Social determinants of health and vaccine uptake during the first wave of the COVID-19 pandemic: A systematic review

Social determinants of health significantly impact population health status. The aim of this systematic review was to examine which social vulnerability factors or determinants of health at the individual or county level affected vaccine uptake within the first phase of the vaccination program. We performed a systematic review of peer-reviewed literature published from January 2020 until September 2021 in Medline and Embase (Bagaria et al., 2022) and complemented the review with an assessment of pre-print literature within the same period. We restricted our criteria to studies performed in the EU/UK/EEA/US that report vaccine uptake in the general population as the primary outcome and included various social determinants of health as explanatory variables. This review provides evidence of significant associations between the early phases of vaccination uptake for SARS-CoV-2 and multiple socioeconomic factors including income, poverty, deprivation, race/ethnicity, education and health insurance. The identified associations should be taken into account to increase vaccine uptake in socially vulnerable groups, and to reduce disparities in uptake, in particular within the context of public health preparedness for future pandemics. While further corroboration is needed to explore the generalizability of these findings across the European setting, these results confirm the need to consider vulnerable groups and social determinants of health in the planning and roll-out of SARS-CoV-2 vaccination programs and within the context of future respiratory pandemics.

A Mixture of Essential Oils from Three Cretan Aromatic Plants Inhibits SARS-CoV-2 Proliferation: A Proof-of-Concept Intervention Study in Ambulatory Patients

INTRODUCTION

The need for effective therapeutic regimens for non-critically ill patients during the COVID-19 pandemic remained largely unmet. Previous work has shown that a combination of three aromatic plants' essential oils (CAPeo) (Thymbra capitata (L.) Cav., Origanum dictamnus L., Salvia fruticose Mill.) has remarkable in vitro antiviral activity. Given its properties, it was urgent to explore its potential in treating mild COVID-19 patients in primary care settings.

METHODS

A total of 69 adult patients were included in a clinical proof-of-concept (PoC) intervention study. Family physicians implemented the observational study in two arms (intervention group and control group) during three study periods (IG2020, n=13, IG2021/22, n=25, and CG2021/22, n=31). The SARS-CoV-2 infection was confirmed by real-time PCR. The CAPeo mixture was administered daily for 14 days per os in the intervention group, while the control group received usual care.

RESULTS

The PoC study found that the number and frequency of general symptoms, including general fatigue, weakness, fever, and myalgia, decreased following CAPeo administration. By Day 7, the average presence (number) of symptoms decreased in comparison with Day 1 in IG (4.7 to 1.4) as well as in CG (4.0 to 3.1), representing a significant decrease in the cumulative presence in IC (-3.3 vs. -0.9, p < 0.001; η2 = 0.20) on Day 7 and on Day 14 (-4.2 vs. -2.9, p = 0.027; η2 = 0.08).

DISCUSSION/CONCLUSIONS

Our findings suggest that CAPeo possesses potent antiviral activity against SARS-CoV-2 in addition tο its effect against influenza A and B and human rhinovirus HRV14 strains. The early and effective impact on alleviating key symptoms of COVID-19 may suggest this mixture can act as a complementary natural agent for patients with mild COVID-19.

Assessing feasibility of targeted primary care referrals for patients with clinical suspicion of interstitial lung disease using lung ultrasound: a prospective case finding study. The potential benefits of LUS utilization

BACKGROUND

In Primary Health Care (PHC) many interstitial lung disease (ILD) cases may remain at diagnostic delay, due to their challenging presentation and the limited experience of general practitioners (GPs) in recognizing their early symptoms.

OBJECTIVE

We have designed a feasibility study to investigate early ILD case-finding competency between PHC and tertiary care.

METHODS

A cross-sectional prospective case-finding study was launched at two private health care centers of Heraklion, Crete, Greece, during nine months (2021-2022). After clinical assessment by GP, PHC attenders, who agreed to participate in the study, were referred to the Respiratory Medicine Department, University Hospital of Heraklion, Crete, underwent Lung Ultrasound (LUS) and those with an overall suspicion for ILDs underwent high resolution computed tomography (HRCT) scan. Descriptive statistics and chi-square tests were used. Multiple Poisson regression analysis was performed to explain positive LUS and HRCT decision with selected variables.

RESULTS

One hundred and nine patients out of 183 were finally included (54.1% females; mean age 61, SD: 8.3 years). Thirty-five (32.1%) were current smokers. Overall, two out of ten cases were assessed to need HRCT due to a moderate or high suspicion (19.3%; 95%CI 12.7, 27.4). However, in those who had dyspnea in relation to counterparts, a significantly higher percentage of patients with LUS findings (57.9% vs. 34.0%, p=0.013) was found, as in those who had crackles (100.0% vs. 44.2%, p= 0.005). Detected possible ILD provisional labelling cases were 6, and most importantly, 5 of those cases were considered highly suspicious for further evaluation based on LUS findings.

CONCLUSIONS

This is a feasibility study exploring potentials by combining data of medical history, basic auscultation skills, as crackles detection, and inexpensive and radiation-free imaging technique, such as LUS. Cases of ILD labeling may be hidden within PHC, sometimes, much before any clinical manifestation.

Systematic review of outbreaks of COVID-19 within households in the European region when the child is the index case

OBJECTIVES

This systematic review aims to identify the secondary attack rates (SAR) to adults and other children when children are the index cases within household settings.

METHODS

This literature review assessed European-based studies published in Medline and Embase between January 2020 and January 2022 that assessed the secondary transmission of SARS-CoV-2 within household settings. The inclusion criteria were based on the Population, Exposure, Outcome framework for systematic reviews. Thus, the study population was restricted to humans within the household setting in Europe (population), in contact with paediatric index cases 1-17 years old (exposure) that led to the transmission of SARS-CoV-2 reported as either an SAR or the probability of onward infection (outcome).

RESULTS

Of 1819 studies originally identified, 19 met the inclusion criteria. Overall, the SAR ranged from 13% to 75% in 15 studies, while there was no evidence of secondary transmission from children to other household members in one study. Evidence indicated that asymptomatic SARS-CoV-2 index cases also have a lower SAR than those with symptoms and that younger children may have a lower SAR than adolescents (>12 years old) within household settings.

CONCLUSIONS

SARS-CoV-2 secondary transmission from paediatric index cases ranged from 0% to 75%, within household settings between January 2020 and January 2022, with differences noted by age and by symptomatic/asymptomatic status of the index case. Given the anticipated endemic circulation of SARS-CoV-2, continued monitoring and assessment of household transmission is necessary.

Prevalence and correlates of physical inactivity in adults across 28 European countries

Background

Physical activity/inactivity is impacted by a plethora of intertwined factors. There are a limited number of studies on physical activity/inactivity that provide a European cross-country perspective. This study aims to present the prevalence and correlates of physical activity in adults across the 28 European Union (EU) member states.

Methods

This is a secondary dataset analysis of the Special Eurobarometer 472 data on physical activity. The cross-sectional survey was conducted during December 2–11 in 2017 across 28 European countries. The data consisted of ∼1000 respondents aged ≧15 years per country. The current analysis was restricted to adults aged 18–64 years (n = 19 645).

Results

More than one in three (36.2%, 95% CI: 35.1–37.3) adults in the EU were physically inactive, with substantial cross-country differences noted. Women were less likely than men to be adequately or highly physically active (aOR: 0.86, 95% CI: 0.78–0.95). Similarly, adults at the age of 40–54 (aOR: 0.65, 95% CI: 0.52–0.81) and 55–64 (aOR: 0.61, 95% CI: 0.49–0.77) were less likely to have moderate or high levels of physical activity in comparison with those 18–24 years of age. Finally, high SES was positively associated with physical activity (aOR: 1.4, 95% CI: 1.16–1.69).

Conclusions

A notable percentage of adults in Europe are physically inactive. Further research is needed to elucidate the factors behind the cross-country differences and identify potential policy actions that may support adopting a physically active lifestyle and decrease the inequalities related to physical activity across Europe.

Over-the-counter medicines, economic conditions, and citizens most in need in Greece: Is it a challenge for primary care research?

INTRODUCTION

Recent austerity experiences in Greece suggest a plausible link between extensive use of over-the-counter (OTC) medicines and socio-economic peculiarities of life.

COMMENTARY

During the economic crisis in Greece, accessibility to healthcare services has been impacted, particularly for people with low income. However, this fact has not been systematically analyzed in conjunction with an observed increase in use of OTC medicines. Gaining a better understanding of the reasons leading to self-care may help to answer additional questions. Further research is needed to assess the gap between self-care and medically assisted care/treatment by designing pilot monitoring actions and focusing on behaviours related to OTC medicine use. Primary care can offer more collaboration between primary care physicians, community pharmacists, patients, and their families.

IMPLICATIONS

It is crucial to create a multimodal research plan to gain a better understanding of motivational reasons that eventually lead to increasing use of OTC medicines. Efforts should be made to develop data collection techniques that will elicit information from various social groups that focus on changeable behaviours and perceived needs in relation to medicine consumption.

Cognitive Impairment and Dementia in Primary Care: Current Knowledge and Future Directions Based on Findings From a Large Cross-Sectional Study in Crete, Greece

Introduction: Dementia severely affects the quality of life of patients and their caregivers; however, it is often not adequately addressed in the context of a primary care consultation, especially in patients with multi-morbidity. Study Population and Methods: A cross-sectional study was conducted between March-2013 and December-2014 among 3,140 consecutive patients aged >60 years visiting 14 primary health care practices in Crete, Greece. The Mini-Mental-State-Examination [MMSE] was used to measure cognitive status using the conventional 24-point cut-off. Participants who scored low on MMSE were matched with a group of elders scoring >24 points, according to age and education; both groups underwent comprehensive neuropsychiatric and neuropsychological assessment. For the diagnosis of dementia and Mild-Cognitive-Impairment (MCI), the Diagnostic and Statistical Manual-of-Mental-Disorders (DSM-IV) criteria and the International-Working-Group (IWG) criteria were used. Chronic conditions were categorized according to ICD-10 categories. Logistic regression was used to provide associations between chronic illnesses and cognitive impairment according to MMSE scores. Generalized Linear Model Lasso Regularization was used for feature selection in MMSE items. A two-layer artificial neural network model was used to classify participants as impaired (dementia/MCI) vs. non-impaired. Results: In the total sample of 3,140 participants (42.1% men; mean age 73.7 SD = 7.8 years), low MMSE scores were identified in 645 (20.5%) participants. Among participants with low MMSE scores 344 (54.1%) underwent comprehensive neuropsychiatric evaluation and 185 (53.8%) were diagnosed with Mild-Cognitive-Impairment (MCI) and 118 (34.3%) with dementia. Mental and behavioral disorders (F00-F99) and diseases of the nervous system (G00-G99) increased the odds of low MMSE scores in both genders. Generalized linear model lasso regularization indicated that 7/30 MMSE questions contributed the most to the classification of patients as impaired (dementia/MCI) vs. non-impaired with a combined accuracy of 82.0%. These MMSE items were questions 5, 13, 19, 20, 22, 23, and 26 of the Greek version of MMSE assessing orientation in time, repetition, calculation, registration, and visuo-constructive ability. Conclusions: Our study identified certain chronic illness-complexes that were associated with low MMSE scores within the context of primary care consultation. Also, our analysis indicated that seven MMSE items provide strong evidence for the presence of dementia or MCI.

Robustness of the EUROPEP questionnaire as regards data quality, reliability, and construct validity: The Greek experience before and after the economic crisis

OBJECTIVES

To assess the data quality, reliability, and construct validity of the Greek EUROPEP and to examine the instrument's robustness in terms of its psychometric properties in a pre- and post-economic crisis period.

METHODS

Taking into account the two key factors that affect the accuracy and quality of survey data, that is the representativeness of the sample selected from the population, and the response rate, four hundred ninety-two and five hundred thirty-two patients (492 and 532 patients) pre- and post-crisis, respectively, consulting GPs at 16 Primary Health Care Centers (PHCCs) in Greece were invited to complete the Greek EUROPEP. We assessed item missing, ceiling and floor effects, and used factor analysis to assess the structure of the 23 items of the EUROPEP. Scales were tested for reliability and construct validity. We further examined if the scales of EUROPEP need to be refined, taking into account the external validity across economic crises.

RESULTS

Factor analysis identified three groups of questions that formed scales with satisfactory internal consistency reliability, and validity. The clinical behavior scale, the support, and services scale, and the organization of care scale, all met the criterion of 0.7 for Cronbach's alpha. All scales were found to have a significant correlation with the majority of the examined variables. Moreover, the EUROPEP was found to be robust in effectively detecting differences in patients' views over time in different economic contexts.

CONCLUSIONS

The study identified three scales in the Greek EUROPEP-questionnaire with satisfactory psychometric properties, and its Greek version could be used in the recent primary health care (PHC) reform in this country.

Organ donation attitudes and general self-efficacy: exploratory views from a rural primary care setting

INTRODUCTION

Behavioral determinants can enable or hinder motivation towards registration and donorship and, subsequently, action or inertia towards organ donation. Nevertheless, there is limited information about the role of self-efficacy in relation to organ donation awareness and presumed consent among individuals and their families. The aim of this study was to explore knowledge, attitudes and general self-efficacy as behavioral determinants for organ donation among rural primary care attendants, in order to tailor awareness strategies for reversing inertia within an opt-out system.

METHODS

This was a prospective face-to-face survey during regularly scheduled appointments of 203 attendants at a rural primary care unit in northern Greece. Responses to a 12-item adapted 'Organ donation awareness' questionnaire measuring knowledge, attitudes and awareness were related to participants' General Self-Efficacy (GSE) Scale score. Hierarchical modelling of a multiple linear regression model was adopted with GSE score added.

RESULTS

About one-third of respondents (34.0%) had discussed presumed consent with a partner, family member or friend. More than half (54.2%) were concerned that donated organs might be used without consent for other purposes, such as medical research. A total of 30% found organ donation unacceptable because of religious beliefs. Organ donation awareness was not influenced by respondents' specific characteristics, but was significantly related to the GSE score (standard &beta;=0.155, p=0.033).

CONCLUSION

Overall, organ donation perceptions among rural primary care recipients were determined by knowledge of the presumed consent procurement system, pre-conceptions, religious beliefs, altruism and GSE scores. The association of self-efficacy with raised awareness could potentially explain the gap between high intent to consent as a donor and subsequent lack of follow-up action. Further comparative research across behavioral determinants between rural/urban groups is needed in order to tailor awareness strategies suitable for an opt-out system.

The Secondhand Smoke Exposure Scale (SHSES): A hair nicotine validated tool for assessing exposure to secondhand smoke among elderly adults in primary care

INTRODUCTION

Accurate estimation of exposure to Secondhand Smoke (SHS) is important in both research and clinical practice. We aimed to develop, an easy to implement, biomarker validated scale to provide an estimation of adult exposure to SHS for use within primary health care or epidemiological research.

METHODS

A pool of 26 baseline questions evaluating exposure to SHS was administered to 178 non-smoking adults (mean age 68.1 years), recruited from both urban and rural primary health care practices in Crete, Greece in November 2011, while concurrent hair samples were collected and nicotine concentrations were measured. To generate scores for each question item, we fitted a backward linear regression using the main predictors of SHS exposure selected from the initial pool of questions, weighted against each individuals biomarker evaluated exposure.

RESULTS

Among the pool of participants and weighted according to hair nicotine levels, in descending order, the most important sources of SHS exposure were the home (5 points, β=0.37), the family car (3 points, β=0.20), public places (2 points, β=0.15) and the workplace (1 point, β=0.013), the relative weighting of which led to the development of an 11-point scale to assess exposure to SHS. For every unit increase in the score, there was an associated increase in mean hair nicotine concentrations by 1.35 ng/mg (95%CI: 1.25-1.45, p<0.0001)

CONCLUSIONS

The SHS exposure score (SHSES) may be a useful tool in an estimating the level of the exposure to SHS among elderly adults and investigating the relationship between SHS exposure and potential health outcomes.

Detection of human papillomavirus (HPV) DNA prevalence and p53 codon 72 (Arg72Pro) polymorphism in prostate cancer in a Greek group of patients

Prostate cancer is the most common neoplasm found in males and the second most frequent cause of cancer-related mortality in males in Greece. Among other pathogens, the detection frequency of human papillomavirus (HPV) has been found to be significantly increased in tumor tissues among patients with sexually transmitted diseases (STDs), depending on the geographical distribution of each population studied. The present study focused on the detection of HPV and the distribution of Arg72Pro p53 polymorphism in a cohort of healthy individuals, as well as prostate cancer patients. We investigated the presence of HPV in 50 paraffin-embedded prostate cancer tissues, as well as in 30 physiological tissue samples from healthy individuals by real-time PCR. Furthermore, the same group of patients was also screened for the presence of the Arg72Pro polymorphism of the p53 gene, a p53 polymorphism related to HPV. Out of the 30 control samples, only 1 was found positive for HPV (3.33 %). On the contrary, HPV DNA was detected in 8 out of the total 50 samples (16 %) in the prostate cancer samples. The distribution of the three genotypes, Arg/Arg, Arg/Pro, and Pro/Pro, was 69.6, 21.7, and 8.7 % in the cancer patients and 75.0, 17.86, and 7.14 % in healthy controls, respectively. No statistically significant association was observed between the HPV presence and the age, stage, p53 polymorphism status at codon 72, or PSA. The increased prevalence of HPV detected in the prostate cancer tissues is in agreement with that reported in previous studies, further supporting the association of HPV infection and prostate cancer.

Perceptions of primary care professionals on quality of services in rural Greece: a qualitative study

INTRODUCTION

Greece is striving to limit its health expenditure to essential needs. General practice and the provision of Primary Health Care (PHC) mainly take place in rural settings, where approximately 200 Primary Health Care Centres (PHCCs) have been established. In order to determine how to optimize the effectiveness and efficiency of PHC services, it is important to first gain insights into the providers' perspectives. The aim of the study was to assess the perceptions of General Practitioners (GPs) and the directors of PHCCs regarding the effectiveness of available PHC services, and to elicit suggestions on how current services could be improved.

METHODS

This qualitative study was based on semi-structured interviews. The setting was 21 PHCCs in the Epirus and Crete regions of Greece. Twenty-nine physicians were interviewed on aspects of capacity, resources, performance and quality of PHC services. Discussions were digitally recorded and transcribed verbatim. The transcriptions were then analysed using thematic content analysis.

RESULTS

The main identified barriers to providing high-quality PHC services were: PHC service shortages in workforce and equipment; inadequate GP and paramedic training; the absence of position/job descriptions or duty statements for GPs and other PHC personnel; and limited public awareness about the role of GPs. Suggestions for remodelling the current PHC system included: the introduction of new technologies; GP empowerment; leadership reforms; and mechanisms for evaluating of the quality of services. Finally, areas of concern regarding future development and utilisation of private PHC infrastructure and services were highlighted.

CONCLUSION

The methodology of this study and the results regarding remodelling the current PHC system could be used to inform policy-making in Greece, particularly in the current period of severe economic crisis; they may also be of relevance to other European countries facing similar challenges in allocating resources and reforming PHC.

Expression analysis of Akt and MAPK signaling pathways in lung tissue of patients with idiopathic pulmonary fibrosis (IPF)

PURPOSE OF THE STUDY

Several studies in patients with lung cancer have shown that epidermal growth factor receptor regulates various tumorigenic processes through the phosphoinositide 3-kinase/Akt/mammalian target of rapamycin and Ras/Raf/Mek/Erk (mitogen-activated protein kinase (MAPK)) signalling pathways. The aim of our study is to evaluate whether these pathways are implicated in the pathogenesis of idiopathic pulmonary fibrosis (IPF) and to seek indirect evidence of a common pathogenetic pathway with lung cancer. m-RNA expression of oncogenes participating in these two signaling pathways, as well as the combined m-RNA expression of the suppressor genes R-kip and p53 in lung tissue of patients with IPF were evaluated.

BASIC PROCEDURES

The study population was composed by two distinct groups. Patients with IPF (n = 25) and control subjects who underwent thoracic surgery for reasons other than interstitial lung disease (n = 10). Expression analysis of the aforementioned oncogenes and suppressor genes was performed using real-time reverse transcription polymerase chain reaction.

MAIN FINDINGS

We found no difference in the overall m- RNA expression between controls and IPF in both investigated pathways. However, Braf has been overexpressed in IPF samples (P = 0.01) in contrast with K-ras that has been found downregulated (P < 0.001) in comparison with controls.

PRINCIPAL CONCLUSIONS

These findings cannot exclude the hypothesis of involvement of Akt and MAPK signalling pathways in pathogenesis of IPF. However, further investigation is needed in order to verify these data.

Restless legs syndrome: literature review

Restless legs syndrome is a distressing condition, with negative effects on sleep and daytime activities that affect personal, family and occupational life. The overall impact of restless legs syndrome on quality of life is comparable to that of chronic and frustrating conditions such as depression and diabetes. Misdiagnosis and inappropriate treatment may increase patients' suffering in terms of uncertainty, overuse or misuse of care services and lack of trust. Presenting a synthesis of the main topics in the literature on restless legs syndrome facilitates for a better understanding and its management in primary care settings.