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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 (p7 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.

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

We aimed to evaluate the feasibility and efficacy of a short training course on frailty destined for primary health care (PHC) professionals. PHC professionals applied frailty screening strategies more frequently 3 months following the workshop compared to baseline and reported improvements in a) their familiarization with the frailty syndrome, b) self-perception of knowledge and skills to detect and manage frailty, and c) the attitude that frailty is an inevitable consequence of aging. Time restrictions was reported to be the main barrier to the application of frailty screening and management strategies. A short skill-oriented training course can significantly and sustainably improve PHC professionals’ attitudes and practices regarding frailty. There is an unmet need for training primary health care professionals on frailty, especially in countries where geriatrics is still emerging. 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. 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). 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

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

Key summary points Aim To explore the perceptions and attitudes of primary health care (PHC) professionals towards frailty in a country where geriatrics is not recognised as a specialty, and to explore their training needs in the identification and management of frailty. Findings The main barriers towards identifying and managing frailty are associated with the healthcare system, with the most important ones identified to be a gap in geriatric education and training of professionals, as well as problems with staffing of allied health professionals (AHPs) in community settings. However, PHC professionals are motivated and receptive to training in frailty, and they particularly value interactive learning with a focus on practical skills. Message There is an imperative need for education and training of PHC professionals, recruitment and training of AHPs and interdisciplinary collaboration for the delivery of person-centred care for people with frailty living in the community. Electronic supplementary material The online version of this article (10.1007/s41999-020-00420-0) contains supplementary material, which is available to authorized users., 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. Electronic supplementary material The online version of this article (10.1007/s41999-020-00420-0) contains supplementary material, which is available to authorized users.

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.

BackgroundAlthough 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.SettingsCross-sectional comparison of PLHIV (Athens-Multicenter-AIDS-Cohort-Study; AMACS) versus general population controls (National health examination survey; EMENO).MethodsAll 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.Results5839 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.ConclusionsDespite 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.

BackgroundAlthough 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.ObjectiveThis 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.MethodsMultistage, 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.ResultsIn 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.ConclusionsHprolipsis 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

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

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 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.

The global economic crisis has affected the Greek economy with unprecedented severity, making Greece an important test of the relationship between socioeconomic determinants and a population’s well-being. Suicide and homicide mortality rates among men increased by 22.7% and 27.6%, respectively, between 2007 and 2009, and mental disorders, substance abuse, and infectious disease morbidity showed deteriorating trends during 2010 and 2011. Utilization of public inpatient and primary care services rose by 6.2% and 21.9%, respectively, between 2010 and 2011, while the Ministry of Health’s total expenditures fell by 23.7% between 2009 and 2011. In a time of economic turmoil, rising health care needs and increasing demand for public services collide with austerity and privatization policies, exposing Greece’s population health to further risks.

To date no nationwide epidemiological study of asthma in the general population has been performed in Greece. The present study evaluated the prevalence of asthma and asthma related symptoms (ARS) in a randomly selected sample representative of the adult general population in Greece. The EΜEΝΟ survey (National Morbidity and Risk Factors Survey) supported by the European Social Fund and national funds, is currently performed in Greece, aiming to include 6,000 adults using a multi-stage stratified random sampling method, involving localities throughout the country. Information on asthma and ARS during the last 12 months was collected through questionnaires administered by trained interviewers. An interim analysis of participants recruited from 03/2014 to 12/2015 was performed. Prevalence of asthma and ARS was determined taking into account the design of the study and additional adjustments for age and sex. A total of 5,137 participants were included. The prevalence of asthma was 6.3% (CI 95%: 5,6%-7,0%) and it was higher in women (7.2% vs 5.3% in men, p=0.011). We also observed higher prevalences of ARS in women except wheezing. Prevalences of ARS (overall) are presented below Asthma and asthma related symptoms prevalence in the general adult population in Greece are higher than the global ones estimated by the World Health Survey (To et al, BMC Public Health 2012; 12: 204).

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.

The main educational aim of our primary care attachment is to advocate community primary care oriented to the health needs of the population. In the case of the Greek National Health System, only Rural Health Centres (RHCs) offer community based health care. In urban areas primary care services are delivered from private physicians and social insurance funds’ health units (polyclinics). The cost of travel and accommodation for medical students is a matter of continuous consideration, especially in a time of economic recession such as the one Greece is currently facing. Collaboration with RHCs in the areas of students’ family residence was preferred, as well as RHCs that could provide free accommodation. Even though such an approach might raise more organisational issues, it also drives to the increase of collaborating teaching RHCs, necessary in the case of medical schools where more than 300 students practise each academic year.