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• Government policy shall address the strategic nature of local resource use decisions. • Local resource users face linked coordination, prisoner's dilemma, and zero-sum/externality situations. • Governments shape the behavior of local resource users via bundles of policy instruments. • Policy instruments contribute to local collective action via a handful of mechanisms. This paper presents a diagnostic approach to the role and capacity of governments to facilitate local collective action and alleviate environmental problems. The paper adds to a nascent scholarship aiming to conciliate theories on "governance by government" and "governance by self-organization". We adopt two premises for that purpose: (1) policy instruments shall be tailored to the strategic nature of local resource management decisions; and (2) such nature is not static and can be modified via governmental policies. We first build on the Institutional Analysis and Development (IAD) framework to characterize the decision-making situations that local resource users face and the local rules that shape said situations. Then, based on common pool resource (CPR) and policy instrument choice theory, we identify four mechanisms through which different policy instruments can facilitate local collective action (change in payoffs and their perception, reduction of transaction costs, reduction of uncertainty, and normative consonance). This analytical approach is then applied to four illustrative cases of water management in Germany, France, Greece and Spain. As shown, local resource users are embedded in not one but many overlapping decision-making situations. In this context, the promotion of collective action is rarely accomplished via a single policy instrument or mechanism but via bundles of them. Also, the paper illustrates the importance of understanding how governmental policies modify the structure of rules and incentives that affect local resource users, potentially facilitating local collective action and the solution of environmental problems. [ABSTRACT FROM AUTHOR]

Nursing education and formation is still heterogenous in spite of The Bologna Declaration in 1999. Apart from the existence of basic curriculum standards, universities have flexibility regarding its design. The objective of this study is to provide an overview of contemporary nursing education and contrast it with the legal frameworks in place in four Southern European countries: Portugal, Spain, Italy, and Greece. A scoping review was conducted in order to revise and obtain an up-to-date review of current nursing education and quality. Then, a content evaluation of the legal public framework was conducted. A total of nine articles were included in the review. Data analysis evoked three main themes from the results: nursing education heterogeneity owing to ECTS increased from 180 to 240 for the diversity of clinical practice hours; the nursing framework lacked a definition; and the evolution of nursing education, alongside quality improvement and more accurate guidelines were required. Regarding their legal framework, the main directives and legislation standards were assessed and compared with the current curriculum. To conclude, nursing heterogeneity education evokes competence inequality among students and future professionals as larger curricular programs (240 ECTS) offer more clinical practice. Nursing education uniformity could enhance international mobility and promote knowledge exchange and nursing competence framework definitions. These are facts that certainly bring nursing empowerment. This study was not registered. [ABSTRACT FROM AUTHOR]

Background The European Union has used Healthy Life Years (HLY) as an indicator to monitor the health of its aging populations. Scholarly and popular interest in HLY across countries has grown, particularly regarding the ranking of countries. It is important to note that HLY is based on self-assessments of activity limitations, raising the possibility that it might be influenced by differences in health reporting behaviours between populations, a phenomenon known as differential item functioning (DIF). Methods We estimated DIF-adjusted HLY at age 50 for Belgium, France, Germany, Greece, Italy, the Netherlands, Spain, and Sweden to determine the extent to which differences in HLY might be influenced by reporting heterogeneity across countries. We used anchoring vignettes, taken from the 2004 Survey of Health, Ageing and Retirement in Europe, to estimate DIF-adjusted prevalence rates of activity limitations measured by the Global Activity Limitations Indicator (GALI). The Sullivan method was used to calculate DIF-adjusted HLY. Results Changes in HLY before and after adjustment ranged from a 1.20-year decrease for men in Italy to a 1.61-year increase for women in Spain. Adjustment for DIF produced changes in the rankings of the countries by HLY, with upward and downward movements of up to three positions. Conclusion Our results show that DIF is likely to affect HLY estimates, thereby posing a challenge to the validity of comparisons of HLY across European countries. The findings suggest that HLY should be used to monitor population health status within a country, rather than to make comparisons across countries. [ABSTRACT FROM AUTHOR]

Background: People experiencing homelessness (PEH) are known to be at higher risk of adverse health outcomes and premature mortality when compared to the housed population and often face significant barriers when attempting to access health services. This study aimed to better understand the specific health care needs of PEH and the barriers and facilitators associated with their timely and equitable access to health services in the European context. Methods: We conducted an exploratory cross-national qualitative study involving people with lived experience of homelessness and health and social care professionals in Austria, Greece, Spain, and the UK. A total of 69 semi-structured interviews comprising 15 social care professionals, 19 health care professionals, and 35 PEH were completed, transcribed, and analysed thematically. Results: Findings were organised into three overarching themes relating to the research question: (a) Health care needs of PEH, (b) Barriers to health care access, and (c) Facilitators to health care access. Overall, the general health of PEH was depicted as extremely poor, and mainstream health services were portrayed as ill-equipped to respond to the needs of this population. Adopting tailored approaches to care, especially involving trusted professionals in the delivery of care, was identified as a key strategy for overcoming existing barriers. Conclusions: The results of this study indicate there to be a high degree of consistency in the health care needs of PEH and the barriers and facilitators associated with their access to health care across the various European settings. Homelessness in itself is recognized to represent an essential social determinant of health, with PEH at risk of unequal access to health services. Changes are thus required to facilitate PEH's access to mainstream primary care. This can also be further complemented by investment in 'in-reach' services and other tailored and person-centred forms of health care. Trial registration: This study was registered retrospectively on June 6, 2022, in the registry of ClinicalTrials.gov under the number NCT05406687. [ABSTRACT FROM AUTHOR]

INTRODUCTION Surveillance of tobacco consumption in public places is an important measure to evaluate the impact of tobacco control interventions over time. The objective of this study was to estimate the prevalence of smoking as seen by smokers and their smoking behaviour in public places, in six European countries. METHODS We used baseline data of the International Tobacco Control Six European countries (ITC 6E) Survey, part of the EUREST-PLUS Project, conducted in 2016 in national representative samples of about 1000 adult smokers aged 18 years and older in Germany, Greece, Hungary, Poland, Romania and Spain. For each setting (workplaces, restaurants, bars/pubs and discos) participants were asked whether they had seen someone smoking during their last visit there and whether they too had smoked there. We report the overall and by-country weighted prevalence of seeing someone smoking and the smokers' own smoking behaviour at each setting. We also assess the relationship between seeing someone smoking and smoking themselves at these settings. RESULTS The prevalence of smoking as seen by smokers was 18.8% at workplaces, with high variability among countries (from 4.7% in Hungary to 40.8% in Greece). Among smokers visiting leisure facilities in the last year, during their last visit 22.7% had seen someone smoking inside restaurants and 12.2% had smoked themselves there, while for bars/pubs the corresponding prevalences were 33.9% and 20.4%, and inside discos 44.8% and 34.8%. CONCLUSIONS Smoking is still prevalent at leisure facilities, particularly at discos in Europe, with high variability among countries. More extensive awareness campaigns and stricter enforcement are needed to increase the compliance of smokefree regulations, especially in leisure facilities. [ABSTRACT FROM AUTHOR]

Background: The databases of children's anthropometric parameters are often outdated, rarely representative and are not always available at an international level. Objectives: To present children's anthropometric parameters in six European countries that contributed to the Feel4Diabetes project and find country-specific differences. Design/Setting: The Feel4Diabetes study was performed between 2016 and 2018, targeting children in Belgium, Bulgaria, Finland, Greece, Hungary and Spain. The current study presents data from the baseline and the yearly follow-up anthropometric measurements. Subjects: In total, 20,832 measurements of children (48.7% boys) between 6 and 10 years of age were conducted. Main outcome measure: weight, height, BMI. Results: Belgian boys had the lowest body weight and height, while Greek boys had the highest body weight, and Finnish had the highest body height. The highest proportion of overweight (percentile above 85%) and obese boys (percentile above 95%) was in Greece, followed by Hungarian, Spanish, Bulgarian and Finnish boys. In contrast, Belgian boys had the lowest ratio in both categories. Among girls, Greece had the highest; Belgium had the lowest body weight; Finland was the highest in all age categories. The ratio in the overweight range was the highest in Greece, followed by Spanish, Bulgarian and Hungarian girls, who were second in the obese category. Finnish girls had lower and Belgian girls had the lowest ratio in both BMI categories. All the detailed data are presented in tables, and the trends are figures. Conclusions: Our study presents fresh and comparable anthropometric data of children between 6 and 10 years of age in six European countries, supporting the need for appropriate obesity prevention. [ABSTRACT FROM AUTHOR]

Background The extreme social circumstances caused by declared COVID-19 pandemic deeply intervene people's everyday life and should not be neglected but seen through the view of social reality pinpointing the 'ordinary' people. In this article, authors explored basic segments of everyday and their subjective perception to what extent sleeping habits, physical inactivity, physical activity, nutritional habits and smoking have changed. Methods The online survey was conducted in nine European countries (Bosnia and Herzegovina, Croatia, Greece, Kosovo*, Italy, Serbia, Slovakia, Slovenia and Spain) in 4108 participants, aged 15–82 years. The survey took place 30–40 days after World Health Organization declared COVID-19 pandemic state, from 15 April to 3 May 2020. Results The results have shown 30 min longer sleeping time, 50% longer physical inactivity time, 65% longer screen time, 43% shorter walking time, 24% shorter sport time and 37% longer physical work time. Additionally, body mass gains (0.3 kg) could be explained in 20.6% with meals sizes, unhealthy food consumption, screen time and sport time. Further, respondents reported more regular meals (44%) and healthier meals with less alcohol consumption and less smoking, which have been positive outcomes of home confinement. Conclusion The findings draw attention to negative changes in everyday praxis (inactivity, body mass gain) after such a short period. Because of possible risk to population's health (especially of countries such as Italy and Spain with serious threat and more stringent measures), findings enable development of recommendations for maintaining healthy lifestyle habits with minimal negative health consequences in similar pandemic circumstances. [ABSTRACT FROM AUTHOR]

Viral hepatitis B is a global public health problem affecting nearly two billion subjects; 3.3% of whom are from the WHO (World Health Organization) Eastern Mediterranean Region (EMRO). It induces both acute and chronic hepatic disorders with subsequent liver cirrhosis and hepatocellular carcinoma (HCC) in a considerable percentage of patients based on the age of exposure. In this review, hepatitis B virus (HBV) and HCC prevalence, distribution and prevalence of different genotypes, and male/female infection frequencies in relation to the vaccination status in the Mediterranean countries were reported. Study Design. This systematic review describes the prevalence of hepatitis B infection, genotype distribution of hepatitis B virus, and prevalence and incidence of hepatocellular carcinoma in Mediterranean countries belonging to three different continents: Southern Europe (Spain, France, Italy, Croatia, and Greece), North Africa (Morocco, Algeria, Tunisia, Libya, and Egypt), and the Near East region (Syria, Lebanon, Turkey, Israel, and Palestine). We tried to collect new data from electronic databases: PubMed, ScienceDirect, ResearchGate, Google Scholar, and public health reports between 1980 and 2019. For each publication, we recorded reference, publication year, study characteristics (date, locations, sample size, and study population), and participant characteristics (population group, year, age, and sex). No language limitation was imposed, and articles or reports from non-peer-reviewed sources were not considered for this analysis. The main keywords were HBV prevalence, hepatitis B infection, HBV genotype, and HCC. Inclusion and Exclusion Criteria. Healthy population-based studies included the following sample populations: (i) voluntary blood donors, (ii) pregnant women, (iii) community studies, (iv) hemodialysis patients, (v) hospitalized patients, (vi) healthcare workers, (vii) sex workers, (viii) drug abusers, and (ix) prisoners. We excluded studies from the following special groups who were assumed to be at a special high risk: patients from sexually transmitted disease clinics and thalassemia clinics and professional or paid blood donors. [ABSTRACT FROM AUTHOR]

Background: Older persons often have interacting physical and social problems and complex care needs. An integrated care approach in the local context with collaborations between community-, social-, and health-focused organisations can contribute to the promotion of independent living and quality of life. In the Urban Health Centres Europe (UHCE) project, five European cities (Greater Manchester, United Kingdom; Pallini (in Greater Athens Area), Greece; Rijeka, Croatia; Rotterdam, the Netherlands; and Valencia, Spain) develop and implement a care template that integrates health and social care and includes a preventive approach. The UHCE project includes an effect and process evaluation.Methods: In a one-year pre-post controlled trial, in each city 250 participants aged 75+ years are recruited to receive the UHCE approach and are compared with 250 participants who receive 'care as usual'. Benefits of UHCE approach in terms of healthy life styles, fall risk, appropriate medication use, loneliness level and frailty, and in terms of level of independence and health-related quality of life and health care use are assessed. A multilevel modeling approach is used for the analyses. The process evaluation is used to provide insight into the reach of the target population, the extent to which elements of the UHCE approach are executed as planned and the satisfaction of the participants.Discussion: The UHCE project will provide new insight into the feasibility and effectiveness of an integrated care approach for older persons in different European settings.Trial Registration: ISRCTN registry number is ISRCTN52788952 . Date of registration is 13/03/2017. [ABSTRACT FROM AUTHOR]

In this paper we assess the impact of the recent European recession on stillbirth indices over the course of the 2000s and 2010s; the analysis focuses on four Southern European countries (Greece, Italy, Spain, Portugal), which were seriously affected by the sovereign debt crisis from around 2008 to 2017. We use national vital statistics and established economic indicators for the period 2000-2017; stillbirth ratios (stillbirths per 1000 livebirths) are the chosen response variable. For the purpose of the study, we employ correlation analysis and fit regression models. The overall impact of economic indicators on the stillbirth indices is sizeable and statistically robust. We find that a healthy economy is associated with low and declining levels of stillbirth measures. In contrast, economic recession appears to have an adverse effect (Greece, Italy and Spain), or an unclear impact (Portugal), on the stillbirth outcome. This study provides evidence of the adverse effect of the European sovereign debt crisis and ensuing period of austerity on a scarcely explored aspect of health., Competing Interests: The authors have declared that no competing interests exist.

In Europe, regions in the Mediterranean area share common characteristics in terms of high sensitivity to climate change impacts. Does this translate into specificities regarding climate action that could arise from these Mediterranean characteristics? This paper sheds light on regional and local climate mitigation actions of the Mediterranean Europe, focusing on the plans to reduce greenhouse gases emissions in a representative sample of 51 regions and 73 cities across 9 Mediterranean countries (Croatia, Cyprus, France, Greece, Italy, Malta, Portugal, Slovenia, Spain). The study investigates: (i) the availability of local and regional mitigation plans, (ii) their goals in term of greenhouse gas emissions reduction targets on the short and medium-long term, and (iii) the impact of transnational climate networks on such local and regional climate mitigation planning. Results of this study indicate an uneven and fragmented planning, that shows a Mediterranean West-East divide, and a link with population size. However, overall, both regional and city action seem insufficiently ambitious with regards to meeting the Paris Agreement, at least at city level. While national frameworks are currently weak in influencing regional and local actions, transnational networks seem to be engaging factors for commitment (at city level) and ambitiousness (at regional level). The uneven and fragmented progress revealed by this study, does not align with the characteristics shared by investigated regions and cities in terms of environmental, socio-political, climatic and economic conditions. The results support the call of a common green deal at the Mediterranean level to further address specific Mediterranean challenges and related needs. This will allow to capitalise on available resources, generate local-specific knowledge, build capacities, and support Mediterranean regions and cities in preparing the next generation of more ambitious mitigation plans., (Copyright © 2021 Elsevier Ltd. All rights reserved.)

Citizens and scientists can work together to improve the collective well-being, if citizens are inspired to help the advancement of science, and researchers motivated to listen to the voices of citizens. The benefits of such collaboration are increasingly recognized by both citizens and scientists, as reflected in the growing number of related publications and initiatives. This is especially relevant for emerging areas of research, where early involvement of citizens could help to envision, prioritize, and plan prospective studies. The Problematic Usage of the Internet (PUI) is one such area, which is fast becoming a public mental health concern. However, there remains a lack of clarity regarding the practical guidelines and ethical requirements for citizen involvement at the earliest stages of PUI. In our paper, we propose a conceptual framework and a template for initial involvement of citizens in PUI. They are derived from our community case studies, conducted in six European countries (Georgia, Greece, Malta, North Macedonia, Portugal, and Spain) and consisting of consultation with diverse groups of interested citizens (students, parents, teachers, and health professionals). Informed by our consultation exercises, we also highlight four ethical aspects for citizen involvement in the research on PUI or novel disciplines in general. They follow simple guiding principles to ensure that scientists will: enable a long-term commitment and inclusive opportunities for citizens, challenge established power hierarchies, and support collaboration, co-production and co-authorship with citizens. We believe that the proposed practical guidelines and ethical considerations, provide a valuable foundation on which to advance our understanding and generate international strategies for citizen involvement in PUI., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2021 Gjoneska, Jones, Vella, Bonanno, Flora, Fontalba-Navas, Hall, Ignjatova, Kirtava, Moreno Sanjuán, Vaz-Rebelo and Sales.)

Mosquito borne diseases are a group of infections that affect humans. Emerging or reemerging diseases are those that (re)occur in regions, groups or hosts that were previously free from these diseases: dengue virus; chikungunya virus; Zika virus; West Nile fever and malaria. In Europe, these infections are mostly imported; however, due to the presence of competent mosquitoes and the number of trips both to and from endemic areas, these pathogens are potentially emergent or re-emergent. Present and future climatic conditions, as well as meteorological, environmental and demographic aspects are risk factors for the distribution of different vectors and/or diseases. This review aimed to identify and analyze the existing literature on the transmission of mosquito borne diseases and those factors potentially affecting their transmission risk of them in six southern European countries with similar environmental conditions: Croatia, France, Greece, Italy, Portugal and Spain. In addition, we would identify those factors potentially affecting the (re)introduction or spread of mosquito vectors. This task has been undertaken with a focus on the environmental and climatic factors, including the effects of climate change. We undertook a systematic review of the vectors, diseases and their associations with climactic and environmental factors in European countries of the Mediterranean region. We followed the PRISMA guidelines and used explicit and systematic methods to identify, select and critically evaluate the studies which were relevant to the topic. We identified 1302 articles in the first search of the databases. Of those, 160 were selected for full-text review. The final data set included 61 articles published between 2000 and 2017.39.3% of the papers were related with dengue, chikungunya and Zika virus or their vectors. Temperature, precipitation and population density were key factors among others. 32.8% studied West Nile virus and its vectors, being temperature, precipitation and NDVI the most frequently used variables. Malaria have been studied in 23% of the articles, with temperature, precipitation and presence of water indexes as the most used variables. The number of publications focused on mosquito borne diseases is increasing in recent years, reflecting the increased interest in that diseases in southern European countries. Climatic and environmental variables are key factors on mosquitoes' distribution and to show the risk of emergence and/or spread of emergent diseases and to study the spatial changes in that distributions., (Copyright © 2020 The Author(s). Published by Elsevier Inc. All rights reserved.)

Background: The emergence of new types of tobacco and tobacco-related products on the European Union (EU) market has precipitated the possibility for both poly-tobacco use and transitions between products. In the EU, the regulatory environment has shifted with the implementation of the European Tobacco Products Directive (TPD) in May 2016, which may influence consumer transitions between products., Methods: The aim of this paper was to examine trends and transitions in tobacco products from 2016 to 2018 -before and after implementation of the TPD in the EU. Data come from Wave 1 (pre-TPD) and Wave 2 (post-TPD) of the EUREST-PLUS ITC Six European Country Survey, a cohort study of adults who at the time of recruitment were smokers from six EU countries- Germany, Greece, Hungary, Poland, Romania, and Spain. D (N = 3195). Bivariate and logistic regression analyses of weighted data was conducted using SAS-callable SUDAAN., Results: Overall, among those who smoked factory-made cigarettes (FM) only at Wave 1, 4.3% switched to roll-your-own tobacco (RYO) only. Among RYO only users at Wave 1, 17.0% switched to FM only, however compared to all other countries, respondents from Hungary had the highest percentage of FM only users at Wave 1 switch to RYO only at Wave 2 (18.0%)., Conclusions: The most prominent transition overall was from smoking RYO exclusively at Wave 1 to smoking FM tobacco exclusively at Wave 2, however this varied across countries. As the tobacco control regulatory environment of the EU develops, it is important to continue to monitor transitions between types of products, as well as trends in cessation., (© The Author(s) 2020. Published by Oxford University Press on behalf of the European Public Health Association. All rights reserved.)

The enactment of the Water Framework Directive (WFD) initiated scientific efforts to develop reliable methods for comparing prevailing lake conditions against reference (or nonimpaired) states, using the state of a set biological elements. Drawing a distinction between impaired and natural conditions can be a challenging exercise. Another important aspect is to ensure that water quality assessment is comparable among the different Member States. In this context, the present paper offers a constructive critique of the practices followed during the WFD implementation in Greece by pinpointing methodological weaknesses and knowledge gaps that undermine our ability to classify the ecological quality of Greek lakes. One of the pillars of WDF is a valid lake typology that sets ecological standards transcending geographic regions and national boundaries. The national typology of Greek lakes has failed to take into account essential components. WFD compliance assessments based on the descriptions of phytoplankton communities are oversimplified and as such should be revisited. Exclusion of most chroococcal species from the analysis of cyanobacteria biovolume in Greek lakes/reservoirs and most reservoirs in Spain, Portugal, and Cyprus is not consistent with the distribution of those taxa in lakes. Similarly, the total biovolume reference values and the indices used in classification schemes reflect misunderstandings of WFD core principles. This hampers the comparability of ecological status across Europe and leads to quality standards that are too relaxed to provide an efficient target for the protection of Greek/transboundary lakes such as the ancient Lake Megali Prespa.