Aims. Few epidemiological studies evaluated associations between perinatal complications and maternal mood at the early postpartum period and the findings are inconsistent. We aimed at investigating a wide range of complications during pregnancy, at delivery, and at the early postpartum period as determinants of postpartum depression (PPD) at 8 weeks postpartum. Methods. A total of 1037 women who enrolled in the Rhea mother–child cohort in Crete, Greece participated in the present study. Information on pregnancy, perinatal and postpartum complications was obtained from clinical records or by questionnaires. Postpartum depressive symptoms were assessed at 8 weeks postpartum using the Edinburgh Postnatal Depression Scale (EPDS). Multivariable linear and logistic regression models were fit to estimate the association between pregnancy, perinatal and postpartum complications and maternal depressive symptoms, adjusting also for potential confounders. Results. The prevalence of women with probable depression (EPDS score ≥ 13) was 13.6% at 8 weeks postpartum. Gestational hypertension and/or preeclampsia ( β coefficient 1.86, 95% CI: 0.32, 3.41) and breastfeeding difficulties ( β coefficient 0.77, 95% CI: 0.02, 1.53) were significantly associated with higher PPD symptoms. Sleep patterns during pregnancy, such as sleep deprivation (OR = 3.57, 95% CI: 1.91, 6.67) and snoring (OR = 1.81, 95% CI: 1.11, 2.93), and breastfeeding duration less than 2 months (OR = 1.77, 95% CI: 1.19, 2.64) were significantly associated with increase in the odds for PPD. Some other complications, such as unplanned pregnancy and hospitalisation during pregnancy were also associated with EPDS score, but these associations were explained by socio-demographic characteristics of the mother. Conclusions. We found that several pregnancy, perinatal and postpartum complications may have an adverse effect on maternal mood at the early postpartum period. These findings have considerable implications for developing effective prevention and early psychoeducational intervention strategies for women at risk of developing PPD.

OBJECTIVE Description of the degree of integration across primary health care (PHC) services in Greece, in the context of providing integrated care through the implementation of unified processes and quality standards. METHOD The study was conducted in the framework of a national program funded under the National Strategic Reference Framework (NSRF) in the operational program "Administrative reform 2007-2013", with the title "Operational integration of PHC units") and the Monitoring Information System (MIS) code no 337424. The study design was embedded in a theoretical framework covering three levels and 10 dimensions of PHC. The study sample consisted of 124 PHC units throughout Greece, selected by stratified random sampling. Two evaluation instruments were used to assess the degree of integration and the quality of the healthcare services provided: The validated questionnaire Primary Care Assessment Tool (PCAT) - short Version of the Primary Care Policy Center for Underserved Populations, Johns Hopkins University, and a questionnaire developed for this study by the project research team, based on synthesis and selection of domains from other standard questionnaires. The data were collected and analyzed using a five point Likert scale (1: minimal, 2: poor, 3: basic, 4: partial, 5: maximum) and a multi-criteria decision algorithm. RESULTS The overall rating of integration for the majority of the PHC units ranged between 3 and 4 (i.e., basic to partial), while a small percentage (5%) were rated as 2 (poorly integrated). Regarding specific PHC dimensions, "Continuity of Health Care" was reported to have a higher degree of integration, with 80% of the PHC units being rated as 4 or 5 (i.e., partial to maximum integration levels). Conversely, the dimensions that were identified as requiring significant improvement were "Economic Conditions of the PHC system" and the "Service Quality of PHC". In the majority of the units, the rating regarding economic conditions was evaluated below the basic level, with 73% rated as having poor integration in terms of the "remuneration system of PHC workforce". CONCLUSIONS In terms of the degree of integration of care, a high degree of heterogeneity was identified across PHC services in Greece. The implementation of targeted actions could effect improvement in the quality of services provided and in the degree of operational integration, thus enhancing their effectiveness.

Breast and cervical cancer are among the leading causes of female mortality in the world. Screening adherence plays a key role in breast and cervical cancer incidence and morbidity. Many factors are involved in women's adherence to screening guidelines. Personal and sociodemographic characteristics, the role of the health professionals in primary care and the national or local screening policies may all enhance or impede screening adherence. Parameters stemming from the social and cultural context play an active role in women's health related behavior. Individual social capital, both as a whole and through its various factors (participation in the community, value of life and tolerance of diversity), has been shown to be associated with breast and cervical cancer screening practices. Social capital encourages screening adherence by facilitating dissemination of relevant information and by providing women with a moral and structural obligation to take care of their health. Successful health policy for the early detection of breast and cervical cancer is a complicated issue with multiple spheres of influence at the level of the individual, the community and health professionals. Health promotion programmes should enable screening adherence through the dissemination of knowledge and the creation of pathways to minimize inequalities in health screening services and social insurance coverage. This paper examines the theoretical background of the personal and social parameters of adherence to breast and cervical cancer screening that facilitate the relevant health policy for cancer prevention.

BACKGROUND Caesarean deliveries are on the increase in Greece and around the world. The objective of the present study was to assess the frequency of planned and emergency caesarean deliveries and their socio-demographic predictors in women with singleton pregnancies followed-up from early pregnancy to delivery. METHODS The mother-child cohort in Crete examines a population sample of pregnant women recruited during one year beginning in February 2007. A cohort of 1096 women, with singleton pregnancies, was included in the present analyses. Multivariable Poisson regression models with robust error variance were used. RESULTS Overall, 48% of the women had a caesarean delivery, with a higher percentage observed in women having their first child (52%). Maternal age was a predictor for caesarean deliveries; type of hospital was associated with the risk for an emergency caesarean, whereas women with lower education were at an increased risk of having a planned caesarean delivery among primiparae. Prior caesarean delivery was by far the strongest predictor (RR=7.68, 95% CI 5.71, 10.33) for a subsequent one among multiparae. CONCLUSIONS Caesarean deliveries are almost as frequent as vaginal births in the study population and even more frequent in first-time mothers. The study findings support that risk factors are indeed mode of delivery and parity status specific. As such, it is becoming clearer which groups of women, especially first-time mothers, need to be targeted in future research and interventions so as to understand better and achieve an appropriate caesarean delivery risk.

BACKGROUND/AIMS:Maternal personality may increase vulnerability to stress, which could lead to an unfavourable intrauterine environment to the fetus. We sought to investigate the impact of maternal personality traits on adverse birth outcomes such as preterm birth, and fetal growth restriction in the mother-child cohort study (RHEA Study) in Crete, Greece 2007-2009. METHODS:Five hundred and eighty pregnant women participating in "Rhea" cohort study completed the Eysenck Personality Questionnaire-Revised (EPQ-R) at 28-32 weeks of gestation. Information on anthropometric measures at birth was obtained from the hospital delivery logs and medical records. Fetal growth restriction was based on a customized model, and multivariate logistic regression models were used adjusting for confounders. RESULTS:A per unit increase in the EPQ Neuroticism scale increased the risk for fetal weight growth restriction by 9% [odds ratio (OR)=1.09, 95 percent CI: 1.01, 1.19)], and for fetal head circumference growth restriction by 6% [OR=1.06, 95 percent CI: 1.01, 1.18] after adjusting for maternal age, education, origin, marital status, working status, pre-pregnancy BMI, delivery type, parity, smoking, and alcohol intake during pregnancy. CONCLUSIONS:Maternal neuroticism, which predisposes to negative mood, may be a risk factor for fetal growth restriction.

OBJECTIVE To record the health conditions and investigate the factors that influence the subjective perceptions about health of immigrant mothers residing in the Municipality of Gazi in Crete. METHOD Immigrant women in the Municipality of Gazi were recruited via their informal networks and a poster campaign. Information on the subjective perceptions of health of the immigrant mothers was elicited using a face-to-face structured interview technique. RESULTS In the course of the research, home visits were made on 47 women who agreed to participate, at which time interviews were conducted. The percentage of the interviewees who reported a chronic illness (20%) was found to be lower than that in the general population. A small number of the sample (8%) had visited the doctor in the two weeks before the interview. The majority of the women (72%) had not undergone a Pap test for at least three years. The abortion to birth ratio was 3:1 and use of birth control was reported by 48% of the women. The common symptoms that the interviewees reported during the course of the previous year were negatively correlated with their subjective perceptions of health. A positive correlation was observed between their degree of satisfaction with their lives and other factors which were investigated, such as satisfaction with their husbands, themselves and their health. CONCLUSIONS The findings of the study indicate the need for improved cooperation of the immigrant mothers with organizations and services of the municipalities and the strengthening of inter-social and inter-cultural communication.

The term social capital can be traced back to the beginning of the last century and many of its features and their relationship to health were well-established long before the introduction of the term into the academic agenda. Social capital is a concept that has now come to reorient the focus of health and social sciences from individuals to social groupings. Social capital is a multidimensional term, which is considered to be the synthesis of different, yet related, social features such as civic engagement, information and community networks, reciprocity and trust among people. It is of great interest to health professionals because of the positive influence it may exert on various health outcomes. References to social capital in the current literature do not share a common approach for its measurement. That is because the different theoretical paradigms do not conclude whether social capital is an individual or an ecological construct, affecting most people or communities. This diversity is reflected in the contradictory results of the empirical investigations of the influence social capital may have on health. It is also revealed by the lack of commonly accepted psychometrically tested tools, constructed specifically to measure the concept of social capital. Another ongoing debate is that of whether social capital has a negative influence on health indicators. This paper argues, based on empirical and theoretical evidence, that social capital is both an individual and contextual construct and that it may affect health both positively and negatively. This paper also analyses recent conceptual developments in social capital theory that distinguish between bonding, bridging, and linking, cognitive and structural, horizontal and vertical social capital. These differentiations will permit better understanding of its various functions in different settings and help in the determination of which type of social capital and which indicators are the most appropriate in promoting health in people with different sociodemographic, ethnic and cultural backgrounds.

OBJECTIVES:To examine the extent to which primary care patients are using the primary healthcare (PHC) services in Gaza Strip, Palestine, and to determine the factors that are associated with the use of these services.METHODS:Using Andersen's behavioural model, the authors interviewed 956 PHC attendees. Patients were questioned about predisposing factors: age, sex, marital status, education, work status, household size, life events (psychological and financial), perceived living conditions and health locus of control. Enabling factors included urbanisation and household income. Need factors included self-rated health. Healthy lifestyle was measured by two variables: smoking and physical activity. Outcome factors were measured by patients' satisfaction with PHC.RESULTS:The study revealed that the majority of interviewed patients (64.7%) reported high use (>3 times per 6 months) of PHC within the 6-month period before the interview. The main factors found to be associated with high use of PHC were older age, married and divorced/widowed status, perceived bad living conditions, not working, high level of income, poorly rated health status and current smoking habit.CONCLUSIONS:Gazean primary care patients are high users of PHC services. The increased use of these services is associated with the basic predisposing, enabling and needs factors and with the unique bad living conditions. Tobacco use was another aspect associated with high use of PHC. Effective health management, based on promoting a healthy lifestyle, is needed. The findings of this study can be used to improve health service planning and guide decision-makers towards healthcare resource allocation according to healthcare needs.

The conception of new, 'avoidable' life style diseases in affluent Western societies is largely based upon observations in groups of middle-aged urban males with mortality as the major end-point. This applies to cancer, too, and studies of morbidity, where cancer is put within the overall disease spectrum, are called for as a necessary intermediary stage for hypothesis generation and initiation of evaluative and interventive epidemiological projects in the community. Here also the conditions and circumstances that determine health and well being, that is, salutogenetic factors, come increasingly into focus. We made a comparative analysis of the total hospitalization for somatic diseases during 1986-1987 at the Linköping University Hospital in the county of Ostergötland, Sweden and the both complementary and commensurable Heraklion University Hospital on Crete. They are representative of their respective European situations, and are the only somatic hospitals in their regions. Large differences were found with lower morbidity in the more 'Arcadian', rural settings. The results provide valuable data on traits and patterns between earlier surveys such as the Seven Countries study and today. We have earlier reported on the findings from the female group of the two populations, and here wish to concentrate on the males. In particular, cancer is compared with the both prominent and 'archetypical' forms of male ill-health that are comprised by cardiovascular diseases and accidents. We discuss some of the salutogenetic as well as pathogenetic factors that call for closer study in the next stage of our project, whose emblem of Ariadne's thread we feel also has a strong bearing on the masculine gender.

Modern health system research emphasises the transition from mortality statistics via morbidity and risk factors observations to comparative site explorations in defined areas. The health of women from the perspective of their gender has become a priority in medical research over the last decade. Studies of morbidity have been called for as necessary intermediary stage for hypothesis generation, and the formulation and inception of epidemiological projects which are recognized as essential for attaining knowledge on the factors and circumstances that determine diseases and wellbeing in the general population. This applies especially to cancer, where the importance of seeing disease, from a ecological, cultural as well as gender context is evident. We made a comparative analysis of the hospitalization for somatic diseases during 1986-1987 at the Heraklion University Hospital on Crete, and the commensurable Linköping University Hospital in the country of Ostergötland, Sweden. They are representative of their complementary Europian situations and comprise the total hospital admissions in their regions. Large differences were found, notably regarding both cardiovascular diseases and cancer, with lower morbidity in the more 'arcadian', rural circumstances. The results provide unique data on traits and patterns intermediate to the pioneering observations of the Seven Countries survey on the rapidly changing European scene. In the field of cancer the data are effectively unmatched both as raw data and as a platform for further investigation, which we are presently pursuing under the emblem of 'Ariadne's thread'. From a salutogenetic point of view the elderly rural women on Crete, and from a pathogenetic point of view the elderly urban women in Linköping warrant particular attention.

The health of women has risen to a priority position in medical research. Comparative studies of female morbidity are called for as an intermediary stage for generation of hypotheses and design of deeper studies of determinants, such as social, ecological, and individual factors. In previous studies, we have noted differences in female hospitalization between Heraklion in Greece and Linköping in Sweden. They were related to age and to urban versus rural dwelling, and fit projections for a more archaic and a more technocratic society, respectively. This paper aims at showing how the study of women's health may proceed from relevant hospitalization observations to the next level, of exploring already available indicators of self-perceived health in elderly females.

Cancer frequency has been studied in a Department of Crete and a Department of Sweden, using in-patient data collected in the Departmental Hospitals, for a two-year period. The results of the study suggest that similar trends exist in the prevalence of different forms of cancer between the two areas studied, as well as some significant differences. The differences observed concern mainly the frequency of cancers of the lung, prostate, bladder and large bowel among men and breast and large bowel among women. These findings could to a great extent be explained by life-style and environmental differences between the two areas and are consistent with data concerning the cancer mortality in the two countries.

The influence of the working at the loom on the appearance of musculoskeletal disorders has been studied in the adult female population of a highland community of Crete, in which home-based handicraft has an important place in the economic activity. Information about symptoms and clinical signs related to the musculoskeletal system, as well as about socioeconomic characteristics was collected by means of a personal interview and a medical examination. Regression analysis shows that there is a statistically significant association between the intensity of symptoms from the upper extremities and the shoulder-neck region and the number of years of working at the loom, independently from other studied variables, such as BMI, age and number of children per woman.

Risk factors for coronary heart disease were studied in a female population aged 20 to 69 years living in a highland community of Crete. 375 women participated in the study. Mean value of total cholesterol was 6.23 mmol/l, of HDL-cholesterol 1.41 mmol/l, of serum triglycerides 1.58 mmol/l, of serum glucose 5.36 mmol/l, of systolic blood pressure 130.64 mmHg and of diastolic blood pressure 78.07 mmHg. 46% of the study population had a body mass index higher than 27. Upon multiple regression analysis, the body mass index correlated positively and independently of age with serum lipid level and the systolic and diastolic blood pressure. The results of this study agree with data from other studies suggesting an increase in frequency of coronary heart disease risk factors in Crete over the past 20 years.

The authors determined the association between metabolic syndrome in early pregnancy (mean, 11.96 weeks) and the risk of preterm birth in the mother-child cohort study (''Rhea'' Study) in Crete, Greece, 2007–2009. Maternal fasting serum samples were collected, and blood pressure was measured at the time of the first major ultrasound examination (n ¼ 625). Multivariable log-binomial regression models were used. Women with metabolic syndrome were at high risk for preterm birth (relative risk (RR) ¼ 2.93, 95% confidence interval (CI): 1.53, 5.58), with the highest risk observed for medically indicated preterm births (RR ¼ 5.13, 95% CI: 1.97, 13.38). Among the components of metabolic syndrome, the most significant risk factor was hypertension (RR ¼ 2.32, 95% CI: 1.28, 4.20). An elevation of 10 mm Hg in diastolic blood pressure increased the relative risk for preterm birth by 29% (RR ¼ 1.29, 95% CI: 1.08, 1.53), while a per unit increase in the low density lipoprotein/high density lipoprotein cholesterol ratio increased this risk by 19% in early pregnancy. These findings suggest that women with metabolic syndrome in early pregnancy had higher risk for preterm birth. The metabolic syndrome is described as a cluster of metabolic abnormalities that appear to directly promote the development of atherosclerotic cardiovascular disease and are characterized by chronic low-grade systemic inflammation (1–3). It is associated with the rising incidence of obesity in developed countries and is reaching epidemic proportions affecting between 24% and 34% of the US population (4) and up to 36% of Europeans aged 40–55 years (5). In a recent study in Greece, the prevalence of metabolic syndrome was 25% in adult men and 15% in women according to the National Cholesterol Education Program, Adult Treatment Panel III, definition (6). Metabolic syndrome is not a universally accepted entity and, although certain cardiovascular risk factors undoubtedly occur together more often than expected by chance, the underlying pathophysiology of the syndrome is unclear (7). A substantial body of epidemiologic evidence suggests that a poor in utero environment elicited by maternal dietary or placental insufficiency may ''program'' susceptibility in the fetus to later development of cardiovascular and metabolic disease. Moreover, epidemiologic studies suggest that women who deliver preterm (8, 9) or low-birth-weight infants (10, 11) have a higher risk later in life for cardiovascular disease. The metabolic profile of pregnant women who give birth to preterm or fetal growth-restricted neonates is not well investigated. A plausible hypothesis is …