vs 5.7%), negligence (14.2 vs 3.8%) and lack of PCP recommendation (9.2 vs 2.5%). PCPs were more likely to agree for fear of pain of colonoscopy (OR:19.6, 95%CI 9.3-41.4), fear of cancer diagnosis (OR:17.7, 95%CI 10.8-29.1), and embarrassment (OR:13.8, 95%CI 8.1-23.6). Regarding FOBT, the most frequent barrier for the unscreened population compared to PCPs (p<0.001), was lack of symptoms (38.2 vs 3.9%), followed by unawareness of the test (22.9 vs 55.2%) and lack of PCP recommendation (13% vs 12.3%). The only barrier that PCPs agreed at significantly lower frequency was the lack of physician recommendation (OR:0.3; 95%CI 0.2-0.4). CONCLUSIONS: PCPs do not share the same views as the general population about CRC screening barriers in Greece. PCPs should focus counseling on patient perceived barriers in order to promote adherence.

Population seroprevalence study after a West Nile virus lineage 2 epidemic, Greece, 2010.

INTRODUCTION: During summer 2010, 262 human cases including 35 deaths from West Nile virus (WNV) infection were reported from Central Macedonia, Greece. Evidence from mosquitoes, birds and blood donors demonstrated that the epidemic was caused by WNV lineage 2, which until recently was considered of low virulence. We conducted a household seroprevalence study to estimate the spread of infection in the population during the epidemic, ascertain the relationship of infection to clinical disease, and identify risk factors for infection. METHODS: We used a two-stage cluster design to select a random sample of residents aged ≥18 years in the outbreak epicentre. We collected demographic, medical, and risk factor data using standard questionnaires and environmental checklists, and tested serum samples for presence of WNV IgG and IgM antibodies using ELISA. RESULTS: Overall, 723 individuals participated in the study, and 644 blood samples were available. Weighted seropositivity for IgG antibodies was 5.8% (95% CI: 3.8-8.6; n=41). We estimated that about 1 in 130 (1:141 to 1:124) infected individuals developed WNV neuroinvasive disease, and approximately 18% had clinical manifestations attributable to their infection. Risk factors for infection reflected high exposure to mosquitoes; rural residents were particularly at risk (prevalence ratio: 8.2, 95% CI: 1.1-58.7). DISCUSSION: This study adds to the evidence that WNV lineage 2 strains can cause significant illness, demonstrating ratios of infection to clinical disease similar to those found previously for WNV lineage 1.