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The present work aimed at identifying the geographical variability, as well as the socioeconomic, lifestyle and environmental determinants of people’s health-related quality of life (HRQoL) at an aggregated level, and to investigate whether men’s and women’s HRQoL are affected differently by these characteristics. A cross-sectional spatial analysis in the context of the ATTICA epidemiological study. HRQoL data were provided by the ATTICA epidemiological study for n = 2749 participants with complete data for geographical identification, (n = 1375 women [44 years old (SD = 14 years)] and n = 1374 men [45 years old (SD = 13 years)]. Socio-economic, demographic, and environmental characteristics were obtained from official national and international databases. Poisson regression and Geographically Weighted Poisson regression analysis were used for the global and the local statistical modelling, respectively. Better HRQoL was detected in areas with higher socioeconomic status, with younger residents following healthier lifestyle and eating habits, higher percent of married individuals, lower percent of illiterate people and rate of immigration, as well as in municipalities with higher land coverage by green urban areas. A significant interaction between sex and studied area on HRQoL was observed, suggesting that men and women follow different patterns regarding their quality of life. In line with the current European policy developments, our findings support the transformation of public health actions to local authorities and provide input for policy makers to better understand how people’s HRQoL is affected by the characteristics of the area in which they live.

To quantify the changes in 10-year cardiovascular disease (CVD) onset, recurrence, and mortality, in relation to transitioning from low to a higher level of adherence to the Mediterranean diet. An individual-level microsimulation was created based on ATTICA (2002–2012, n = 3042 subjects free-of-CVD) and GREECS (2004–2014, n = 2172 patients with acute coronary syndrome (ACS)) studies (in total n = 5214). Eight scenarios regarding the proportion of participants and the size of improvement of the level of adherence to the Mediterranean diet (corresponding to one to ten point increases in MedDietScore) were compared in terms of relative change in CVD incidence and mortality, as well as, the number of preventable CVD events and deaths. Improving adherence to the Mediterranean diet in at least 10% of the population, a significant relative percentage reduction could be observed in 10-year CVD onset, recurrence, and mortality. At least 851 first CVD events, 374 recurrent CVD events, and 205 CVD deaths per 100,000 of the population could be averted or delayed. In addition, Mediterranean diet clustering revealed that scoring higher in fruits, vegetables, whole wheat products, and legumes was more important than achieving higher scores in low consumption of meat and full-fat dairy products against CVD (all HRs in the former cluster were lower than the latter, indicating a stronger protective effect). This microsimulation process confirms the added value of the Mediterranean diet in primary and secondary CVD prevention having great achievements even with modifications in a small part of the population (10%), while challenges the orientation of Mediterranean-diet interventions giving higher weights to plant-based part.

The built and food environments are widely acknowledged to play an important role in defining human health by influencing, among others, behaviors such as nutrition habits and physical activities. The aim of this study was to identify the spatial variability of the sex-specific prevalence of the metabolic syndrome (MetS) and its environmental determinants in the Athens metropolitan area. Data on the prevalence of the MetS were provided by the ATTICA epidemiological study for 2749 participants, with complete data for geographical identification (1375 women [44 years old {SD = 14 years}] and 1374 men [45 years old {SD = 13 years}]), while socioeconomic, demographic, and environmental characteristics were provided by official national and international databases. Approximately 20% of the people residing in the study area were diagnosed with MetS, with its prevalence being almost two times higher in men compared to women. Areas more extensively covered by green urban spaces and sports facilities were shown to have a lower prevalence of MetS, while greater density and availability of supermarkets and street markets were inversely related to MetS prevalence in both sexes. In addition, the present analysis revealed that the beneficial role of the built environment’s characteristics on MetS prevalence was significantly stronger in the male population, while the preventive effect of the food environment’s characteristics was almost 1.5 times stronger in the female population Although individualized prevention and treatment approaches are necessary to decrease the burden of MetS, environmental modifications that promote healthy behaviors represent an essential health approach.

Background: Missing data constitutes a common phenomenon, especially, in questionnaire-based, population surveys or epidemiological studies, with the statistical power, the efficiency and the validity of the conducted analyses being significantly affected by the missing information. The aim of the present work was to investigate the socio-demographic, lifestyle and clinical determinants of low response rate in a self- rating multi-item scale, estimating the individuals’ hostility and direction of hostility. Methods: 3042 apparently healthy volunteers residing in the Athens metropolitan area participated in the ATTICA epidemiological study [1514 (49.8%) were men [46 years old (SD= 13 years)] and 1528 (50.2%) were women [45 years old (SD= 14 years)]]. Hostility and Direction of Hostility was assessed with the Hostility and Direction of Hostility (HDHQ) scale. Binary logistic regression with backward model selection was used in order to identify the key demographic, clinical and lifestyle determinants of higher non-response rate in the HDHQ scale. Results: The vast majority of the participants (87.0%) had missing information in the HDHQ scale. Older age, lower educational level, poorer health status and unhealthy dietary habits, were found to be significant determinants of high nonresponse rate, while female participants were found to be more likely to have missing data in the items of the HDHQ scale. Conclusions: The present work augments prior evidence that higher non-response to health surveys is significantly affected by responders’ background characteristics, while it gives rise to research towards unrevealed paths behind this claim.

Background To explore the effect of household food insecurity on dietary patterns of children and adolescents participating in a school food-aid programme in regions of Greece with low socioeconomic status. Methods A cross-sectional study was conducted during the school year 2013–14, among 406 schools in low socioeconomic status regions of Greece. Dietary habits and sociodemographic characteristics of students and their families were recorded. Factor analysis was used in order to derive children’s and adolescents’ dietary patterns and analysis of covariance was performed to examine the effect of households’ food insecurity level on those patterns. A total of 31 399 students participated in the study; 16 652 children (5–11 years) and 14 747 adolescents (12–18 years). Results Factor analysis identified five dietary patterns in both age groups, explaining the 49.1% (children) and 53.0% (adolescents) of the total variation in intake. After adjusting for various factors, the household’s food insecurity was significantly associated with the majority of the derived patterns in both age groups, with most pronounced differences being observed for the consumption of red meat, poultry and fish, fruits, as well as red processed meat, cereals and dairy products, which was lower among children and adolescents with food insecurity. Children with food insecurity consumed significantly more unhealthy food, such as chips, fast food, sugared drinks, sweets, French fries and mayonnaise sauce. Conclusions Promotion of healthy eating to households facing food insecurity is of crucial importance, giving emphasis in the design of low cost, yet highly nutritious programmes.

Background/Introduction Some plant-based diets like the Mediterranean diet have been suggested to have a beneficial impact on liver disease. However, the quality of plant-based diets – in general – varies. Purpose The association between plant-based diet indices and non-alcoholic fatty liver disease (NAFLD) as well as their interaction on ten-year cardiovascular disease incidence was examined. Methods A prospective study was conducted during 2001–2012 studying n=1,514 males and n=1,528 females (aged >18 years old) free of CVD. Healthy metabolic status was defines as absence of all NCEP ATP III (2005) metabolic syndrome components (excluding waist circumference). Follow-up CVD assessment (2011–2012) was achieved in n=2,020 participants (n=317 cases). Overall, healthful and unhealthful plant-based dietary indices (PDI, hPDI and uPDI) were created through a standard procedure; hPDI was principally characterized by increased consumption of fruits/vegetables, whole grains, nuts, legumes, oils, tea/coffee while uPDI was related with increased intake of juices, sweetened beverages, refined grains, potatoes and sweets. NAFLD was defined according to validated liver steatosis indices. Results In total, n=707 (35%) participants presented NAFLD at baseline. Ranking from 1st to 3rd PDI tertile, NAFLD prevalence was 40.3%, 35.6% and 30.9%, respectively (p=0.04). Multiadjusted analysis revealed significant inverse associations between PDI and NAFLD prevalence [Odds Ratio (OR) (3rd vs. 1st tertile)=0.60 95% Confidence Interval (95% CI) (0.35, 0.92)] as well as hPDI [OR (3rd vs. 1st tertile) = 0.75 95% CI (0.64, 0.89)]. On the other side, increased uPDI had a positive association with NAFLD prevalence [OR (3rd vs. 1st hPDI tertile) = 1.22 95% CI (1.05, 1.34)]. NAFLD predicted CVD in multi-adjusted model [Hazard Ratio (HR) = 1.35, 95% CI (1.08, 2.10)]. Subgroup analyses according to participants' adherence to overall, healthy and unhealthy plant-based patterns revealed that this observation remained significant in the following cases: participants in the 1st PDI tertile, [HR=1.40, 95% CI (1.15, 2.09)] and participants in the 1st hPDI tertile [HR=1.47, 95% CI (1.22, 2.12)]. Conclusions Lower adherence to plant-based diet was associated with substantially higher long-term CVD risk for a NAFLD individual. Most importantly, the healthy or unhealthy food choices within this pattern seemed to determine liver steatosis progression and in turn cardiometabolic health. Funding Acknowledgement Type of funding sources: None.

Background: In studies of all-cause mortality, a one-to-one relation connects the hazard with the survival and as a consequence the regression models which focus on the hazard, such as the proportional hazards model, immediately dictate how the covariates relate to the survival function, as well. However, these two concepts and their one-to-one relation are totally different in the context of competing risks, where the terms of cause-specific hazard and cumulative incidence function appear. Objective: The aim of the present work was to present two of the most popular methods (cause-specific hazard model and Fine & Gray model) through an application on cardiovascular disease epidemiology (CVD), as well as, to narratively review more recent publications, based on either the frequentist, or the Bayesian approach to inference. Methods: A narrative review of the most widely used methods in the competing risks setting was conducted, extended to more recent publications. For the application, our interest lied in modeling the risk of Coronary Heart Disease in the presence of vascular stroke, by using the cause-specific hazard and the Fine & Gray models, two of most commonly encountered approaches. Results-Conclusions: After the implementation of these two approaches in the context of competing risks in CVD epidemiology, it is noted that while the use of the Fine & Gray model includes information about the existence of a competing risk, the interpretation of the results is not as easy as in the case of the cause-specific risk Cox model.

Circulating vitamin D is linked with the risk of cardiovascular disease (CVD). A meta-analysis has yet to explicitly explore correlation between vitamin D and the risk of CVD incidence and recurrent CVD. This meta-analysis examines the association between 25-hydroxy-vitamin D (25(OH)D) and the risk of CVD incidence (fatal, non-fatal, fatal and non-fatal combined events) and the risk of recurrent CVD (fatal, recurrent, and fatal and recurrent combined events). PROSPERO registration-CRD42021251483.A total of 79 studies (46 713 CVD cases in 1 397 831 participants) were included in the meta-analysis, of which 61 studies examined the risk of CVD incidence events, and 18 studies examined risk of recurrent CVD events. The risk of CVD incidence events (RR = 1.34, 95% CI: 1.26-1.43, p 0.001) and recurrent CVD events (RR = 1.86, 95% CI: 1.46-2.36, p 0.001) was higher in the lowest than the highest category of circulating 25(OH)D. Dose-response analysis reported a linear association for every 10 ng/ml increment of 25(OH)D and non-fatal CVD incidence events (RR = 0.94; 95% CI = 0.89-0.98, p = 0.005), lower fatal recurrent CVD events (RR = 0.45; 95% CI = 0.32-0.62, p 0.001) and lower combined recurrent CVD events (RR = 0.80; 95% CI = 0.65-0.97, p = 0.023). A non-linear association was observed between higher 25(OH)D and lower fatal CVD incidence events (P-nonlinear0.001), lower combined CVD incidence events (P-nonlinear = 0.001), and lower non-fatal recurrent CVD events (P-nonlinear = 0.044).The lowest category of circulating 25(OH)D was associated with a higher risk of CVD incidence events and recurrent CVD events.

Funding Acknowledgements Type of funding sources: Other. Main funding source(s): The ATTICA study is supported by research grants from the Hellenic Cardiology Society [HCS2002] and the Hellenic Atherosclerosis Society [HAS2003]. Background/Introduction: Among all behaviors, nutrition makes the largest contribution to cardiovascular disease (CVD) morbidity across Europe. Purpose: The aim of the present work was to quantify the changes in 10-year CVD onset or recurrence or mortality, in relation to transitioning from low to higher level of adherence to Mediterranean diet. Methods: An individual-level microsimulation was created based on ATTICA (2002-2012, n = 3042 subjects free-of-CVD) and GREECS (2004-2014, n = 2172 patients with acute coronary syndrome (ACS)) studies (in total n = 5214). Eight scenarios regarding the proportion of participants and the size of improvement of level of adherence to Mediterranean diet were compared in terms of relative change in CVD incidence and mortality, as well as, the number of preventable CVD events and deaths. Results: Improving the level of adherence to the Mediterranean diet, even in 10% of the population, a significant relative percentage reduction was observed in the 10-year risk for CVD onset, recurrence and mortality, with the observed reductions being higher among women. In particular, at least 851 first CVD events, 374 recurrent CVD events and 205 CVD deaths per 100,000 of population could be averted or delayed. Additionally, Mediterranean diet clustering revealed that high consumption of fruits, vegetables, whole wheat products and legumes was more important than low consumption of meat and full fat dairy products against CVD. Conclusion: This microsimulation process confirms the added value of Mediterranean diet in primary and secondary CVD prevention having great achievements even with small modifications on a population basis, while challenges the orientation of a Mediterranean-diet intervention giving higher weights to plant-based part.

The aim of this study was to identify the geographical variability, the socio-economic and the environmental determinants of adherence to the Mediterranean diet in a general population sample. Level of adherence to the Mediterranean diet was estimated by the ATTICA epidemiological study for 2,749 participants, while socio-economic, demographic, and environmental characteristics were provided by official national and international databases. Higher adherence to the Mediterranean diet was detected in areas with a greater proportion of females and older people, with lower unemployment rate and immigrant population, as well as, in areas covered at a greater extent by green and with higher frequency of supermarkets and street markets. The present findings provide evidence for policy makers to better understand how layers of influence intersect to shape individuals' eating habits, while they may also contribute in identifying areas of emerging interventions needed.

Background Missing data is a common problem in epidemiological studies, while it becomes more critical, when the missing data concern a multi-item instrument, since lack of information in even one of its items, leads to the inability to calculate the total score of the instrument. The aim was to investigate the socio-demographic, lifestyle and clinical determinants of low response rate in two self- rating multi item scales, estimating the individuals’ nutritional habits and psychological disorders, as well as, to compare different missing data handling techniques regarding the imputation of missing values in this context. Methods The sample from ATTICA epidemiological study was used, with complete baseline information (2001–2002) regarding their demographic characteristics [n = 2194 subjects (1364 men: 64 years old (SD = 12 years) and 830 women: 66 years old (SD = 12 years))]. Adherence to the Mediterranean diet and depressive symptomatology were assessed at baseline, with the MedDietScore scale and the Zung’s Self- rating Depression Scale (SDS), respectively. Logistic and Poisson regression analysis were used, in order to explore the low response’s determinants in each scale. Seven missing data handling techniques were compared in terms of the estimated regression coefficients and their standard errors, under different scenarios of missingness, in the context of a multivariable logistic regression model examining the association of each scale with the participants’ likelihood of being hypertensive. Results Older age, lower educational level, poorer health status and unhealthy lifestyle habits, were found to be significant determinants of high nonresponse rates, both in the MedDietScore scale and the Zung’s SDS. Female participants were more likely to have missing data in the items of the MedDietScore scale, while a significantly higher number of missing items in the depression scale was found for male participants. Concerning the analysis of such data, multiple imputation was found to be the most effective technique, even when the number of missing items was large. Conclusions The present work augments prior evidence that higher non-response to health surveys is significantly affected by responders’ background characteristics, while it gives rise to research towards unrevealed paths behind this claim, especially in the era of nutritional epidemiology.

Background Lifestyle e-coaching applications have the potential to be successful in changing people’s lifestyles although it is unclear whether such support would indeed help people with lower socioeconomic status (SES). The aim of the present study, conducted within the INHERIT EU project, was to investigate the effectiveness of a lifestyle e-coaching application in increasing physical activity (PA) in lower SES groups and whether such an increase is sustained after its prolonged use. Methods A two-site (Greece: N = 105, Netherlands: N = 89), two arm [Greece: 50 (experimental) and 55 (control), Netherlands: 45 (experimental) and 44 (control)], parallel group, randomized controlled trial proceeded in three phases over 19 weeks, comparing PA (as measured by the IPAQ questionnaire) of participants using a lifestyle e-coaching application with participants not using any such application. Inclusion criteria involved participants to be in low SES, have an age of 18-65 years and an estimated level of physical activity of less than 210 minutes/week, while they needed to possess a smartphone, willing to install the application and being fluent in Dutch or Greek. Results Results showed that the use of the app significantly improved participants’ PA in both countries, at 6 (Greece: p = 0.015, Netherlands: p = 0.003) and 19 weeks (Greece: p = 0.002, Netherlands: p < 0.001), while the effect was even higher for low physically active participants as measured at baseline, after both time periods. Compared to the control group, after adjusting for several characteristics, the experimental group achieved a better improvement of PA at 19 weeks compared to baseline (p = 0.006) and week 6 (p = 0.007). Conclusions Positive effects on participants’ PA after 19 weeks were observed, with the findings suggesting that the longer the application is used, the greater the improvement of PA, while the effect was more obvious among those following a sedentary lifestyle as measured at baseline. Key messages E-coaching applications could be useful in promoting physical activity among people from low SES. E-coaching applications are cost effective and environmentally friendly methods of promoting physical activity. Uptake by national health systems should be examined further.

Background Effective communication between Health Professionals (HP) and patients is crucial for the overall functioning of the healthcare system with positive impacts on readmission rates, treatment outcomes, adherence and costs. However, health communication training is limited especially during medical training. In the framework of the EU H-COM project an exploration of health communication needs and gaps and preferred training methods was performed among HP. Methods A cross-sectional online survey was conducted among 702 health professionals (Physicians: n = 315; Nurses: n = 258; Other: n = 129) through a purpose made questionnaire available in English, Greek, Polish, Spanish and German. Results Health communication training is considered necessary for physicians (89.8%) and nurses (89.7%), although 42.4% of them never received relevant training in the past. Professional status (p < 0.001), age (p = 0.079), gender (p = 0.090) and years of experience (p = 0.012) affected the likelihood of not having received such training, with physicians, HPs aged 45-54 years old, males and those having 6-10 years of experience being most in need. At least 50.0% reported encountering problems in communicating with their patients and facing several barriers either in primary health care settings and hospitals or in private practice. The ability to listen and answer patients, deliver bad news and obtain medical history were the most important communication skills identified, while the most suitable training method was learning relevant practical skills. The availability of such trainings is reported as being fair or poor at all educational levels by the majority. Conclusions Health communication training is considered important although currently not available to the extent needed. This research provides evidence concerning the preferred type, frequency and mode of health communication training providing also insight on differences between various HPs. Key messages Health communication training is crucial but inadequate in Europe. There are specific training needs and preferences among HP which need to be considered. Health communication training needs to be adapted and tailored to professionals’ age, experience and status.

Background In recent decades there has been keen research interest in the concept of procrastination and its impact on the student population with few studies being conducted in the Greek student population. The present study aimed to contribute to our knowledge regarding the causes that bring about academic procrastination and to further explore participants’ characteristics regarding these causes. Methods A cross-sectional study conducted in Greece with 628 college students at the University of Ioannina. Specially designed instruments were used to record students’ sociodemographic characteristics and causes of procrastination (CP). Factor Analysis (FA) with principal components (PCA) was used to derive the main students’ causes of procrastination, though Analysis of Covariance was used to examine the effect of their characteristics on these causes. Results 5 main causes of procrastination were identified explaining 48% of the total variation. Students’ lack of duty/ low tolerance for frustration was significantly associated with their gender (p = 0.005), year of study (p = 0.048) and grades (p = 0.008), while their dependency/difficulty of claim was significantly affected by students’ gender (p = 0.042), way of living (p = 0.034), place of residence (p = 0.001) and their age (p = 0.006). Moreover, their place of residence was significantly associated with their fear of failure (p = 0.001) and their difficulties in time management and decision making (p = 0.049), with those not living in the place of origin presenting greater values in relation to the aforementioned factors. Conclusions Procrastination is a widespread phenomenon in academic settings that affects differently each gender and is also affected by the sociodemographic factors. This study demonstrates the importance of investigating the causes of procrastination as a concept that helps us understand students’ behaviour and patterns associated with it. Key messages There is a great need for further studies on the causes of procrastination in order to help Universities to design learning environments that will be helpful for their students. The college instructors should train students not to procrastinate via preventing interventions.

Background Despite the fact that the Meditteranean diet is highly beneficiary for people’s health, there are many factors which cause disparities in the level of adherence. The aim of the present work was to investigate the effect of household food insecurity (FI) on adherence to the Mediterranean diet (AMD), to explore the participants’ characteristics modifying the studied relationship and find the social determinants of students’ low adherence to the specific dietary pattern. Methods A cross-sectional study with 140 schools and 4,242 students was conducted in Greece (2017-2018). Especially designed and validated instruments were used to record students’ sociodemographic characteristics, household’s FI status and students’ AMD. Analysis of Variance (ANOVA) and Covariance (ANCOVA) was used to investigate the effect of FI and to identify the significant social determinants of students’ AMD, according to students’ school grade. Results After adjusting for other characteristics, students whose both parents are born in other countries, spend at most 4 hours/week on TV/electronic games, live in the regions of Peloponnese, Central Macedonia or Attica and attend primary schools adhere more to the Mediterranean diet, while higher level of physical activity and lower FI are significantly associated with better AMD. Parents’ educational level in nursery schools (p = 0.002) and employment status in nursery schools (p = 0.012) and in high schools/ lyceums (p = 0.008) were found to modify significantly the studied relationship in the univariate analysis, while school grade (p = 0.013) and physical activity (p = 0.088) were found to modify the studied relationship in the multivariable analysis. Conclusions Several demographic, socioeconomic and lifestyle characteristics were significantly associated with students’ AMD. Thus, emphasis should be given on the design of special programs to reduce household FI and intervene in the rest characteristics. Key messages Researchers and policymakers should consider food insecurity as important risk factor for school-aged children, particularly for those who live in poverty. Emphasis should be given on the design of special low-cost programs aiming to reduce food insecurity.

Background Defense mechanisms have been a central concept in the field of mental health and psychotherapy. Recently, there has been some research interest in defence mechanisms in empirical psychology. Causes of procrastination are shown to be related to defence mechanisms in terms of students’ dilatory behaviour. Furthermore, the causes of procrastination seem to affect students’ well-being. The aim of the present study is to investigate the effect of defence mechanisms and causes of procrastination on well-being, separately for each gender. Methods A cross-sectional study was conducted in Greece with 628 college students at the University of Ioannina (490 females and 138 males). Specially designed and validated instruments were used to record students’ sociodemographic characteristics, defence mechanisms (DM), causes of procrastination (CP) and well-being (WB). Analysis of Variance (ANOVA) and Covariance (ANCOVA) was used to investigate the effect of DM and CP on students’ WB separately for each gender. Results Students’ defence mechanisms and causes of procrastination had a statistically significant effect on their well-being. More specifically, female students with a lower percentage of fear of success/ influence of peers (p < 0.001) and maladaptive defense style (p < 0.001) as well as those with higher image-distorting (p < 0.001), self-sacrificing (p = 0.004) and adaptive defense styles (p < 0.001) seemed to have a significantly higher percentage of well-being. On the other hand, male students with a lower percentage of lack of duty/ tolerance of frustration (p = 0.039) and maladaptive style (p < 0.001) but a higher percentage of image distorting (p < 0.001) and adaptive defence styles (p < 0.001) had a significantly higher percentage of well-being. Conclusions Students’ causes of academic procrastination in the combination with the use of defence mechanisms significantly affect their well-being despite, being differentiated according to their gender. Key messages Defense mechanisms play a crucial role in students’ adaptation at the university as well as in their mental health. Emphasis should be given on the design of intervention on students’ procrastination involving non-conscious processes and more structural elements of personality.

E-coaching applications can improve people&rsquo, s lifestyles, however, their impact on people from a lower socioeconomic status (low SES) is unknown. This study investigated the effectiveness of a lifestyle e-coaching application in encouraging people facing low SES disadvantages to engage in a more active lifestyle over a course of 19 weeks. In this bicountry study, 95 people with low activity level (GR: 50, NL: 45) used a mobile application linked to a wearable activity tracker. At the start and after 6 and 19 weeks, self-reported physical activity levels, attitudes, and intention towards increasing activity levels, perceived behavioral control, and wellbeing were measured. Results indicated that participants using the lifestyle e-coaching application reported significantly more often an increase in activity levels than a parallel control group. Additionally, the people using the application also more often reported increased levels of wellbeing and perceived behavioral control. Therefore, lifestyle e-coaching applications could be a cost-effective solution for promoting healthier lifestyles in low-SES populations.

Background Aim of this cluster randomized trial was to examine the impact of a school feeding programme combining healthy meals provision and educational activities to reduce food insecurity. Methods Schools participating in the DIATROFI Program in Greece during the 2014-2015 school year were randomly allocated between a multicomponent intervention (MI: each student received a daily healthy meal along with educational actions; 28 schools) and an educational intervention (EI; 23 schools). A linear-mixed model was used to examine intervention effect on change from baseline in the food insecurity score, as measured via the Food Security Survey Module (FSSM). The analysis was based on 1442 pre-post intervention questionnaire pairs in the MI group and 986 in the EI group. Results The reduction in food insecurity score in the MI group was statistically significantly greater compared to the EI group, by 9.8% or -0.31 [95% confidence interval (CI) -0.61 to -0.01] FSSM units after adjusting for potential confounders. MI intervention was significantly more effective compared to EI, among students in food insecure households (mean -0.44, 95% CI -0.84 to -0.04), students in households facing hunger (mean -1.04, 95% CI -1.91 to -0.17) and overweight/obese students (mean -0.36, 95% CI -0.72 to -0.01). Conclusion For interventions aiming to address childhood food insecurity, public health focus should be oriented towards school-based programmes combining food assistance with activities that promote healthy nutrition.

Background Renal transplantation is known to be associated with increased risk of malignancy. Concurrent presence of malignant diseases and transplantation may influence overall survival. This study summarizes our 35-year experience in breast cancer (BC) in renal transplant patients focusing on the incidence of BC and its impact on survival of this population. Methods Prospectively collected data of female patients treated with renal transplantation for chronic renal failure from 1973 to 2017 were analysed. Patients diagnosed with BC were identified. Age at transplantation, age at BC diagnosis, date and causes of death were recorded for all patients. BC incidence and overall survival were calculated. Kaplan-Meier and Cox proportional hazards models were used to determine the difference in survival and hazard between the two patient groups. Results Out of 821 transplant patients, 7 developed BC. The mean age in the total population of kidney transplant patients was 42.7 years (SD = 13.8), while the mean age of women diagnosed with BC was 48.3 years (SD = 10.2) and 53.0 years (SD = 12.3), at transplantation and BC diagnosis respectively. In total 7 women (1.0%) were diagnosed with BC of which 4 died from BC and 1 from a different cause. The median survival for women diagnosed with BC was 193 months (16.1 years) compared to 299 months (24.9 years) from transplantation for women not diagnosed with BC (p Conclusions BC incidence appears increased in this population. BC diagnosis may adversely affect survival of renal transplant recipients. Further study of predisposing BC risk factors may reveal additional associations. Legal entity responsible for the study The authors. Funding Has not received any funding. Disclosure All authors have declared no conflicts of interest.

The Mig-HealthCare consortium conducted a qualitative study of the health care needs of vulnerable migrants/refugees in Europe. The research was conducted between Fall 2017 and Spring 2018. In total, 20 focus group discussions or, where necessary individual interviews (19), were organised with health care professionals and service providers; policymakers; and representatives from Non-Governmental Organisations - NGOs. Thematic qualitative analysis was employed. The main results of the analysis show that: Health care provision for migrants is uneven throughout the EU and variations exist even within the same country. Health care providers and NGOs agree that health care for migrants is inadequate and biased in favour of particular conditions and cases (minors, pregnant women and acute conditions). Challenges faced by different countries vary; while in some countries the main issue is legal access, in other basic needs such as sanitation and basic infrastructure were emphasised. Austerity measures following the 2008 financial crisis have negatively affected the health care system in general, which in turn has negatively affected the provision of health care for migrants/refugees. Discrimination linked to socio-economic and ethnic conditions is reported as a barrier to equal health care access. Knowledge, language and communication on both the demand and the supply side of health care provision emerge as crucial to ensure equal access for migrants/refugees. Gender may act as a barrier with women tending to be more marginalised in the host country, in terms of language proficiency and health literacy, lowering health care access. One of the main challenges for providing equal health care access for migrants has to do with the ability to balance a universal right to health with the particular means of achieving it. The evidence collected here shows how this tension between end and means is at work in different moments of the provision of health care for migrants/refugees.

This study discusses the main findings of the quantitative research conducted within the Mig-HealthCare consortium countries to explore the physical and mental health of migrants and refugees. The study population is defined as migrants/refugees who have been residing in Europe, for at least 6 months and up to 5 years. In order to be able to capture the recent migration flow, the analysis was based on 1169 questionnaires collected in 10 EU-Member States, answered by adult migrants residing less than 5 years in the specific country. A total of 29% of migrants stated that their health is poor or fair. Overall, 56.9% of migrants needed health care services during the last 6 months, however approximately one in four did not have access to them. The most frequent problems were long waiting times, not being able to organize an appointment, not knowing where to go, lack of communication and long distances. The most frequent chronic health problem migrants/refugees face is caries and headaches/migraines, followed by psychological disease and sleep disorders. Approximately one in three women have been pregnant since entering the current EU country, whereas one in four have had a miscarriage or abortion and 21.5% are currently pregnant. Summing up, most of the migrants face common medical problems such as bad teeth, headaches and psychological problems. However long waiting times, not knowing where to go and lack of communication are barriers to accessing healthcare. The fact that the immunization status of migrants/refugees is unclear, a significant number suffer from serious chronic diseases and the limited breast and cervical cancer screening of female migrants/refugees pose serious threats to their health and important challenges for the health services of Europe.