Non-binary gender, vulnerable populations and mental health during the COVID-19 pandemic: Data from the COVID-19 MEntal health inTernational for the general population (COMET-G) study

BACKGROUND

The COVID-19 pandemic has brought significant mental health challenges, particularly for vulnerable populations, including non-binary gender individuals. The COMET international study aimed to investigate specific risk factors for clinical depression or distress during the pandemic, also in these special populations.

METHODS

Chi-square tests were used for initial screening to select only those variables which would show an initial significance. Risk Ratios (RR) were calculated, and a Multiple Backward Stepwise Linear Regression Analysis (MBSLRA) was followed with those variables given significant results at screening and with the presence of distress or depression or the lack of both of them.

RESULTS

The most important risk factors for depression were female (RR = 1.59-5.49) and non-binary gender (RR = 1.56-7.41), unemployment (RR = 1.41-6.57), not working during lockdowns (RR = 1.43-5.79), bad general health (RR = 2.74-9.98), chronic somatic disorder (RR = 1.22-5.57), history of mental disorders (depression RR = 2.31-9.47; suicide attempt RR = 2.33-9.75; psychosis RR = 2.14-10.08; Bipolar disorder RR = 2.75-12.86), smoking status (RR = 1.15-5.31) and substance use (RR = 1.77-8.01). The risk factors for distress or depression that survived MBSLRA were younger age, being widowed, living alone, bad general health, being a carer, chronic somatic disorder, not working during lockdowns, being single, self-reported history of depression, bipolar disorder, self-harm, suicide attempts and of other mental disorders, smoking, alcohol, and substance use.

CONCLUSIONS

Targeted preventive interventions are crucial to safeguard the mental health of vulnerable groups, emphasizing the importance of diverse samples in future research.

LIMITATIONS

Online data collection may have resulted in the underrepresentation of certain population groups.

Somatic multicomorbidity and disability in patients with psychiatric disorders in comparison to the general population: a quasi-epidemiological investigation in 54,826 subjects from 40 countries (COMET-G study)

BACKGROUND

The prevalence of medical illnesses is high among patients with psychiatric disorders. The current study aimed to investigate multi-comorbidity in patients with psychiatric disorders in comparison to the general population. Secondary aims were to investigate factors associated with metabolic syndrome and treatment appropriateness of mental disorders.

METHODS

The sample included 54,826 subjects (64.73% females; 34.15% males; 1.11% nonbinary gender) from 40 countries (COMET-G study). The analysis was based on the registration of previous history that could serve as a fair approximation for the lifetime prevalence of various medical conditions.

RESULTS

About 24.5% reported a history of somatic and 26.14% of mental disorders. Mental disorders were by far the most prevalent group of medical conditions. Comorbidity of any somatic with any mental disorder was reported by 8.21%. One-third to almost two-thirds of somatic patients were also suffering from a mental disorder depending on the severity and multicomorbidity. Bipolar and psychotic patients and to a lesser extent depressives, manifested an earlier (15-20 years) manifestation of somatic multicomorbidity, severe disability, and probably earlier death. The overwhelming majority of patients with mental disorders were not receiving treatment or were being treated in a way that was not recommended. Antipsychotics and antidepressants were not related to the development of metabolic syndrome.

CONCLUSIONS

The finding that one-third to almost two-thirds of somatic patients also suffered from a mental disorder strongly suggests that psychiatry is the field with the most trans-specialty and interdisciplinary value and application points to the importance of teaching psychiatry and mental health in medical schools and also to the need for more technocratically oriented training of psychiatric residents.

Students' mental health during the pandemic: results of the observational cross-sectional COVID-19 MEntal health inTernational for university Students (COMET-S) study

Introduction

The aim of the study was to search rates of depression and mental health in university students, during the COVID-19 pandemic.

Materials and methods

This is an observational cross-sectional study. A protocol gathering sociodemographic variables as well as depression, anxiety and suicidality and conspiracism was assembled, and data were collected anonymously and online from April 2020 through March 2021. The sample included 12,488 subjects from 11 countries, of whom 9,026 were females (72.2%; aged 21.11 ± 2.53), 3,329 males (26.65%; aged 21.61 ± 2.81) and 133 "non-binary gender" (1.06%; aged 21.02 ± 2.98). The analysis included chi-square tests, correlation analysis, ANCOVA, multiple forward stepwise linear regression analysis and Relative Risk ratios.

Results

Dysphoria was present in 15.66% and probable depression in 25.81% of the total study sample. More than half reported increase in anxiety and depression and 6.34% in suicidality, while lifestyle changes were significant. The model developed explained 18.4% of the development of depression. Believing in conspiracy theories manifested a complex effect. Close to 25% was believing that the vaccines include a chip and almost 40% suggested that facemask wearing could be a method of socio-political control. Conspiracism was related to current depression but not to history of mental disorders.

Discussion

The current study reports that students are at high risk for depression during the COVID-19 pandemic and identified specific risk factors. It also suggested a role of believing in conspiracy theories. Further research is important, as it is targeted intervention in students' groups that are vulnerable both concerning mental health and conspiracism.

Results of the COVID-19 mental health international for the health professionals (COMET-HP) study: depression, suicidal tendencies and conspiracism

INTRODUCTION

The current study aimed to investigate the rates of anxiety, clinical depression, and suicidality and their changes in health professionals during the COVID-19 outbreak.

MATERIALS AND METHODS

The data came from the larger COMET-G study. The study sample includes 12,792 health professionals from 40 countries (62.40% women aged 39.76 ± 11.70; 36.81% men aged 35.91 ± 11.00 and 0.78% non-binary gender aged 35.15 ± 13.03). Distress and clinical depression were identified with the use of a previously developed cut-off and algorithm, respectively.

STATISTICAL ANALYSIS

Descriptive statistics were calculated. Chi-square tests, multiple forward stepwise linear regression analyses, and Factorial Analysis of Variance (ANOVA) tested relations among variables.

RESULTS

Clinical depression was detected in 13.16% with male doctors and 'non-binary genders' having the lowest rates (7.89 and 5.88% respectively) and 'non-binary gender' nurses and administrative staff had the highest (37.50%); distress was present in 15.19%. A significant percentage reported a deterioration in mental state, family dynamics, and everyday lifestyle. Persons with a history of mental disorders had higher rates of current depression (24.64% vs. 9.62%; p < 0.0001). Suicidal tendencies were at least doubled in terms of RASS scores. Approximately one-third of participants were accepting (at least to a moderate degree) a non-bizarre conspiracy. The highest Relative Risk (RR) to develop clinical depression was associated with a history of Bipolar disorder (RR = 4.23).

CONCLUSIONS

The current study reported findings in health care professionals similar in magnitude and quality to those reported earlier in the general population although rates of clinical depression, suicidal tendencies, and adherence to conspiracy theories were much lower. However, the general model of factors interplay seems to be the same and this could be of practical utility since many of these factors are modifiable.

The effect of different degrees of lockdown and self-identified gender on anxiety, depression and suicidality during the COVID-19 pandemic: Data from the international COMET-G study

INTRODUCTION

During the COVID-19 pandemic various degrees of lockdown were applied by countries around the world. It is considered that such measures have an adverse effect on mental health but the relationship of measure intensity with the mental health effect has not been thoroughly studied. Here we report data from the larger COMET-G study pertaining to this question.

MATERIAL AND METHODS

During the COVID-19 pandemic, data were gathered with an online questionnaire from 55,589 participants from 40 countries (64.85% females aged 35.80 ± 13.61; 34.05% males aged 34.90±13.29 and 1.10% other aged 31.64±13.15). Anxiety was measured with the STAI, depression with the CES-D and suicidality with the RASS. Distress and probable depression were identified with the use of a previously developed cut-off and algorithm respectively.

STATISTICAL ANALYSIS

It included the calculation of Relative Risk (RR), Factorial ANOVA and Multiple backwards stepwise linear regression analysis RESULTS: Approximately two-thirds were currently living under significant restrictions due to lockdown. For both males and females the risk to develop clinical depression correlated significantly with each and every level of increasing lockdown degree (RR 1.72 and 1.90 respectively). The combined lockdown and psychiatric history increased RR to 6.88 The overall relationship of lockdown with severity of depression, though significant was small.

CONCLUSIONS

The current study is the first which reports an almost linear relationship between lockdown degree and effect in mental health. Our findings, support previous suggestions concerning the need for a proactive targeted intervention to protect mental health more specifically in vulnerable groups.

Overall mortality trends in Greece during the first period of austerity and the economic crisis (2009-2015)

OBJECTIVES

The economic crisis and the resulting austerity in Greece led to a drastic reduction in healthcare spending, which has been assumed to have impacted people's health. This paper discusses official standardized mortality rates in Greece between 2000 and 2015.

METHODS

This study was designed to analyze population-level data and collected data from the World Bank, the Organisation for Economic Co-operation and Development, Eurostat, and the Hellenic Statistics Authority. Separate linear regression models were developed for the periods before and after the crisis and were compared.

RESULTS

Standardized mortality rates do not support a previously reported assumption of a specific and direct negative effect of austerity on global mortality. Standardized rates continued to decrease linearly, and their correlation to economic variables changed after 2009. Total infant mortality rates show an overall rising trend since 2009, but the interpretation is unclear because of the reduction in the absolute number of deliveries.

CONCLUSIONS

The mortality data from the first six years of the financial crisis in Greece and the decade that preceded do not support the assumption that budget cuts in health are related to the dramatic worsening of the overall health of the Greek people. Still, data suggest an increase in specific causes of death and the burden on a dysfunctional and unprepared health system that is working in an overstretched manner trying to meet needs. The dramatic acceleration of the aging of the population constitutes a specific challenge for the health system. HIPPOKRATIA 2022, 26 (3):98-104.

Adherence to facemask use in public places during the autumn-winter 2020 COVID-19 lockdown in Greece: observational data

BACKGROUND

Wearing facemasks is of proven efficacy as a public health protective measure against COVID-19. Currently there are no observational data concerning the wearing of facemasks and the adherence to guidelines concerning their handling.

METHODS

Registration of the way passers-by were wearing facemasks at 26 different locations of five major cities in Greece. The results were correlated with the rate of COVID-19 deaths in the region.

RESULTS

In total, 119,433 passers-by were registered, 57,043 females (47.8%) and 62,390 males (52.2%). From the total sample, 81.1% were wearing the mask properly, 10.8% had their nose out, 6.2% were wearing it under the jaw, and 1.9% had no mask at all . There was a significant difference between males and females concerning any use of mask. Inappropriate use of was correlated with COVID-19 death rate in the studied region.

CONCLUSION

Our findings suggest that under conditions of mandatory wearing and in central locations of major cities, during walking, proper use of masks is suboptimal, but still contributes with some protection. Fear and risk perception seem to be strong factors contributing to adherence to proper mask wearing.

Results of the COVID-19 mental health international for the general population (COMET-G) study

INTRODUCTION

There are few published empirical data on the effects of COVID-19 on mental health, and until now, there is no large international study.

MATERIAL AND METHODS

During the COVID-19 pandemic, an online questionnaire gathered data from 55,589 participants from 40 countries (64.85% females aged 35.80 ± 13.61; 34.05% males aged 34.90±13.29 and 1.10% other aged 31.64±13.15). Distress and probable depression were identified with the use of a previously developed cut-off and algorithm respectively.

STATISTICAL ANALYSIS

Descriptive statistics were calculated. Chi-square tests, multiple forward stepwise linear regression analyses and Factorial Analysis of Variance (ANOVA) tested relations among variables.

RESULTS

Probable depression was detected in 17.80% and distress in 16.71%. A significant percentage reported a deterioration in mental state, family dynamics and everyday lifestyle. Persons with a history of mental disorders had higher rates of current depression (31.82% vs. 13.07%). At least half of participants were accepting (at least to a moderate degree) a non-bizarre conspiracy. The highest Relative Risk (RR) to develop depression was associated with history of Bipolar disorder and self-harm/attempts (RR = 5.88). Suicidality was not increased in persons without a history of any mental disorder. Based on these results a model was developed.

CONCLUSIONS

The final model revealed multiple vulnerabilities and an interplay leading from simple anxiety to probable depression and suicidality through distress. This could be of practical utility since many of these factors are modifiable. Future research and interventions should specifically focus on them.

The impact of economic austerity and prosperity events on suicide in Greece: a 30-year interrupted time-series analysis

OBJECTIVES

To complete a 30-year interrupted time-series analysis of the impact of austerity-related and prosperity-related events on the occurrence of suicide across Greece.

SETTING

Greece from 1 January 1983 to 31 December 2012.

PARTICIPANTS

A total of 11 505 suicides, 9079 by men and 2426 by women, occurring in Greece over the study period.

PRIMARY AND SECONDARY OUTCOMES

National data from the Hellenic Statistical Authority assembled as 360 monthly counts of: all suicides, male suicides, female suicides and all suicides plus potentially misclassified suicides.

RESULTS

In 30 years, the highest months of suicide in Greece occurred in 2012. The passage of new austerity measures in June 2011 marked the beginning of significant, abrupt and sustained increases in total suicides (+35.7%, p<0.001) and male suicides (+18.5%, p<0.01). Sensitivity analyses that figured in undercounting of suicides also found a significant, abrupt and sustained increase in June 2011 (+20.5%, p<0.001). Suicides by men in Greece also underwent a significant, abrupt and sustained increase in October 2008 when the Greek recession began (+13.1%, p<0.01), and an abrupt but temporary increase in April 2012 following a public suicide committed in response to austerity conditions (+29.7%, p<0.05). Suicides by women in Greece also underwent an abrupt and sustained increase in May 2011 following austerity-related events (+35.8%, p<0.05). One prosperity-related event, the January 2002 launch of the Euro in Greece, marked an abrupt but temporary decrease in male suicides (-27.1%, p<0.05).

CONCLUSIONS

This is the first multidecade, national analysis of suicide in Greece using monthly data. Select austerity-related events in Greece corresponded to statistically significant increases for suicides overall, as well as for suicides among men and women. The consideration of future austerity measures should give greater weight to the unintended mental health consequences that may follow and the public messaging of these policies and related events.

Relationship of suicide rates to economic variables in Europe: 2000-2011

BACKGROUND

It is unclear whether there is a direct link between economic crises and changes in suicide rates.

AIMS

The Lopez-Ibor Foundation launched an initiative to study the possible impact of the economic crisis on European suicide rates.

METHOD

Data was gathered and analysed from 29 European countries and included the number of deaths by suicide in men and women, the unemployment rate, the gross domestic product (GDP) per capita, the annual economic growth rate and inflation.

RESULTS

There was a strong correlation between suicide rates and all economic indices except GPD per capita in men but only a correlation with unemployment in women. However, the increase in suicide rates occurred several months before the economic crisis emerged.

CONCLUSIONS

Overall, this study confirms a general relationship between the economic environment and suicide rates; however, it does not support there being a clear causal relationship between the current economic crisis and an increase in the suicide rate.

Possible delayed effect of unemployment on suicidal rates: the case of Hungary

BACKGROUND

During the last few years, many countries in Europe suffered from a severe economic crisis which resulted in high unemployment rates. In this frame, the possible relationship between unemployment rate and suicidal rates at the level of the general population has been debated recently.

MATERIAL AND METHODS

The official data concerning completed suicides and unemployment rates from the Hungarian Central Statistical Office for the years 2000-2011 were used. The percentage of changes from the previous year in the unemployment rate and the suicidal rates concerning both the general and the unemployed populations was calculated. Pearson correlation coefficient between the change in suicidal rates and change in unemployment rates was calculated both for the same year as well as after 1-6 years.

RESULTS

The correlations between the unemployment rate and suicide rates were strongly negative both for the general and for the unemployed populations (-0.65 and -0.55, respectively). The correlation of unemployment change with suicidality change after 1-6 years gave a peak strong positive correlation at 5 years for the general population (0.78). At 4 years after the index year, there is a peak correlation with a moderate value for the unemployed population (0.47) and a similar moderate value for the general population (0.46).

DISCUSSION

The current findings from Hungary suggest that unemployment might be associated with suicidality in the general population only after 3-5 years. It is possible that the distressing environment of the economic crisis increases suicidality in the general population rather than specifically in unemployed people.

Prevalence and sociodemographic associations of common mental disorders in a nationally representative sample of the general population of Greece

BACKGROUND

No study in Greece has assessed so far the full range of common mental disorders using a representative sample of the population from both mainland and insular regions of the country. The aim of the present paper was to present the results of the first such study.

METHODS

The study was carried out between 2009-2010 in a nationally representative sample of 4894 individuals living in private households in Greece. Common mental disorders in the past week were assessed with the revised Clinical Interview Schedule (CIS-R). We also assessed alcohol use disorders (using AUDIT), smoking and cannabis use.

RESULTS

14% of the population (Male: 11%, Female: 17%) was found to have clinically significant psychiatric morbidity according to the scores on the CIS-R. The prevalence (past seven days) of specific common mental disorders was as follows: Generalized Anxiety Disorder: 4.10% (95% CI: 3.54, 4.65); Depression: 2.90% (2.43, 3.37); Panic Disorder: 1.88% (1.50, 2.26); Obsessive-Compulsive Disorder: 1.69% (1.33, 2.05); All Phobias: 2.79% (2.33, 3.26); Mixed anxiety-depression: 2.67% (2.22, 3.12). Harmful alcohol use was reported by 12.69% of the population (11.75, 13.62). Regular smoking was reported by 39.60% of the population (38.22, 40.97) while cannabis use (at least once during the past month) by 2.06% (1.66, 2.46). Clinically significant psychiatric morbidity was positively associated with the following variables: female gender, divorced or widowed family status, low educational status and unemployment. Use of all substances was more common in men compared to women. Common mental disorders were often comorbid, undertreated, and associated with a lower quality of life.

CONCLUSIONS

The findings of the present study can help in the better planning and development of mental health services in Greece, especially in a time of mental health budget restrictions.

Suicide by firearms on the island of Crete: a 9-year record

BACKGROUND

Whereas firearm suicide mortality has been a longstanding public concern worldwide, in Greece no systematic analysis has been reported so far despite the recent evidence of a rising rate of gun ownership.

AIMS

To estimate the proportion of firearm suicides on the island of Crete, Southern Greece, well-known for its widespread gun ownership; to describe the victims' sociodemographic profile and firearm-related suicide variables; and to assess the severity of suicidal intention in the group.

METHODS

Records of suicides between 1999 and 2007 were reviewed and information was extracted into a computerized database. A rating of the circumstances section of the Beck's Suicide Intent Scale (SIS) for each case was also performed.

RESULTS

The firearm suicide rate was 1.3 per 100,000, with males constituting the vast majority. These men were more likely to be less than 55 years of age, to have lived in the western part of the island, to have some degree of planning prior to the suicidal act, and to have used a shotgun, but less likely to have left a note.

CONCLUSIONS

As an important first step toward implementing preventive initiatives the authors stress the need for a thorough look at the sociocultural factors associated with firearms in the region.

Identifying intimate partner violence (IPV) during the postpartum period in a Greek sample

Research has highlighted the wide impact of intimate partner violence (IPV) and the public health role of community health professionals in detection of victimized women. The purpose of this study was to identify postpartum emotional and physical abuse and to validate the Greek version of the Women Abuse Screening Tool (WAST) along with its sensitivity and specificity. Five hundred seventy-nine mothers within 12 weeks postpartum were recruited from the perinatal care registers of the Maternity Departments of two public hospitals in Athens, Greece. Participants were randomly selected by clinic or shift. The WAST and the Partner Violence Screen (PVS) surveys were administered in random order to the mothers from September 2007 to January 2008. The WAST was compared with the PVS as a criterion standard. Agreement between the screening instruments was examined. The psychometric measurements that were performed included: two independent sample t tests, reliability coefficients, explanatory factor analysis using a Varimax rotation, and Principal Components Method. Confirmatory analysis-also called structural equation modeling-of principal components was conducted by Linear Structural Relations. A receiver operating characteristic (ROC) analysis was carried out to evaluate the global functioning of the scale. Two hundred four (35.6%) of the mothers screened were identified as experiencing IPV. Scores on the WAST correlated well with those on the PVS; the internal consistency of the WAST Greek version-tested using Cronbach's alpha coefficient-was found to be 0.926 and that of Guttman's split-half coefficient was 0.924. Our findings confirm the multidimensionality of the WAST, demonstrating a two-factor structure. The area under ROC curve (AUC) was found to be 0.824, and the logistic estimate for the threshold score of 0/1 fitted the model sensitivity at 99.7% and model specificity at 64.4%. Our data confirm the validity of the Greek version of the WAST in identifying IPV. The validated Greek WAST scale could be used for screening purposes in both clinical practice and research.

Suicide by Pesticide Poisoning

Background: The role of pesticides in suicidal acts has not yet received adequate attention in Greece despite an evident rise of 39% in pesticide use over the period 1990–1992 to 2002–2004. Aims: To investigate the epidemiology of pesticide suicide on the Greek island of Crete, a largely rural agricultural area, and by further exploring the victim profiles, as well as patterns and trends of pesticide ingestion, to suggest probable preventive measures. Methods: Self-poisoning suicides between 1999 and 2007 were reviewed and information gathered was entered into a computerized database. Results: The overall incidence of intentional pesticide poisoning was 1.7 per 100,000, representing the second most frequently used suicide method after hanging. The victim profile was composed of the following features: middle aged male, rural habitant, who carried out a suicidal act by consuming primarily methomyl or paraquat (WHO toxicity class Ib and class II, respectively). As to the place of death, the vast majority was found dead in the place of intoxication. Conclusions: Pesticide self-poisoning accounts for a quarter of the suicides in Crete. More detailed research is required to identify aspects of these deaths amenable to prevention, but measures such as bans on the most toxic pesticides and changes in storage practice would appear to be sensible initial approaches.

Identifying dyspepsia in the Greek population: translation and validation of a questionnaire

Background

Studies on clinical issues, including diagnostic strategies, are considered to be the core content of general practice research. The use of standardised instruments is regarded as an important component for the development of Primary Health Care research capacity. Demand for epidemiological cross-cultural comparisons in the international setting and the use of common instruments and definitions valid to each culture is bigger than ever. Dyspepsia is a common complaint in primary practice but little is known with respect to its incidence in Greece. There are some references about the Helicobacter Pylori infection in patients with functional dyspepsia or gastric ulcer in Greece but there is no specific instrument for the identification of dyspepsia. This paper reports on the validation and translation into Greek, of an English questionnaire for the identification of dyspepsia in the general population and discusses several possibilities of its use in the Greek primary care.

Methods

The selected English postal questionnaire for the identification of people with dyspepsia in the general population consists of 30 items and was developed in 1995. The translation and cultural adaptation of the questionnaire has been performed according to international standards. For the validation of the instrument the internal consistency of the items was established using the alpha coefficient of Chronbach, the reproducibility (test – retest reliability) was measured by kappa correlation coefficient and the criterion validity was calculated against the diagnosis of the patients' records using also kappa correlation coefficient.

Results

The final Greek version of the postal questionnaire for the identification of dyspepsia in the general population was reliably translated. The internal consistency of the questionnaire was good, Chronbach's alpha was found to be 0.88 (95% CI: 0.81–0.93), suggesting that all items were appropriate to measure. Kappa coefficient for reproducibility (test – retest reliability) was found 0.66 (95% CI: 0.62–0.71), whereas the kappa analysis for criterion validity was 0.63 (95% CI: 0.36–0.89).

Conclusion

This study indicates that the Greek translation is comparable with the English-language version in terms of validity and reliability, and is suitable for epidemiological research within the Greek primary health care setting.

Measuring health inequalities in Albania: a focus on the distribution of general practitioners

BACKGROUND

The health workforce has a dynamically changing nature and the regular documentation of the distribution of health professionals is a persistent policy concern. The aim of the present study was to examine available human medical resources in primary care and identify possible inequalities regarding the distribution of general practitioners in Albania between 2000 and 2004.

METHODS

With census data, we investigated the degree of inequality by calculating relative inequality indices. We plotted the Lorenz curves and calculated the Gini, Atkinson and Robin Hood indices and decile ratios, both before and after adjusting for mortality and consultation rates.

RESULTS

The Gini index for the distribution of general practitioners in 2000 was 0.154. After adjusting for mortality it was 0.126, while after adjusting for consultation rates it was 0.288. The Robin Hood index for 2000 was 11.2%, which corresponds to 173 general practitioners who should be relocated in order to achieve equality. The corresponding figure after adjusting for mortality was 9.2% (142 general practitioners), while after adjusting for consultation rates the number was 20.6% (315). These figures changed to 6.3% (100), 6.3% (115) and 19.8% (315) in 2004.

CONCLUSION

There was a declining trend in the inequality of distribution of general practitioners in Albania between 2000 and 2004. The trend in inequality was apparent irrespective of the relative inequality indicator used. The level of inequality varied depending on the adjustment method used. Reallocation strategies for general practitioners in Albania could be the key in alleviating the inequalities in primary care workforce distribution.

Inequalities in the distribution of rural primary care physicians in two remote neighboring prefectures of Greece and Albania

INTRODUCTION

Inequalities in the distribution of primary care physicians are of great importance in the provision of health care. This becomes more apparent mainly in the rural and remote areas of each country. The objective of the present study was to evaluate and compare the degree of inequality in the provision of primary care physicians in two rural and remote prefectures of neighboring countries. We studied the cases of Ioannina, Greece and Gjirokaster, Albania during 2001.

METHODS

In both prefectures, for all calculations made, we used the total number of physicians providing primary care in rural areas. This includes GPs, internal medicine specialists, non-specialised graduate physicians. All other physician specialties (eg. microbiologists) were excluded from the calculations of the present study. We calculated the population per physician ratio (PPR) for each health center in each prefecture. For the comparison of the inequality we used two relative inequality measures. We plotted the Lorenz curves and calculated the Gini coefficients for the distribution of physicians' workforce adjusted by population in the two districts. Finally, we calculated the difference in the inequalities in these distributions. The p values were two tailed and calculated for 95% confidence levels.

RESULTS

The PPR for the whole prefecture of Ioannina, Greece was 1222. The lowest PPR, which corresponds to higher supply of human resources, was 205, while the highest (worst) was 8166. In the case of Gjirokaster the PPR was 2376 for the whole prefecture. The lowest PPR was 1323, while the highest was 4546 inhabitants per physician. Because the two curves do not intersect we can assume with certainty that primary care physicians in the prefecture of Ioannina were more unevenly distributed than those in the prefecture of Gjirokaster. The Gini coefficient for the distribution of primary care physicians in Ioannina was 0.489 (SD = 0.045), while that of the Gjirokaster district was 0.186 (SD = 0.034). The difference between the two Gini indices was 0.303 (p < 0.001).

CONCLUSIONS

Primary care physicians in both prefectures were unevenly distributed. The inequality in the distribution of primary care physicians was significantly higher in the prefecture of Ioannina, Greece compared with that of the prefecture of Gjirokaster, Albania. Further investigations could be made using a need adjusted index instead of PPR. For this purpose, the number of physicians could be adjusted for mortality, morbidity of chronic diseases or limiting longstanding illness. Studying the inequality patterns in districts could be aided by the use of other disciplines, such as geographical information systems, giving a clearer picture of the situation of primary care provision in these districts. The results of the present study could be considered by health policy researchers. It seems that human resources' density and inequality in the distribution of health manpower are both needed as indicators for a more thorough investigation of health services, especially in the case of rural and remote areas. Furthermore, health policy makers should focus on the redistribution of the health manpower towards a more equitable situation, based on the results of similar studies. Finally, the documentation of inter-country differences would prove helpful in terms of international cooperation and sharing of knowledge by policy makers when the objective is the equality and quality of health services provision.

[Geographical inequalities in the distribution of general practitioners in Sweden]

AIM

To estimate trends in the inequalities in the distribution of general practitioners in Sweden during the past fifteen years.

METHODS

Relative inequality indicators. We plotted the Lorenz curves and calculated the Gini coefficients for the entire country during 1986, 1991, 1996 and 2001.

RESULTS

During the past 15 years in all a declining trend was noted in the inequalities in the geographical distribution of general practitioners in Sweden, with the lowest level in 1996.

CONCLUSIONS

The degree of inequality in the geographical distribution of general practitioners appeared rather stable during the period, although with some increase in the final year studied. Since equality is part of quality, policy makers in all levels--national, regional and local--should pay attention as to how human resources are distributed.

Postgraduate training in family medicine in Albania

In the Balkan context education in general practice varies greatly and it is in different stages of reorganisation and curriculum development. The postgraduate training in family medicine in Albania started in January 1997 with the goal of providing future family doctors with the proper knowledge, skills, attitudes, and professional values that will enable them to address the medical problems in the community. This paper describes the structure and content of the training programme and discusses some of its key elements.

Medical education in Albania: current situation and perspective, with reference to primary care

A radical primary health care-oriented reform of the medical services in Albania is now under way, calling for adequate revision in medical education. The reform has started in 1994. In January 1997, the Department of Family Medicine at the Faculty of Medicine, University of Tirana, was established for the development of general practice and family medicine, and with it a new era in medical education in Albania has begun. Mutual agreements for international collaborations are being realized, modern medical textbooks are being published, and the importance of continuous medical education is gaining a deserved appreciation. Here we describe medical education in Albania, including undergraduate education, vocational training, and continuing professional development. The emphasis is given on primary care, with some suggestions for concrete actions that would improve the current situation. A brief descriptive account is given of the ongoing Albanian medical education reform, primarily in the field of primary health care, which assumes its most interesting global aspects and at the same time reflects the unique demands of the country.