Yannis Tountas

KIDSCREEN-52 quality-of-life measure for children and adolescents

This study describes the development and reports the first psychometric results of the European KIDSCREEN-52 generic health-related quality-of-life questionnaire for children and adolescents. The KIDSCREEN-52, including ten dimensions, was applied in a European survey involving 12 countries (i.e., Austria, Switzerland, Czech Republic, Germany, Greece, Spain, France, Hungary, The Netherlands, Poland, Sweden and the UK) and 22,110 children and adolescents aged between 8 and 18 years of age. Questionnaire development included a literature search, expert consultation, and focus group discussions with children and adolescents. After definition of dimensions and collection of items, a translation process following international translation guidelines, cognitive interviews and a pilot test were performed. Analysis regarding psychometric properties showed Cronbach-α ranged from 0.77 to 0.89. Correlation coefficients between KINDLR and KIDSCREEN-52 dimensions were high for those assessing similar constructs (r = 0.51–0.68). All KIDSCREEN-52 dimensions showed a gradient according to socioeconomic status and most dimensions showed a gradient according to psychosomatic health complaints. The first results demonstrate that the KIDSCREEN-52 questionnaire is a promising cross-cultural measure of health-related quality-of-life assessment for children and adolescents in Europe.

THE KIDSCREEN-52 QUALITY OF LIFE MEASURE FOR CHILDREN AND ADOLESCENTS: PSYCHOMETRIC RESULTS FROM A CROSS-CULTURAL SURVEY IN 13 EUROPEAN COUNTRIES

OBJECTIVE This study assesses the reliability and validity of the European KIDSCREEN-52 generic health-related quality of life (HRQoL) questionnaire for children and adolescents. RESEARCH DESIGN The KIDSCREEN-52, which measures HRQoL in 10 dimensions, was administered to a representative sample of 22,827 children and adolescents (8 to 18 years) in 13 European countries. Psychometric properties were assessed using the Classical Test Theory approach, Rasch analysis, and structural equation modeling (SEM). A priori expected associations between KIDSCREEN scales and sociodemographic and health-related factors were examined. Test-retest reliability was assessed in 10 countries. RESULTS For the overall sample, Cronbachs alpha values ranged from 0.77 to 0.89. Scaling success (Multitrait Analysis Program) was >97.8% for all dimensions and Rasch analysis item fit (INFITmsq) ranged from 0.80 to 1.27. The intraclass correlation coefficients ranged from 0.56 to 0.77. No sizeable differential item functioning (DIF) was found by age, sex or health status. Four items showed DIF across countries. The specified SEM fitted the data well (root mean square error of approximation: 0.06, comparative fit index: 0.98). Correlation coefficients between Pediatric Quality of Life Inventory, Child Health and Illness Profile-Adolescent Edition, and Youth Quality of Life Instrument scales and KIDSCREEN dimensions assessing similar constructs were moderate for those (r = 0.44 to 0.61). Statistically significant differences between children with and without physical and mental health problems (Children with Special Health Care Needs screener: d = 0.17 to 0.42, Strengths and Difficulties Questionnaire: d = 0.32 to 0.72) were found in all dimensions. All dimensions showed a gradient according to socioeconomic status. CONCLUSIONS The KIDSCREEN-52 questionnaire has acceptable levels of reliability and validity. Further work is needed to assess longitudinal validity and sensitivity to change.

Reforming the reform: the greek national health system in transition

The National Health System (ESY) in Greece, which was established in 1983, is in a state of continuous crisis. This situation is caused mainly by the systems problematic administration, low productivity and inadequate Primary Health Care. These have led the re-elected PASOK government to introduce by the end of 2000 a radical reform of the health system. The 200 reform measures announced by the new Minister of Health and Welfare include changes aiming at: the decentralization of the ESY, the creation of a unified financing system for the social insurance funds, a new management structure in public hospitals, the organization of a Primary Health System in urban areas, and the strengthening of Public Health and Health Promotion. These changes are presented and discussed in this paper.

Validity of the EuroQoL (EQ-5D) Instrument in a Greek General Population

OBJECTIVES The main purpose of this study was to assess the construct validity of the Greek EQ-5D instrument in measuring health-related quality of life, as well as to address the issues of concurrent validity, internal consistency reliability, and sensitivity. METHODS A stratified, representative sample (n = 1388) of the Greek general population was approached for interview (response rate 72.4%). The survey included the EQ-5D, the SF-36, and questions on sociodemographic and clinical characteristics of the sample. RESULTS The EQ-5D dimensions, the EQ visual analog scale, and the UK-based utility index were capable of distinguishing between groups of respondents, in the expected manner, on the basis of sex, age, education, socioeconomic status, self-reported health problems, and health services utilization, thus providing evidence of construct validity. Convergent and divergent validity of the EQ-5D descriptive system were supported by expected relationships with SF-36 scale and summary scores. Additionally, reporting a problem in a given EQ dimension was generally associated with lower SF-36 scores, supporting concurrent validity. Internal consistency reliability and sensitivity were also satisfactorily demonstrated. CONCLUSIONS The results provide initial support for the construct validity of the EQ-5D in Greece, and, in conjunction to future studies addressing test-retest reliability and responsiveness, they support administering the instrument in health status studies, which in turn can contribute to transnational comparisons.

The association between consumption of breakfast cereals and BMI in schoolchildren aged 12-17 years: the VYRONAS study.

OBJECTIVE To evaluate whether consumption of breakfast cereals is associated with BMI in a sample of Greek adolescents. DESIGN A cross-sectional health and nutrition survey. SETTING AND SUBJECTS During 2004-5, 2008 schoolchildren aged 12-17 years were selected from twelve schools located in Vyronas region (Athens metropolitan area). Height and weight were measured and BMI was calculated. A semiquantitative FFQ was applied and multiple logistic regression analysis was used. RESULTS Overall, 4.7% of boys and 1.7% of girls were obese, whereas 19.4% of boys and 13.2% of girls were overweight. Only 20.7% of boys and 15.5% of girls reported that they consume cereals as a first choice for breakfast. Consumption of breakfast cereals was associated with lower BMI in boys (P=0.08) and girls(P=0.019), irrespective of age and physical activity status. More prominent results were observed for daily cereal consumption or for more than two daily servings of cereals consumed for breakfast. Consumption of pre-sweetened breakfast cereals was associated with lower BMI compared with non-pre-sweetened or no intake of cereals, in both genders (P<0.001). Consumption of breakfast cereals was associated with 33% (95% CI 14%, 48%) lower likelihood of overweight/obesity, irrespective of age, sex and physical activity status. CONCLUSIONS Consumption of breakfast cereals was associated with lower BMI levels and a lower likelihood of overweight/obesity in both genders; thus a solid basis for public health professionals could be built when issuing advice on weight management.

Evaluation of a nutrition intervention in adolescents of an urban area in Greece: short- and long-term effects of the VYRONAS study.

OBJECTIVE To assess the short-term (15-d) and long-term (12-month) effects of a school-based health and nutrition education intervention on diet, nutrition intake and BMI. DESIGN The 12-week teacher-implemented intervention in combination with seminars organized for parents was aimed at improving childrens diet and nutrition knowledge. The intervention took place between September 2007 and January 2008. The participants were randomized to two study groups, the intervention group (IG) and control group (CG), and were examined prior to the intervention on a variety of health knowledge, dietary, behavioural and anthropometric indices. The same measurements were collected 15 d and 1 year after the intervention. SETTING All high schools in Vyronas, a densely populated district of Athens, Greece. SUBJECTS The sample consisted of 191 students aged 12-13 years. RESULTS Twelve months after the intervention, the programme was effective in reducing various indices in the IG compared with baseline findings (BMI: 23.3 (sd 2.8) v. 24.0 (sd 3.1) kg/m2, P < 0.001; daily energy intake: 8112.4 (sd 1412.4) v. 8503.3 (sd 1419.3) kJ/d, P < 0.001; total fat intake: 31.3 (sd 4.4) v. 35.4 (sd 4.7) % of daily energy, P < 0.001). Except for BMI, decreases in the aforementioned indices were also observed 15 d after the intervention. In addition, students of the IG reduced their weekly consumption of red meat and non-home-made meals and increased their frequency of fruit and breakfast cereal consumption. CONCLUSIONS The beneficial effects of this nutrition education intervention among adolescents may highlight the potential of such programmes in the prevention of obesity.

Investigating Unmet Health Needs in Primary Health Care Services in a Representative Sample of the Greek Population

Unmet health care needs are determined as the difference between the services judged necessary and the services actually received, and stem from barriers related to accessibility, availability and acceptability. This study aims to examine the prevalence of unmet needs and to identify the socioeconomic and health status factors that are associated with unmet needs. A cross-sectional study was conducted in Greece in 2010 and involved data from 1,000 consenting subjects (>18 years old). Multiple binary logistic regression analysis was applied to investigate the predictors of unmet needs and to determine the relation between the socio-demographic characteristics and the accessibility, availability and acceptability barriers. Ninety nine participants (9.9%) reported unmet health needs during the 12 months prior to the research. The most frequently self-reported reasons were cost and lack of time. Youth, parenthood, physician consultations, and poor mental health increased the likelihood of unmet needs. Women were less likely to report accessibility and availability than acceptability barriers. Educational differences were evident and individuals with primary and secondary education were associated with significantly more accessibility and availability barriers compared with those with tertiary education. Unmet health needs pose a significant challenge to the health care system, especially given the difficult current financial situation in Greece. It is believed that unmet health needs will continue to increase, which will widen inequalities in health and health care access.

Use of cancer screening services in Greece and associated social factors: results from the nation-wide Hellas Health I survey

This study estimated the rates of age-appropriate screening practices for breast, cervical, colon and prostate cancer within the general population in Greece and explored the influences of social factors on their use. Data were based on the cross-sectional Hellas Health I survey (2006) conducted on a representative sample of 1005 adults, aged 18–69 years. The percentage of women aged 21–69 years having received the papanicolaou smear test within the past 3 years was 59.4%, and the percentage of women aged 50–69 years having received mammography and the faecal occult blood test (FOBT) within the past 3 years was 53.8 and 8.3%, respectively. There were significant effects of age, education and marital status on carrying out the papanicolaou smear test, age on carrying out mammography, and existence of a family doctor on carrying out the FOBT. In men aged 50–69 years, 40.6% had received the prostate-specific antigen test and 10.9% of men had received the FOBT during the past 3 years. The percentage of men aged 50–69 years who had undergone digital rectal examination within the past 5 years was 20.3%. Multivariate analyses showed significant effects of age, social class, smoking status and type of insurance on carrying out the prostate-specific antigen test and of age on carrying out the digital rectal examination. No effects were revealed for the FOBT in men. The percentage of the population in Greece receiving screening services recommended by the European Council is low and seriously affected by social factors. Public health policies should direct their efforts towards introducing good-quality universal cancer screening and find culturally sensitive ways of addressing the barriers that prevent Greek people from adopting poor-quality cancer screening practices.

Mediterranean Diet and Metabolic Syndrome in an Urban Population The Athens Study

BACKGROUND Previous studies demonstrated the beneficial impact of the Mediterranean diet (MedDiet) on metabolic syndrome (MetS). The aim of this study was to retrospectively investigate the association between MedDiet and MetS in a representative sample of the Athenian population in the early 1980s, when MetS had not been established as an entity yet. METHODS In a cross-sectional epidemiologic survey of cardiovascular disease (CVD), 2,074 randomly selected adults were examined: 900 men and 1,174 women (age, 46.9 ± 14.9 years). MetS was defined according to criteria of the National Cholesterol Education Program-Adult Treatment Panel III. A validated questionnaire concerning nutrition habits was administered, and MedDiet was assessed according to guidelines of the Division of Nutrition/Epidemiology, Athens University Medical School. RESULTS Overall, 1,023 participants (49.3%) followed MedDiet (47.3% men, 52.0% women, P = .033) with similar rates across age groups (P = .337). MetS was diagnosed in 24.0% of those following MedDiet, compared with 27.9% of those not following it (P = .041). Participants with CVD or diabetes mellitus were less likely to follow MedDiet (43% vs 50%, P = .009). Multivariate analysis revealed that MedDiet is associated with a 20% reduction in MetS (odds ratio = 0.80, 95% confidence interval = 0.65-0.98), after adjustment for age, gender, smoking, light physical activity, serum levels of low-density lipoprotein cholesterol and γ-glutamyl transferase, diabetes mellitus, CVD, family history of hypertension, and/or hyperlipidemia. CONCLUSIONS Results indicate that adherence to MedDiet may attenuate the prevalence of MetS and, consequently, the increasing burden of diabetes mellitus and CVD, especially in urban populations.

Sociodemographic and socioeconomic determinants of health services utilization in Greece: the Hellas Health I study.

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.