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There is limited information about doctors' communication behaviors and their salient beliefs with regard to bad news disclosure in Greece. In this qualitative study we investigated the self-reported practices of doctors on breaking bad news, their perceptions about the factors affecting the delivery of such news, and their beliefs about the most appropriate disclosure manner. A focus group discussion and individual interviews were conducted. Twenty-five resident and specialist doctors from primary health care and hospital settings participated. We analyzed the collected data with content analysis techniques. Participants were found to acknowledge the importance of appropriate and effective delivery of bad news; however, none of them reported the implementation of empirically informed communication practices. They described communication patterns mainly formed by their work experience and often guided by the patient's family requests. Doctor, patient, and family characteristics and organizational features and resources were reported to affect the delivery of bad news. Participants perceived the most appropriate disclosure manner as an individualized approach to each patient's unique needs. They suggested an interdisciplinary, collaborative management of the delivery process and the establishment of formal supportive services. These findings may provide useful information for the development of tailored, empirically informed curriculum interventions and educational programs in order to address several barriers to communication. Sociocultural characteristics that influence the disclosure practice, as well as physicians' perceptions that are consistent with the optimal information delivery, should be taken into account. System-level strategies that focus on the development of patient-centered communication also need to be prioritized.

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BACKGROUND: Economic crises may have a significant impact on public health. The objective of this study was to assess trends in health-related behaviours and cardiovascular risk factors within Greece before, at the beginning and during the current financial crisis by comparing data from three waves of the Greek cross-sectional household 'Hellas Health' surveys. METHODS: Data from three waves were analysed. The first wave was conducted in 2006 (n = 1005), the second in 2008 (n = 1490) and the third in 2011 (n = 1008). Samples were representative of the Greek adult population in terms of age and residency. Smoking status, height, weight and fruit and vegetable consumption were self-reported. Physical activity levels were assessed with the International Physical Activity Questionnaire. RESULTS: The prevalence of smoking in Greece decreased from 42.6 to 38.1% during the crisis period 2008-11 (P = 0.026), but not during 2006-8. The prevalence of high levels of physical activity increased among Greek adults (from 21.9 to 31.7%, P < 0.001) in all socio-economic and demographic groups, with the exception of the highest socio-economic status (SES) group. On the contrary, the consumption of at least five portions of fruit and vegetables per day significantly decreased during the crisis among those of lower SES (from 9.0 to 4.1%, P = 0.006). Prevalence of obesity did not show significant trends. CONCLUSIONS: During the economic crisis, fruit and vegetable consumption alarmingly decreased, especially among those of lower SES, whereas trends in smoking prevalence and physical activity levels seem favourable. These results indicate that the economic crisis may unequally impact cardiovascular risk factors among different socio-economic groups.

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BACKGROUND: Adolescence has been documented as the peak age of onset for mental health perturbations, clinical disorders and unsubstantiated health complaints. The present study attempted to investigate associations between multiple, recurrent subjective health complaints (SHC) with emotional/behavioural difficulties, as measured by the Strengths and Difficulties Questionnaire scale (SDQ), among Greek adolescents. METHODS: Questionnaires were administered in a large, nation-wide, random, school-based sample of Greek adolescents, aged 12-18 years. Data from 1170 participants were analyzed. Adolescents with multiple, recurrent SHC were compared in terms of their emotional/behavioural difficulties to their peers with lower levels of health complaints. SDQ scales were separately investigated for their associations with multiple, recurrent SHC, after adjustment for gender, age and socioeconomic status (ses). Further analysis included multiple logistic regression models with multiple, recurrent SHC as the dependent variable and gender, age, ses and SDQ Total difficulties score as independent factors. Potential gender and age interactions were also explored. RESULTS: Almost half of the study participants reported multiple, recurrent SHC. Adolescents with multiple, recurrent SHC had higher scores on all SDQ scales, except from the Prosocial behavior scale, compared to their peers with lower levels of health complaints. Emotional Symptoms, Conduct Problems, Hyperactivity/Inattention and Peer Problems were associated with greater likelihood of having multiple, recurrent SHC, after adjustment for gender, age and ses. The multiple logistic regression models revealed that older adolescents and girls, as well as those with increased Total difficulties score had an increased risk for multiple, recurrent SHC reporting. No significant interaction between SDQ scales and gender or age was found. CONCLUSIONS: Our study highlights the magnitude of psychological burden among adolescents experiencing multiple, recurrent SHC. Professionals in school and clinical settings should be cautious for impaired emotional/behavioural functioning when assessing adolescents with multiple, recurrent SHC, so as early identification of at-risk individuals and timely, appropriate referrals are facilitated.

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BACKGROUND: Early childhood education services create potentially optimal opportunities to identify and respond effectively to preschoolers' mental health problems. However, little is known about the knowledge, skills and competencies of early childhood educators in the area of mental health. The present study aimed to contribute to this field through conducting focus group interviews with professionals from public early childhood education centres in Greece. METHODS: Thirty-four educators attended five focus group meetings, with each group consisting of five to nine participants and two discussion facilitators. A thematic analysis was conducted using line-by-line open coding. Constructed codes from the wording used by the participants in the interviews were created, and constant comparisons for developing themes as well as seeking data not conforming to each theme were used independently by two researchers. At the end of this process, no new information was being provided and there was repetition in each of the categories. RESULTS: The analysis identified three themes in the data: risk factors for preschoolers' mental health problems, signs of preschoolers' mental health problems and practices of helping preschoolers with mental health problems. Results suggested that early childhood educators had satisfactory awareness of many preschoolers' mental health issues, although they showed a rather limited understanding in some domains. Moreover, they seemed to deliver inadequate practices in responding effectively to children's and families' mental health problems. CONCLUSIONS: Best practice training in working with preschoolers, families and mental health services seems essential for helping young children receive the best level of support through early identification and intervention services for possible mental health problems.

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The objective of the present survey was to assess the extent and socio-economic determinants of population exposure to secondhand smoke (SHS) in Greece in 2011. The national household survey Hellas Health IV was conducted in October 2011. SHS exposure was based on self-reported exposure within home, workplace and public places. Thirty-three per cent of the respondents reported living in a smoke-free home. Smokers (p < 0.001) and single individuals (p < 0.017) were less likely to prohibit smoking at home. SHS exposure at work, in restaurants and in bars/clubs/cafes was frequently mentioned by 41.6, 84.2 and 90.5%, respectively. SHS exposure in a bar/club/cafe was noted more among single individuals (p = 0.004) and those aged 18-34 years (p = 0.007). Inhabitants of rural areas were more likely to report someone smoking indoors in all the above venues. Public health education and effective enforcement of the nationwide smoke-free legislation are imperative.

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OBJECTIVES: The objective of the present study was to explore the trends in the intention to quit smoking among adults in Greece between 2006 and 2011, a period characterized by financial instability and newly endorsed tobacco control initiatives. METHODS: Trend analysis of 3 representative national and cross-sectional surveys, 'Hellas Health I' (2006), "Hellas Health III" (2010) and Hellas Health IV (2011). RESULTS: Since 2006, the intention to quit smoking has significantly increased among both genders (33.3% [in 2006] to 42.4% [in 2011], p=0.002), among respondents aged >54years (26.9% [in 2006] to 45.1% [in 2011], p=0.019) and among residents of rural areas (26.4% [in 2006] to 46.7% [in 2011], p=0.001). Both highest (32.1% [in 2006] to 49.4% [in 2011], p=0.036) and lowest (31.7% to 46.0%, p=0.021) socioeconomic (SE) strata showed an increase in the proportion of smokers who intend to quit. However, in 2011, quit attempts were more frequent (35.3%, p=0.009) in smokers of high socioeconomic status. Moreover, smoking prevalence has significantly decreased (43.1% [in 2006] to 38.1% [in 2011], p=0.023), mainly among men (52.4% to 45.7%, p=0.037), respondents of low socioeconomic status (38.9% to 29.4%, p=0.008) and residents of urban areas (45.2% to 37.9%, p=0.005). CONCLUSIONS: Over the past 5years and possibly as a combined result of the implemented tobacco control policies and austerity measures, the intention to quit smoking has increased among all SE strata, however actual quit attempts were higher among those less disadvantaged. Further effort should be made to support quit attempts, especially among vulnerable populations.

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AIM: This national study of schoolchildren in Greece investigated the association between adolescents' subjective health complaints (SHC) and a number of family characteristics. METHODS: Questionnaires were completed by a random, school-based sample of children from 12 to 18 years of age, and one of their parents (76.6% mothers), in 2003. Data from 1041 adolescent-parent pairs were analysed. Multiple linear regression analysis was used to assess the associations between the adolescent's SHC and the following characteristics: parent's marital status, parent's physical and mental health status, parent's worries about their child's SHC, the parent-child relationship, family cohesion, family socio-economic status and the adolescent's sex and age. RESULTS: The analysis showed that the adolescents' SHC were independently and significantly correlated with poor parental subjective mental health status, poor quality parent-child relationships and parental worry. There were also associations between levels of SHC and female and older adolescents. CONCLUSION: Certain family features can be seen as potential contributing factors to SHC in adolescence and should therefore constitute complementary targets for prevention and treatment planning.

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BACKGROUND: During adolescence children are usually confronted with an expanding social arena. Apart from families, schools and neighbourhoods, peers, classmates, teachers, and other adult figures gain increasing importance for adolescent socio-emotional adjustment. The aim of the present study was to investigate the extent to which Greek adolescents' perceived well-being in three main social contexts (family, school and peers) predicted self-reported Subjective Health Complaints. METHODS: Questionnaires were administered to a Greek nation-wide, random, school-based sample of children aged 12-18 years in 2003. Data from 1.087 adolescents were analyzed. A hierarchical regression model with Subjective Health Complaints as the outcome variable was employed in order to i) control for the effects of previously well-established demographic factors (sex, age and subjective economic status) and ii) to identify the unique proportion of variance attributed to each context. Bivariate correlations and multicollinearity were also explored. RESULTS: As hypothesized, adolescents' perceived well-being in each of the three social contexts appeared to hold unique proportions of variance in self-reported Subjective Health Complaints, after controlling for the effects of sex, age and subjective economic status. In addition, our final model confirmed that the explained variance in SHC was accumulated from each social context studied. The regression models were statistically significant and explained a total of approximately 24% of the variance in Subjective Health Complaints. CONCLUSIONS: Our study delineated the unique and cumulative contributions of adolescents' perceived well-being in the family, school and peer setting in the explanation of Subjective Health Complaints. Apart from families, schools, teachers and peers appear to have a salient role in adolescent psychosomatic adjustment. A thorough understanding of the relationship between adolescents' Subjective Health Complaints and perceived well-being in their social contexts could not only lead to more effective tailored initiatives, but also to promote a multi- and inter-disciplinary culture in adolescent psychosomatic health.

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OBJECTIVES: The purpose of the current study is to investigate the use of preventive healthcare services by the adult Greek population and the factors that determine such use. METHODS: Data were obtained from a national household survey (Hellas Health I) conducted during 2006. The survey population consisted of 1,005 individuals, with a mean age of 47.4 years. Candidate respondents were selected by means of a three-stage, proportional to size, sampling design. Chi-square tests and logistic regression analyses were used (p < 0.05). RESULTS: Among the determinants of performance of screening tests, gender, age, marital status, the presence of chronic illness and self-reported health status and the use of a family doctor play an important role. CONCLUSIONS: According to the findings of our study, screening tests are performed in a low percentage of the Greek population, even for individuals at increased risk for cardiovascular disease. It is obvious that doctors should focus more on such population groups, while national health policies promoting screening tests and prevention in general are warranted.

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OBJECTIVE: The purpose was to assess the validity and reliability of health belief model variables (perceived benefits, perceived barriers, and self-efficacy beliefs) that are often the target of mammography screening interventions. METHODS: Based on Champion's health belief model scales, questionnaire data were obtained from a nationally representative sample of 408 Greek women, 40 years of age or older and with no personal history of cancer. RESULTS: Using confirmatory factor analysis, we found all items to load significantly on their respective factors. Standardized factor loadings ranged from 0.55 to 0.88. An analysis of localized areas of respecification of a three-factor model revealed that measurement error correlations between a few items existed. Known-groups and criterion-related validity was supported for all scales, while internal consistency reliability of the scales was satisfactory, with Cronbach's alpha ranging from 0.71 to 0.88. CONCLUSIONS: The Greek version of the scales measuring perceived benefits, perceived barriers, and self-efficacy beliefs is a reliable and valid tool when used to assess health beliefs for mammography screening among women. Implications for intervention strategies aimed at increasing the likelihood of mammography utilization are considered.

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BACKGROUND: Experience of common health symptoms without a clear physical or psychological cause, such as headache or dizziness, is often reported in adolescence. The present study attempted to investigate associations of self-reported subjective health complaints (SHC) with a number of sociodemographic factors of Greek adolescents. METHODS: Questionnaires were administered to a Greek nationwide random school-based sample of adolescents aged 12 to 18 years and their parents in 2003. Data from 922 adolescent-parent pairs were analyzed (response rate = 63%). Adolescents' reported subjective health complaints were assessed for their association with a number of sociodemographic factors: age, sex, type of area of residence according to level of urbanization, immigration background, parental education and employment status, family socioeconomic status and perceived quality of financial resources (PQFR). Multiple linear regression analysis was used to assess the association of the aforementioned factors with subjective health complaints as the dependent variable. RESULTS: Most sociodemographic variables, apart from area of residence and immigration background, were independently associated with subjective health complaints in the univariate analyses. The multiple linear regression analysis, however, limited the factors that could predict adolescents' subjective health complaints to four (age, sex, Family Affluence Scale score and perceived quality of financial resources). Some considerations regarding parental employment status and immigration background are highlighted. CONCLUSIONS: Our study highlights the sociodemographic components of subjective health complaints in the Greek adolescent population. The need to include adolescent-specific measures when collecting information on adolescents' social background is underlined. Identifying vulnerable adolescent populations could lead to effective health promoting and preventive interventions.

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BACKGROUND: The KIDSCREEN-52 is a worldwide instrument for measuring health-related quality of life (HRQoL) in children and adolescents. The aim of this study is to assess reliability and validity of the Greek version of KIDSCREEN. METHODS: Questionnaires were collected from a representative nationwide sample of 1,194 adolescents aged from 11 to 17 years. Internal consistency reliability was determined by calculation of the Cronbach α coefficient. A confirmatory factor analysis (CFA) was conducted in order to test the construct validity of the questionnaire. Validity was further examined by investigating the correlation of KIDSCREEN with the Strengths and Difficulties Questionnaire (SDQ) and its association with socioeconomic and health-related factors. RESULTS: Internal consistency reliability was accepted with a Cronbach α above 0.73 for all KIDSCREEN dimensions. CFA showed that the ten-dimensional model fitted the data well (root mean square error of approximation (RMSEA) = 0.048, comparative fit index (CFI) = 0.971 and goodness of fit index (GFI) = 0.965). Correlation coefficients between KIDSCREEN and SDQ dimensions were significant. Adolescents of low socioeconomic status reported lower scores in the majority of KIDSCREEN dimensions. Also, adolescents with chronic health problem had poorer quality of life concerning physical well-being and other dimensions of KIDSCREEN. CONCLUSIONS: The Greek version of KIDSCREEN-52 was found to have satisfied psychometric properties and could be suitable for assessing HRQoL in Greek adolescents.

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Previous research has shown that, although routine mammography screening can reduce mortality from breast cancer, the use of annual mammography screening remains well under 65%. In an effort to determine the factors that are associated with women's mammography behaviors, this study used the health belief model and the common-sense model of self-regulation as the theoretical frameworks to explore health beliefs, illness representations, and women's mammography practice. Data were obtained from a nationally representative sample of 408 Greek women, 40 years of age or older, with no personal history of cancer. Three dependent variables were considered: recent mammography, repeat mammography, and no mammogram during lifetime. Predictors included socio-demographic and medical variables, perceived benefits of mammography screening, perceived barriers to mammography screening, self-efficacy, as well as illness perceptions. Multivariate analyzes indicated that never having had a mammogram was more likely for women who perceived fewer benefits and more barriers to mammography screening, had more negative emotional representations of breast cancer, and had no private health insurance coverage. Factors associated with recent mammography were younger age, a good knowledge of the recommended mammography screening interval, a family history of breast cancer, and use of patient reminders for next mammogram. Adequate knowledge about the recommended mammography screening interval and higher values for breast cancer worry were associated with an increased number of repeat lifetime mammograms. Implications of the results and suggestions for future research are outlined.

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The purpose of the study was to estimate the demographic and socioeconomic determinants of utilization of the Greek primary and hospital health care services. Data were obtained from the cross-sectional nationwide household survey Hellas Health I (2006). The sample (N = 1005) was representative of the Greek adult population in terms of age and residency, and was selected by means of a three-stage, proportional-to-size sampling design. The presence of a family doctor was reported in a higher degree by participants of higher social classes and private insurance. After adjusting for self-perceived general health and chronic illness, contacts with health care professionals during the past four weeks were found less for residents of rural areas, while contacts with health care professionals during the past 12 months were found less for men than women, for individuals without private insurance and for individuals of lower education. More out-of-pocket payments were reported by the 34-44 age group, rural area residents and individuals with private insurance. Higher use of private health care services was reported by participants of higher social classes and residents of rural areas and private insurance. Only hospital admissions were not directly influenced by demographic and socioeconomic factors. The findings imply the existence of inequities in access and use of primary health services with clear implications to related policies.

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Compliance with laws making certain environments smoke free has focused mainly on smokers' behavior, while the role of non-smokers has scarcely been investigated. Our cross-sectional study interviewed 4043 adults (2037 smokers and 2006 non-smokers) in the general population of Greece during April 2009. Non-smokers reported that they would actively work for compliance with the law. The non-smokers were older, more educated (odds ratio, OR 1.4), and were more likely to be annoyed by the smell of environmental tobacco smoke (OR 2.4) or report that it irritates their eyes (OR 1.8). Policymakers should evaluate how non-smokers could actively support smoke-free laws through reporting of violations using media campaigns that inform them of their rights, and other measures.

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BACKGROUND: Although several studies have reported findings concerning the association between smoking and emotional/behavioural problems, little research has investigated this association after controlling for confounding factors which have been found to be significantly correlated with both cigarette smoking and emotional/behavioural problems and may have a strong effect on the relationship between adolescents' mental health and smoking. The present study attempted to assess the association between adolescents' smoking status and their emotional/behavioural problems after controlling for a number of possible confounders (i.e. age, gender, parental smoking status, exposure to family smoking, family socioeconomic status, adolescents' leisure time) in a Greek nation-wide school-based sample. METHODS: Participants completed a questionnaire which retrieved information about age, gender, family socioeconomic status, smoking status, parental smoking, adolescents' leisure time and emotional/behavioural problems. Data were modelled using multiple logistic regression analysis with adolescents' smoking status as the dependent variable. RESULTS: A total of 1194 (i.e. 63% response rate) of self-reported questionnaires (40.1% boys, 59.9% girls; 12-18 years old) were returned. Data from 1030 participants with full data were analyzed. Cigarette smoking was strongly associated with higher levels of emotional/behavioural problems (p < 0.001) and the association was not moderated (OR = 1.13, 95% CI: 1.08-1.18) after controlling for the effects of other covariates. Emotional symptoms, conduct problems and hyperactivity/inattention were all significantly associated with adolescents' current smoking. CONCLUSIONS: This study supports the association between smoking and emotional/behavioural problems among adolescents. Addressing adolescents' needs regarding their emotional/behavioural health could be helpful in the development of effective anti-smoking strategies in school environment and elsewhere.

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OBJECTIVES: This study was intended to present evidence for the reliability and validity of a Greek translation of the Medical Outcomes Study-HIV Health Survey (MOS-HIV). DESIGN: Sample consisted of 154 HIV-positive men and women, regardless of disease stage, who are being followed at the department of Infectious Diseases of a tertiary hospital of Athens, Greece. METHODS: The translated Greek version of the MOS-HIV instrument, a brief, comprehensive 35-item health-related quality of life questionnaire, was used to assess ten dimensions of health including overall quality of life, pain, physical functioning, role functioning, social functioning, mental health, energy/fatigue, cognitive function, health distress, and health transition. Additional socio-demographic data and clinical parameters were also collected. Standard guidelines were followed for questionnaire translation to the Greek language. Internal consistency reliability using Cronbach's alpha and the range of measurement of the MOS-HIV subscales were examined. Convergent validity was further examined with the intercorrelations of subscales. ROC analysis was used to estimate the ability of the subscales to discriminate patients according to the characteristics of the disease [i.e. asymptomatic, symptomatic and AIDS, CD4+ lymphocyte count (<200 cells/mm(3) and >200 cells/mm(3))] and assess concurrent validity. RESULTS: All the MOS-HIV scales exceeded the minimum reliability standard of 0.70. Physical functioning and health distress had the greatest reliability coefficient, equal to 0.87 and 0.88, respectively. Correlations among MOS-HIV scales were all significant. Physical functioning, pain, and physical health summary scales were significantly lower for AIDS patients compared to asymptomatic HIV+ individuals. All scales except for role functioning and health transition could discriminate well subjects with CD4+ lymphocyte count <200 cells/mm(3) and >200 cells/mm(3). CONCLUSIONS: The Greek version of the MOS-HIV had good reliability and validity among patients with AIDS. Convergent and concurrent validity were generally confirmed. The MOS-HIV may be useful in assessing health-related quality of life in AIDS patients in Greece. Further research is needed for the evaluation of the Greek version of the MOS-HIV responsiveness to changes over time.

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The frequency of health care use is crucial for adolescent well-being and health systems. The present study was the first to test a set of variables in a representative sample of Greek adolescents in order to identify factors that predict health care use and contribute to improving health service planning. Questionnaires were administered to a random sample of adolescents (N=1 194) aged 11-18 years and their parents (N=973) in 2003. Data from 894 participants with full data were analyzed. Parents' education, adolescents' chronic health needs, physical well-being and emotional/behavioural problems as well as parent-child relationship were independent predictors of health care use, although some factors, such as gender, age, type of residence, family affluence, social support and parental health status that previous research identified as predictors were not confirmed. Beyond the need of health care, other factors also play an important role in the utilization of health services by adolescents and their families.

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BACKGROUND: This study aimed at examining the relationship between parental subjective health status and adolescents' health-related quality of life (HRQoL) as well as the role of gender, socioeconomic status, presence of chronic health care needs and social support on the above interaction. METHODS: Questionnaires were administered to a Greek nation-wide random sample of adolescents (N = 1,194) aged 11-18 years and their parents (N = 973) in 2003. Adolescents' and parents' status was assessed, together with reports of socio-economic status and level of social support. Various statistical tests were used to determine the extent to which these variables were related to each other. RESULTS AND DISCUSSION: Parental subjective mental health status was significantly correlated with adolescents' better physical and psychological wellbeing, moods and emotions, parent-child relationships, school environment and financial resources. Parental subjective physical health status was strongly associated with more positive adolescents' self-perception. Adolescents' male gender, younger age, absence of chronic health care needs, high social support, and higher family income were positively associated with better HRQoL. CONCLUSIONS: This study reinforces the importance of parental subjective health status, along with other variables, as a significant factor for the adolescents' HRQoL.

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BACKGROUND: The Strengths and Difficulties Questionnaire (SDQ) is a practical, economic and user-friendly screening instrument of emotional and behavioural problems in children and adolescents. This study was aimed primarily at evaluating the factor structure of the Greek version of the SDQ. METHODS: A representative nationwide sample of 1,194 adolescents (11 to 17 years old) completed the questionnaire. Confirmatory factor analysis (CFA) was conducted to assess the factor structure of the SDQ. RESULTS: CFA supported the original five-factor structure. The modification of the model provided some improvements. Internal consistency was acceptable for total difficulties, emotional symptoms and prosocial behaviour scale, moderate for hyperactivity/inattention scale and inadequate for peer and conduct problems scale. Older adolescents (aged 15 to 17 years) reported more hyperactivity/inattention and conduct problems than younger ones (aged 11 to 14 years) and girls reported more emotional symptoms and less prosocial behaviour problems than boys. Adolescents of low socioeconomic status (SES) reported more difficulties than those of medium and high SES. CONCLUSION: The Greek SDQ could be potentially considered as a community-wide screening instrument for adolescents' emotional and behavioural problems.