Nikolaos Maniadakis

Background/Objectives: Obesity represents a major and growing economic challenge, yet evidence on its long-term economic burden and the potential value of sustained reductions in obesity prevalence remains limited in Greece. This study estimated the future economic burden of adult obesity in Greece and quantified the gross healthcare and societal costs avoided from alternative sustained reductions in obesity prevalence. Methods: A prevalence-based, top–down dynamic model was developed for the Greek adult population over 2026–2055. The analysis adopted a societal perspective and incorporated direct medical costs associated with obesity pharmacotherapy, bariatric surgery, and 36 obesity-related comorbidities, together with productivity losses from absenteeism and presenteeism. Adult population and obesity prevalence were projected using exponential smoothing, while population-attributable fractions (PAFs) linked obesity prevalence to comorbidity-related expenditure. The primary illustrative scenario assumed a hypothetical 5% annual relative reduction in adult obesity prevalence, rather than a 5% reduction in individual body weight. Potential gross costs avoided were estimated by comparing the projected obesity-attributable economic burden under this scenario with the corresponding burden under the status quo trajectory over the 2026–2055 modelling horizon. Costs were expressed in 2025 euros and discounted at 5% annually. Scenario, deterministic, and probabilistic sensitivity analyses were conducted. Results: Under the status quo, adult obesity prevalence was projected to increase from 29.24% in 2025 to 42.87% in 2055, while annual obesity-attributable costs increased from EUR 4.23 billion to EUR 5.11 billion. Direct medical costs accounted for 86.38% of cumulative expenditure. Under the 5% annual prevalence-reduction scenario, obesity prevalence declined to 6.28% by 2055, generating cumulative undiscounted gross costs avoided of EUR 71.12 billion and discounted gross costs avoided of EUR 29.25 billion. Probabilistic analysis produced discounted gross costs avoided of approximately EUR 27.85 billion, with a 95% uncertainty interval of EUR 23.83–31.61 billion. Conclusions: Adult obesity is projected to impose a substantial economic burden on Greece, with the findings illustrating the potential gross healthcare and societal costs avoided under hypothetical, sustained reductions in adult obesity prevalence, rather than the expected economic outcomes of specific interventions. These estimates are conditional on the assumed prevalence trajectories and do not establish the feasibility or cost-effectiveness of achieving such reductions.

Background: The Academic Resilience Scale-30 (ARS-30) was originally developed to assess cognitive, emotional, and behavioral responses following negative academic evaluation. Because structured performance appraisal has recently become an established component of the Greek public healthcare system, the present study examined whether this evaluative response framework could be meaningfully adapted to occupational performance evaluation. Methods: Test–retest reliability and descriptive analyses were conducted in an initial sample of 140 public healthcare employees, while EFA, internal-consistency analyses, and CFA were conducted in a separate larger sample of 483 employees. Results: Test–retest reliability was very high to excellent across items (ICC = 0.904–1.000). Internal consistency was acceptable for the total score (α = 0.799), good for Performance-Oriented Coping (α = 0.889), and acceptable for Negative Emotional Reactions/Passive Coping (α = 0.767). Positive Reappraisal/Growth Orientation (α = 0.705) and Acute Negative Emotional Reaction (α = 0.707) demonstrated marginally acceptable internal consistency and should therefore be interpreted cautiously. Item 23 was reverse-coded based on its semantic and conceptual direction. Exploratory factor analysis identified a preliminary four-component solution explaining 42.17% of the variance. However, the rotated solution included cross-loadings, and confirmatory factor analysis did not provide adequate support for the prespecified four-factor structure (CFI = 0.661, TLI = 0.629, RMSEA = 0.105, and SRMR = 0.105). Conclusions: Although some reliability findings were encouraging, the hypothesized four-factor structure was not supported by CFA and cannot currently be considered structurally validated. Further psychometric evaluation and model development are therefore required.

Background: Seasonal influenza remains a major public health challenge worldwide, causing significant morbidity each year and imposing substantial burdens on individuals, healthcare systems, and national economies. Vaccination is considered the most effective available strategy for prevention; however, uptake rates vary considerably across countries, with many failing to achieve the recommended coverage levels. The aim of this umbrella review is to systematically synthesize and critically appraise the existing evidence on healthcare professionals’ beliefs, attitudes, and behaviors regarding seasonal influenza vaccination. Methods: This umbrella review was conducted in accordance with the PRISMA 2020 statement. A literature search was conducted in PubMed, the Cochrane Library, and Google Scholar. The following search terms were used: beliefs, attitudes, behaviors, influenza vaccination, flu vaccine, healthcare professionals and primary healthcare. The inclusion criteria were as follows: (1) Reviews, (2) Published after 1 January 2000, (3) English language, (4) Healthcare professionals as the target-population. Results: Twenty-five studies met the selection criteria and were included in this review. Twelve out of 25 studies were systematic reviews. Globally, vaccination uptake remains below recommended levels, with reported coverage ranging from approximately 2% to 44% in several settings, while rates can exceed 90% in countries with mandatory vaccination policies. North America demonstrates the highest vaccination coverage, while the lowest coverage is reported in Africa and South America. Overall, low- and middle-income countries show significantly lower vaccination behavior compared with high-income countries. Attitudes and beliefs appear to shape vaccination behavior in high-income countries. The main driver of acceptance is perceived protection of oneself and family, whereas hesitancy is mainly driven by concerns about side effects and vaccine safety. Across studies, non-physician healthcare professionals consistently demonstrated lower influenza vaccine acceptance compared with physicians, while pediatricians and general practitioners were found to receive the influenza vaccine more frequently. In addition, younger physicians and those with fewer years of professional experience showed higher vaccination coverage and a greater likelihood of recommending influenza vaccination to patients. Conclusions: Vaccination coverage, worldwide, is lower than what is recommended by the World Health Organization. Healthcare professionals working in hospital settings tend to be vaccinated at a higher rate compared with those working in primary care or community-based healthcare settings. The recommendations that healthcare professionals give are influenced by whether they accept influenza vaccines themselves. Beliefs and attitudes seem to influence behavior in countries where structural barriers, such as limited access to primary healthcare and socio-economic status are absent.

Background: Influenza vaccination uptake among healthcare professionals remains suboptimal despite their key role in influencing public vaccination behavior. This study investigated motivational and behavioral determinants of influenza vaccination uptake and advocacy among primary healthcare professionals in Greece. Methods: A cross-sectional study was conducted among 304 physicians and pharmacists using an anonymous online questionnaire. Vaccination uptake (2023–2024 season and annual) and motivational and advocacy constructs were assessed using the validated MoVac-flu and MovAd scales. Factor structure was evaluated using confirmatory and exploratory factor analyses. Multivariable logistic regression models were applied to identify predictors of vaccination uptake. Results: The study sample consisted of 304 healthcare professionals of whom 61.2% were physicians and 38.8% were pharmacists. More than half of the participants were female (52.6%) and aged 41–60 years (57.6%). Influenza vaccination uptake was 77.6% for the 2023–2024 season and 75.3% for annual vaccination. A two-factor structure was identified for the MoVac-flu scale (F1: Vax Self-Care, F2: Vax Awareness), whereas a four-factor structure was identified for the MovAd scale (F1: Vax Communication, F2: Vax Influence, F3: Vax Confidence, F4: Vax Choice). The overall scales demonstrated high internal consistency, while most subscales showed satisfactory to high reliability. Motivation toward influenza vaccination and vaccination advocacy were high among the participants. Vaccinated participants demonstrated higher motivation and vaccination advocacy scores compared with non-vaccinated participants. In multivariable analyses, higher scores on Vax Self-Care (aOR = 3.22, 95% CI: 2.08–4.96, p < 0.001) and Vax Communication (aOR = 1.64, 95% CI: 1.14–2.34, p = 0.007) subscales, reflecting higher motivation and vaccination advocacy, respectively, as well as male sex (aOR = 2.35, 95% CI: 1.14–4.83, p = 0.020) were associated with higher odds of annual vaccination. Higher scores on the Vax Self-Care subscale (aOR = 3.66, 95% CI: 2.33–5.77, p < 0.001) were also found to be associated with higher odds of 2023–2024 vaccination uptake, as well as living with vulnerable individuals (aOR = 2.95, 95% CI: 1.18–7.38, p = 0.020). Conclusions: Influenza vaccination uptake among primary healthcare professionals in Greece was relatively high; however, it was strongly driven by intrinsic motivational factors, particularly the perceived personal and public health benefits of vaccination. Communication-related competencies also independently contributed to vaccination behavior, highlighting the link between professional practice and personal uptake. In contrast, household-related contextual characteristics, such as cohabitation with vulnerable individuals, appeared to exert a less consistent influence on vaccination behavior. These findings suggest that interventions focusing on strengthening intrinsic motivation and communication skills may contribute to sustained improvements in both vaccination uptake and advocacy among healthcare professionals.

Background: Influenza vaccination uptake among healthcare professionals remains subop-timal despite their key role in influencing public vaccination behavior. This study investi-gated motivational and behavioral determinants of influenza vaccination uptake and ad-vocacy among primary healthcare professionals in Greece. Methods: A cross-sectional study was conducted among 304 physicians and pharmacists using an anonymous online questionnaire. Vaccination uptake (2023–2024 season and annual) and motivational and advocacy constructs were assessed using the validated MoVac-flu and MovAd scales. Factor structure was evaluated using confirmatory and ex-ploratory factor analyses. Multivariable logistic regression models were applied to identify predictors of vaccination uptake. Results: The study sample consisted of 304 healthcare professionals of whom 61.2% were physicians and 38.8% were pharmacists. Most of the participants were female (52.6%) and aged 41-60 years (57.6%). Influenza vaccination uptake was 77.6% for the 2023–2024 sea-son and 75.3% for annual vaccination. A two- and a four-factor structure was found for the MoVac-flu (F1: Vax Self-Care, F2: Vax Awareness) and MoVAd (F1: Vax Communica-tion, F2: Vax Influence, F3: Vax Confidence, F4: Vax Choice) scales, respectively. Both scales demonstrated high internal consistency (Cronbach’s alpha coefficient > 0.87). Mo-tivation toward influenza vaccination and vaccination advocacy were high among the participants. Vaccinated participants had higher motivation and advocacy scores than non-vaccinated ones. In multivariable analyses, higher scores on Vax Self-Care (aOR = 3.22, 95% CI: 2.08-4.96, p < 0.001) and Vax Communication (aOR = 1.64, 95% CI: 1.14-2.34, p = 0.007) subscales, demonstrating enhanced motivation and advocacy, respectively, as well as male sex (aOR = 2.35, 95% CI: 1.14-4.83, p = 0.020) were associated with higher odds of annual vaccination. Higher scores on the Vax Self-Care subscale (aOR = 3.66, 95% CI: 2.33-5.77, p < 0.001) were also found to be associated with higher odds of 2023–2024 vaccination uptake, as well as living with vulnerable individuals (aOR = 2.95, 95% CI: 1.18-7.38, p = 0.020) Conclusions: Influenza vaccination uptake among primary healthcare professionals in Greece was relatively high; however, it was strongly driven by intrinsic motivational fac-tors, particularly the perceived personal and public health benefits of vaccination. Com-munication-related competencies also independently contributed to vaccination behavior, highlighting the link between professional practice and personal uptake. In contrast, con-textual factors, such as cohabitation with vulnerable individuals, appeared to exert a more situational and less consistent influence. These findings suggest that interventions focus-ing on strengthening intrinsic motivation and communication skills may lead to more sustained improvements in both vaccination uptake and advocacy among healthcare professionals.

Introduction: Patients undergoing surgery are exposed to various stressors that may increase psychological distress during the perioperative period. These repercussions may be substantial, affecting both physical and mental health, as well as the ability to resume regular activities and overall quality of life. Aim: This study aimed to compare the preoperative psychological distress levels of patients admitted to long-term preoperative hospitalization (LONG) to those of patients admitted to day care (DC) facilities for ambulatory surgery within an oncology hospital and to examine potential sociodemographic predictors. Methods: This was a prospective observational study that included 176 individuals who underwent surgery in two cohorts. Patients in the DC cohort (n = 88) were treated in a day care surgery clinic, whereas patients in the LONG cohort (n = 88) were treated in a long-term oncology hospital. Demographic and clinical data were collected. Patients’ psychological distress (depression, anxiety, and stress) was preoperatively evaluated using the DASS-42. Univariate and multivariate logistic regression analyses were performed. Results: The DASS-42 scale’s Cronbach’s alpha was 0.923. There was no significant difference between the cohorts in terms of age; however, waiting time before surgery differed significantly (U = 2884, p = 0.002). Stress levels differed significantly between the two cohorts (p = 0.05). Conclusions: Health managers and health care providers should consider gender, surgical severity, and rural/urban residence as factors associated with preoperative psychological distress. Studies assessing gender-specific dynamics, as well as mixed-methods approaches, could provide deeper insights into patients’ experiences and the correlations of distress and highlight implications for oncology nursing practice across different hospitalization models.

Background/Objectives: Machiavellianism has long been associated with unethical tendencies and behaviors. High-Mach people have been stereotyped to choose business-related professions, contrary to low-Mach individuals choosing the helping professions. There has been a clear shift in scholarly focus, such as Machiavellian leadership and Machiavellian personality traits in healthcare. The objective of this narrative literature review was to provide a structured synthesis of empirical evidence on Machiavellianism within healthcare settings, focusing on its prevalence, manifestations, and organizational implications, while identifying conceptual and research gaps in the field. Methods: Literature research was conducted for articles published in PubMed, Scopus, and Google Scholar from 2014 until 2025. Articles written in English, examining Machiavellian traits in healthcare workers and students, were included in this review. Results: The search strategy produced 347 items, of which 11 original studies were included. Machiavellianism was described as a personality trait featuring emotional coldness and manipulativeness for the achievement of one’s own ends; individuals exhibiting those traits may prioritize personal gain over collective welfare. Machiavellian tendencies manifesting in organizational culture often lead to a toxic work environment where manipulation might become normalized. Machiavellians show high commitment to their careers, but low commitment to their current organizations, supervisors, and teams. Conclusions: Machiavellianism emerges as a relevant but underexplored personality trait in healthcare, associated with unethical behaviors, reduced organizational commitment, and toxic work environments. Addressing its impact requires ethical leadership development, supportive organizational environments, and early identification during professional training to safeguard workforce well-being and patient safety.

Background: Seasonal influenza remains a major public health challenge worldwide, causing significant morbidity each year and imposing substantial burdens on individuals, healthcare systems and national economies. Vaccination is considered the most effective available strategy for prevention; however, uptake rates vary considerably across countries, with many failing to achieve the recommended coverage levels. The aim of this review is to examine the beliefs, attitudes and behaviors of healthcare professionals worldwide regarding seasonal influenza vaccination. Methods: This is an umbrella review, according to the PRISMA Statement 2020, searching PubMed, Cochrane Library and Google Scholar. The following search terms were used: beliefs, attitudes, behaviors, influenza vaccination, flu vaccine, health professionals, primary health care. Selection criteria were the following: 1) Reviews, 2) Published after 1/1/2000, 3) English language 4) Healthcare professionals as target-population. Results: Twenty-five studies met the selection criteria and were included in this review. Twelve out of 25 studies were systematic reviews. Globally, vaccination uptake among healthcare professionals remains below recommended national and international targets. North America demonstrates the highest vaccination coverage, while the lowest coverage is reported in Africa and South America. Overall, low- and middle-income countries show significantly lower vaccination behavior compared with high-income countries. Attitudes and beliefs appear to shape vaccination behavior in high-income countries. The main driver of acceptance is perceived protection of oneself and family, whereas hesitancy is mainly driven by concerns about side effects and vaccine safety. Across studies, non-physician healthcare professionals consistently demonstrated lower influenza vaccine acceptance compared with physicians while pediatricians and general practitioners were found to receive the influenza vaccine more frequently. In addition, younger physicians and those with fewer years of professional experience showed higher vaccination coverage and a greater likelihood of recommending influenza vaccination to patients. Conclusions: Vaccination coverage, worldwide, is lower than what is recommended by the World Health Organization. Healthcare professionals, working in hospital settings, tend to be vaccinated at a higher rate and are more likely to recommend the vaccine to their patients. The recommendations that health professionals give are influenced by whether they accept influenza vaccines themselves. Beliefs and attitudes seem to influence behavior in countries where structural barriers, such as limited access to primary healthcare and socio-economic status are absent.

Background/Objectives: Obesity is a global health issue with profound humanistic and financial implications. Novel pharmacological treatments, such as tirzepatide and semaglutide, offer promising options for sustained weight management; however, their cost-effectiveness warrants assessment. This study investigates the short-term cost-effectiveness of tirzepatide compared to semaglutide in achieving weight loss targets over 72 weeks in Greece. Methods: A short-term cost-effectiveness analysis was conducted from the perspective of the Greek third-party payer (EOPYY), comparing treatment costs and clinical outcomes for semaglutide and tirzepatide over a 72-week horizon. Clinical efficacy was assessed by the proportion of patients achieving weight loss targets of ≥10%, ≥15%, ≥20%, ≥25%, and ≥30%, using data from the SURMOUNT-5—a 72-week, phase 3b, head-to-head study among overweight adults or those with obesity without diabetes. Only direct medical costs were included, and no discount was employed due to the short time horizon. Price scenario, deterministic, and probabilistic sensitivity analyses were performed. Results: Over 72 weeks, the deterministic analysis found the total treatment cost was EUR 5645.70 for tirzepatide and EUR 3201.68 for semaglutide. These base-case results indicated the cost per responder for tirzepatide at higher weight loss targets (e.g., EUR 28,658 and EUR 46,401 at ≥30%) and lower costs for semaglutide at lower targets (e.g., EUR 1627 lower at ≥10%). However, probabilistic sensitivity analysis revealed overlapping 95% confidence intervals at all thresholds, indicating no statistically significant difference in the cost of control between the treatments. Conclusions: Semaglutide showed a numerically lower cost of control at lower weight loss targets, while tirzepatide was favoured at higher targets; however, these differences were not statistically significant.

Background/Objectives: This study introduces the Multi Group Cost Malmquist Index (CMgm), a novel tool for comparing and ranking the cost efficiency of multiple groups of similar decision-making units operating in different contexts. It was applied to Greek public hospitals to assess productivity change between 2009 and 2021, covering the period before the economic recession and after the second lockdown during the COVID-19 pandemic. The study aimed to determine the impact of these external shocks on hospital efficiency and to identify differences in cost productivity based on hospital size and regional location. Methods: Data envelopment analysis was employed to compute the Malmquist indices for productivity change and ranking. Overall, 109 Greek public hospitals were analysed using three models: as a single group, classified by bed capacity, and classified by regional health authority (RHA). Cost productivity was decomposed into its core measures. Results: During the economic crisis, hospitals improved their cost productivity by 13.2%, whereas during the pandemic, it declined by 32.1%, primarily due to cost frontier deterioration resulting from increased healthcare demand and strained resources. Medium-sized hospitals exhibited higher cost efficiency than small and large hospitals. Regional disparities were also observed, with hospitals in the 5th and 7th RHAs outperforming those in 1st and 2nd RHAs. Conclusions: The findings highlight the pandemic’s disruptive impact on hospital cost productivity compared to the efficiency gains during the economic crisis. It is encouraging, though, that hospitals are recovering again after the lifting of strict lockdown measures. The CMgm is a valuable tool for policymakers, offering insights into hospital performance across multiple groups. Future healthcare policies should prioritise resource optimisation and address regional disparities to enhance system-wide efficiency and resilience in times of crisis.